dr. Herdiman B. Purba, Sp.

KFR-K
Born: Bandung, 8 February 1969

Education & Training:

•  Medical Doctor: Faculty of Medicine Christian University of Indonesia,
1995
•  Physical Medicine and Rehabilitation Specialty: Faculty of Medicine
University of Indonesia, 2004
•  Basic Intensive Course of Sexology, Udayana University, 2006
•  Advance Intensive Course of Sexology, Udayana University, 2008
•  International Training of Comprehensive Rehabilitation, Thailand,
2009

Current Activities & Organization:

•  Medical Staff at Neuromusculoskeletal Division, Dept. Physical
Medicine and Rehabilitation, FMUI-RSCM
•  Member of Perhimpunan Dokter Spesialis Kedokteran Fisik dan
Rehabilitasi Indonesia (PERDOSRI)
 Symposium Stroke Rehabilitation:
Optimizing the Role of General Practitioners
A Building, 8th Floor, RSCM
Jakarta, 22nd July 2017

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

dr. Herdiman B. Purba SpKFR-K
 Stroke
• Stroke is a rapidly developing clinical signs of focal (at times global)
disturbance of cerebral function, lasting more than 24 hours or
leading to death with no apparent cause other than that of vascular
origin (WHO)

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Prevalence of Stroke
• Stroke is the 3rd leading cause of death in America (#1 in Asia) and
the 1st leading cause of adult disability. 1
• Stroke accounts for 1 of every 18 deaths in the US. 1
• In Indonesia, incidence of stroke is 12,1/1000 (Riskesdas, 2013)2
• By using Modified Shah Barthel Index, it shows dependency on
chronic phase stroke patients in RSCM, Jakarta, 2016.3
• The risk of stroke increases with aging1
• About 87% of strokes are ischemic, 10% are secondary to
intracerebral hemorrhage, and another 3% may be secondary to
subarachnoid hemorrhage2
1. Heart Disease and Stroke Statistics. Circulation, Feb. 2011
2. Riskesdas 2013
3. Relationship between Daily Activities using MSBI with Several Risk Factors in Stroke Patients, 2016
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 Infarct Progression After Stroke

Preventive?

Delayed
therapeutic?
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

Complexity of Stroke Injury Progression

hours

Source: S, Irawan, MD, PhD., Prof Guest lecture: Update on neuroscience research MMP: matrix metallo-proteinase
Mei, 2017. IMERI FKUI BBB: blood brain barrier
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 The brain is not only about the weight!
Human brain consist
more gyrus and sulcus
compared to elephant’s
brain neurons and
synaps are more dense
and complex higher
cortical function

BL Hart, LA Hart, N Pinter-Wollman, 2007

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Brain Plasticity
• Plasticity
“A persistent change in the neural control system (morphology
and/or function) based on prior experience”
Mitchell and Johnson, 2003

“A fundamental property of a neuron or synapse to change its

internal parameters in response to its experienced”
Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 • BDNF excert its effects on
neuroplasticity by facilitating
long-term potentiation (LTP) or
long term facilitation (LTF), a
long-lasting increase in the
strength of connection between 2
neurons that are repeatedly
activated together and by
promoting dendritic growth and
remodeling.
• BDNF is secreted in the CNS
through both a constitutive and
an activity-dependent pathway.
One of the constitutive pathway
is through the release of
serotonin

Source: S, Irawan, MD, PhD., Prof Guest

lecture: Update on neuroscience research
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc Mei, 2017. IMERI FKUI
Other growth factors are affected by repetitive Acute Intermitten Hypoxia: VEGF

Repetitve acute intermitten

hypoxia (AIH) induce the
production of VEGF
(vascular endothelial
growth factors) which have
a role contributing to LTF

Source: S, Irawan, MD, PhD., Prof Guest

lecture: Update on neuroscience research
Mei, 2017. IMERI FKUI

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Stages of motor recovery (Brunstormm)

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc Source: Evidence based review for stroke rehabilitation, 2016
 Principles of recovery after stroke
• Patients tend to improve over time after an acute stroke
• Gains occur in motor impairments, with the larger increass in
strength occuring in patients who are not initially paralyzed
(Hendricks et al, 2002)
• Six months after a non-hemorrhagic stroke ± half of
patients have no significant motor impairment better
daily activities better functioning better quality of life
Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Table 1. Recovery of walking by impairment group

