After stroke, many patients improve spontaneously, at least to some extent, and after the acute period the principal mechanism appears to be brain plasticity. The task for rehabilitation is to improve on spontaneous recovery, and this might well be accomplished by manipulating plasticity. Body parts compete for representation in brain, and use of a body part enhances its representation. Hence, physical therapy should help, as has been demonstrated by constraint-induced movement therapy. Other techniques use the same principle such as neuromuscular electrical stimulation, robot-enhanced training and virtual reality training. Bilateral, symmetical arm movement training helps, possibly by enhancement of function of the undamaged hemisphere. Sensory stimulation enhances plasticity and can be delivered in a number of ways, from passive movement to cutaneous stimulation. Reduction of inhibition enhances plasticity, and this can be used in rehabilitation using deafferentation. Pharmacological agents can enhance plasticity by several mechanisms.
A 49-year-old man, treated with coagulation factor VIII since being diagnosed with hemophilia A at age four, was admitted to our hospital with a massive intraabdominal hemorrhage. Although he had hemophilic arthropathy, and arthrodesis of the right knee from the age of thirteen, he had been able to live independently and engage in limited social activity. However, a month of immobilization due to intensive medical treatment for the intra-abdominal hemorrhage resulted in severe impairment from multiple joint contractures and generalized muscle atrophy. Following consultation with our department, we prescribed physical and occupational therapy including physical modalities for joint contracture, ROM exercise, isometric muscle strengthening, underwater exercise and activity training in combination with a daily prophylactic infusion of coagulation factor VIII. After 5 months of intensive rehabilitation, the patient's physical functioning was restored and he was able to walk outdoors and perform daily activities independently. During the course of inpatient rehabilitation, not a single hemorrhage episode occurred. Adult hemophilic arthropathy patients may tend to become severely disabled due to acute medical problems. Although recovery of physical function may take much time, intensive rehabilitation combined with prophylactic use of coagulation factor may be an effective treatment in cases such as this.
In short below-the-elbow stumps with insufficient muscle strength to flex the forearm through the normal range, it is very important to select suitable prosthesis. The wrong prosthesis may result in some clinical problems such as stump pain or abrasion. We reported two cases in which clinical problems were improved when using the Robin-Aids elbow hinge. Both patients had wide scarring around the stump, muscle atrophy of the upper limb, and limited range of motion in the elbow joint. They could perform standard active prosthesis techniques without trouble when using the Robin-Aids elbow hinge. Because the motion of the stump was used only for “locking or unlocking” when using the Robin-Aids elbow hinge, there was no need to burden the stump end with a heavy load. Though, in recent years, modern high-technology devices such as myoelectric hands have attracted people's attention, we should not forget old time-tested techniques which are as useful as modern ones.