Recovery (%) after months

Impairment group Onset (%) 1 3 6
Motor 18 50 75 85
Sensorimotor 10 48 72 72
Motor, hemianopsia 7 28 68 75
Sensorimotor, 3 16 33 38
hemianopsia

Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 • Principles of recovery may be subsumed within three
general changes within the sensorimotor networks
(Dobkin, 2003):
• Restitution
• Subtitution
• Compensation
Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Restitution
• Restitution: relatively independent of external variables such
as physical and cognitive stimulation
• Includes biochemical and gene induced events for better
restoring the functionality of neural tissue, such as:
• reduction of edema
• absorption of heme
• restoration of ionic currents
• restoration of axonal transport

Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Substitution
• Depends on external stimuli such as practice with the affected
hemiparetic arm during rehabilitation
• Substitution includes the functional adaptation of diminished,
but partially restored, neural networks that compensate for
components lost or disrupted by the injury
• Substitution may proceed through partially spared neural
pathways, reorganizational plasticity in cortical representation for
movements, changes in activity in components of motor
network, and changes in synaptic efficacy
Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Compensation
• Aims to improve the mismatch between a patient’s impaired skills
and the demands of the patient or the environment
• Domains of compensation:
• Remediation: increase training to maintain/regain basic aspects of an affected
skill
• Behavioral subtitution: use a latent skill already in the patient’s repertoire or
develop a new skill that replaces the defective skills. e.g: ankle-foot orthosis
serves as a partial subtitute for the biochemical and physiological control of
ankle and knee
• Accomodation: adjust intention or select new goals. Walking may not be
feasible, so training in wheelchair becomes more important
• Asimiliation: adjust the expectations of others or modify the environment

Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Potential intrinsic biological mechanisms to lessen impairments
and disabilities;
Plasticity mechanisms (1)
• Network:
• Recovery of neuronal excitability: resolve cell and axon ionic dysequilibrium;
reverse edema, resorbs blood; reverse transynaptic diaschisis
• Activity in partially spared pathways
• Representational plasticity within neuronal assemblies
• Recruit a parallel network not ordinarilly activated by a task (e.g. unaffected
hemisphere or ipsilateral prefrontal cortex)
• Engage a subcomponent of a distributed network (e.g. A pattern generator for
stepping)
• Modulation of excitability by neurotransmitters (e.g. Serotonin, dopamine)
Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Potential intrinsic biological mechanisms to lessen impairments
and disabilities;
Plasticity mechanisms (2)
• Pre/postsynaptic:
• Modulate neuronal intracellular signaling for trophic function (e.g.
Neurotrophic factors, protein kinase)
• Alter synaptic plasticity (e.g. Modulate basal synaptic transmission, regulation
of number/types of receptor)
• Axonal and dendrittic collateral sprouting from uninjured neurons
• Axonal regeneration
• Remyelination
• Reverse conduction blocks; ion channel changes on axons
• Neurogenesis
Barnes, Michael. et al. Recovery after stroke. 2005
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 Axonal sprouting
• Stroke induce axonal sprouting in local intercortical connections
• Ischemic lesions induce long distance axonal sprouting, such as in the
collosal connections between cortical hemispheres and in crossed
corticostriatal projection these neurons (that give rise to this long
distance axonal sprouting) lie in the hemisphere opposite to the
lession, in the corresponding cortical region
• Stroke induces a wholesale remapping of the adjacent body map
• Axonal sprouting after stroke can be followed not only through
neuroanatomical remapping, but also through growth cone protein
expression that correlate with functional recovery
Barnes, Michael. et al. Recovery after stroke. 2005
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 Axonal sprouting

Source: Stephen MS. Regulating axon

growth within the postnatal central
nervous system, 2004
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 The effect of exercise practice on nerve system
• Repetitive, rewarded practice enhances long term potentiation at
many levels of the central nervous system for memory
• Mechanisms involved during practice:
• increase production of neurotransmitters; acetylcholine and serotonine,
• increases synthesis of neurotrophins; brain-derived neurotrophic factors
(BDNF) and neurotrophin-3
• lead to the proliferation and greater survial of hippocampal progenitor cells
• All mechanisms may be important for new learning and memory

Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 What styles of practice are best for an individual patient?
Styles of practice include the following:
• Blocked practice: all practice trials done consecutively (leaning the same
motor program)
• Variable or random practice: practice on one task is interrupted by practice
at other tasks, producing contextual interference (learning diferent
programs)
• Massed practice: continuous practice or with little rest
• Distributed practice: more rest compared to practice time
• Mental rehearsal: imagine doing a task
• Virtual reality: practice in a virtual environment

Rehabilitation training on a random schedule, is generally more effective for

long term retention of functional, skilled movements, rather than practice
with continuous repetition
Barnes, Michael. et al. Recovery after stroke. 2005

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 • Recovery of motor function after stroke involves relearning motor
skills and is mediated by neuroplasticity
• Although many molecular signaling pathways are involved, brain-
derived neurotrophic factor (BDNF) has emerged as a key facilitator
of neuroplasticity involved in motor learning and rehabilitation after
stroke
• Two potential poststroke rehabilitation strategies to increase BDNF:
the use of aerobic exercise and the incorporation of genetic
information to individualize therapy
• Mang CS. Promoting Neuroplasticity for Motor Rehabilitation After Stroke, December 2013
• Irawan, MD, PhD., Prof Guest lecture: Update on neuroscience research. Mei, 2017. IMERI FKUI

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Aerobic exercise effect on brain plasticity (1)
• Aerobic exercise enhance BDNF levels by inducing a cascade of events
that leads to increased BDNF gene expression in multiple regions of
the CNS (hippocampus, cerebellum, cerebral cortex, and spinal cord)
• A meta-analysis study involved aerobic exercise 3x/week at a
moderate intensity (ie, 70% maximum heart rate) increases cognitive
function, especially in the executive control domain, including
functions such as planning, scheduling, working memory, and
multitasking
Mang CS. Promoting Neuroplasticity for Motor Rehabilitation After Stroke, December 2013

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Aerobic exercise effect on brain plasticity (2)
• Aerobic exercise training not only improves poststroke cognitive function
but also enhances poststroke mobility, balance, and motor function
• Systemic levels of BDNF are increased for approximately 10 to 60 minutes
following aerobic exercise in humans
• BDNF transports across the blood-brain barrier and is released from the
brain into the periphery nerve during aerobic exercise
• A study by Quaney et al shows that participation in an 8-week aerobic
cycling program (70% maximum heart rate, 45 minutes, 3 times perweek)
improved within-session performance of a motor sequence task compared
with those who participated in an 8-week stretching program.
Mang CS. Promoting Neuroplasticity for Motor Rehabilitation After Stroke, December 2013
Quaney, BM, et al. Aerobic Exercise Improves Cognition & Motor Function Post Stroke, 2011
DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc
 Mang CS. Promoting Neuroplasticity for Motor Rehabilitation After Stroke, December 2013

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 • To induce large positive effects on cognitive function
and increase BDNF levels, exercise training studies
should use:
• aerobic exercise sessions of more than 30 minutes
• training intensities of approximately 70% heart rate
maximum
• a frequency of 4 days per week
• a combination of aerobic and resistance exercises.
• 1

Mang CS. Promoting Neuroplasticity for Motor Rehabilitation After Stroke, December 2013

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 Excercises for stroke patients at Department of Rehabilitation
Medicine, FK UI-RSCM, Jakarta

Mirror therapy Latihan berjalan pada horizontal platform Constraint induced

menggunakan body weight support movement therapy

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

 References
• Heart Disease and Stroke Statistics. Circulation, Feb. 2011
• Riskesdas 2013
• Relationship between Daily Activities using MSBI with Several Risk Factors in Stroke
Patients, 2016
• S, Irawan, MD, PhD., Prof Guest lecture: Update on neuroscience research, 2017
• BL Hart, LA Hart, N Pinter-Wollman, 2007
• Barnes, Michael. et al. Recovery after stroke. 2005
• Evidence based review for stroke rehabilitation, 2016
• Stephen MS. Regulating axon growth within the postnatal central nervous system, 2004
• Mang CS, et al. Promoting Neuroplasticity for Motor Rehabilitation After Stroke,
December 2013
• Quaney, BM, et al. Aerobic Exercise Improves Cognition & Motor Function Post Stroke,
2011

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc

DR. dr. Widjajalaksmi Kusumaningsih, SpKFR-K, MSc