Theoretical Foundations of Neurologic Rehabilitation

theory

a speculation, general idea or notion that is not directly testable; abstract but can be used to generate testable hypotheses; in principle, they are always tentative and subject to corrections or inclusion in a larger one

List the three motor control theories.

reflex, hierarchical, systems

reflex theory

motor control theory
based on "reduced" cat experiments of Charles Sherrington

reflex theory assumptions

sensory inputs control motor outputs
sensation is necessary for movement
movement is a summation of reflexes

reflex theory limitations

de-afferented animals show coordinated movement
open-loop control demonstrated (sherry glass adaptation, putting in contacts)
anticipatory, feed-forward control (anterior tibialis fires prior to heel strike)

reflex theory clinical implications

use of reflexes to facilitate movement
will this improve voluntary movement or control

hierarchial theory

motor control theory; findings of English neurologist Hughlings Jackson; has formed basis for clinical neurology today

hierarchical theory assumptions

central programs/reflexes control muscle activation patterns
organization is top down
motor control emerges from reflexes and nested in a hierarchy of levels in CNS
recovery from injury follows a step-like pattern similar to child development

hierarchical theory limitations

locomotion in spinal cats (low level of control)
central pattern generators
development not step-like following CNS damage
blurred distinctions between voluntary and reflex

hierarchical theory clinical implications

lesions disrupt high level control of lower level reflexes
goal of therapy to facilitate normal, mature reflex action and inhibiting more primitive reflexes

systems theory of motor control

motor control theory; first proposed in 1932 by Russian neurologist Nicoli Bernstein

systems theory of motor control assumptions

adaptive anticipatory mechanisms
reflexes and synergies are normal strategies to limit degrees of freedom
interactive systems on same level control motor behavior to achieve task

systems theory of motor control limitations

ack of consensus on terminology and definitions (dynamic action, distributed control, ecological theory)
difficult for scientific study
relation of neuroanatomy to systems unclear

systems theory of motor control clinical implications

movement organized around behavioral goals (ex: weight shifting)
motor deficits following brain damage not only reflect lack of neural control but also reflect the best attempt by remaining system to accomplish task or goal ("abnormal synergy hierarchical vs. systems)

neurologic rehabilitation philosophies

used to build frame work for treatment
should be based on latest research and scientific knowledge in many areas such as motor
motor control, motor learning, recovery of function, nervous system plasticity, psychology and sociology

muscle reeducation

neurologic rehabilitation philosophies; first advocated by Ssister Kenny for treatment of poliomyelitis; prior to this patient, waited in bed to see what outcome would be; she felt patients would benefit from activity; based on isolated muscle function not systems model of motor control

muscle reeducation therapeutic aims

isolate muscle actions by focusing on individual muscles
maximize strength and use of motor units remaining
teach functional activities
provide orthopedic support

muscle reeducation dissatisfactions

CNS plasticity not considered
cannot isolate muscle action in upper motor neuron lesions
not lack of muscle activation but abnormal patterns often a problem

neurotherapeutic facilitation

neurologic rehabilitation philosophies; developed by physicians dissatisfied with muscle reeducation model of rehab; wanted to affect nervous system itself rather than secondary effects of change to muscles and joints; based on Reflex and Hierarchical theory of motor control

neurotherapeutic facilitation therapeutic aims

facilitate normal movement through proprioceptive input
modify CNS by allowing patient to experience "normal movement"
inhibit abnormal tone, primitive reflexes, and synergies
do not allow CNS to learn abnormal patterns of movement

neurotherapeutic facilitation dissatisfactions

little functional carryover
patients passive recipients of therapy
does not look at biomechanical, musculoskeletal, and environmental constraints
inhibiting abnormal reflexes does not necessarily allow normal movement

contemporary task-oriented

neurologic rehabilitation philosophies; newer theory of neurologic rehab based on reflex, hierarchical, and systems model of motor control; targets both peripheral (musculoskeletal, environment) and CNS systems

contemporary task-oriented therapeutic aims

treatment centered around achievement of task or goal
"teach" problem-solving skills so patient can adapt to different contexts
be aware of musculoskeletal and environmental factors

contemporary task-oriented dissatisfactions

no scientific consensus on definitions terminology
requires cognitive processing by the patient
hard to provide time consuming practice of skills
no specific techniques, requires creativity and thinking by therapist

neuromuscular developmental treatment (NDT)

specific treatment approaches; developed by Karl and Bertha Bobath

What is NDT based on

reflex and hierarchical theories of motor control
"spasticity" is due to release of gamma system from higher control which releases abnormal reflexes

neuromuscular developmental treatment (NDT) treatment emphasis

inhibit abnormal reflex patterns
special handling techniques used to facilitate movement patterns of higher control
avoid reinforcing abnormal movements
do not use associated reactions
treatment should be active and dynamic
need to establish righting and equilibrium reactions to allow foundation for normal movement
rotation is important to separate upper and lower trunk control
use sensory input to give patient a more normal sensation of movement
patient will learn midline only by moving in and out of it

Brunnstrom

specific treatment approaches; based on hierarchical and reflex theories of motor control; based on belief that patients in early recovery from CVA should be assisted to gain use of limb synergy movement patterns; synergistic movements are necessary milestones for further recovery; basic limb synergies are primitive spinal cord patterns; evaluation and progress based on 6 stages of recovery

Brunnstrom stages of recovery; no volitional movement initiated (flaccid)

1

Brunnstrom stages of recovery; appearance of basic limb synergy (beginning of spasticity)

2

Brunnstrom stages of recovery; synergies are performed voluntarily (spasticity increases)

3

Brunnstrom stages of recovery; movement patterns no longer totally dictated by synergy (spasticity begins to decrease)

4

Brunnstrom stages of recovery; increased movement out of limb synergies (spasticity continues to decrease)

5

Brunnstrom stages of recovery; isolated joint movements are performed with coordination

6

UE flexion, LE extension

List the two strongest synergy patterns.

UE flexion synergy

retraction, ER, ABD, elbow flexion, supination

What is the weakest UE flexor synergy pattern?

ABD

What is the strongest UE flexor synergy pattern?

elbow flexion

UE extension synergy

protraction, IR, ADD, elbow extension, pronation

What is the weakest UE extensor synergy pattern?

elbow extension

What are the two strongest UE extensor synergy patterns?

ADD, pronation

LE flexion synergy

hip flexion, ABD, ER; knee flexion; ankle DF, inversion; toe flexion

What are the two weakest LE flexion synergy patterns?

hip ABD, knee flexion

What is the strongest LE flexion synergy pattern?

hip flexion

LE extension synergy

hip extension, ADD, IR; knee extension; ankle PF, inversion; toe PF (great toe may extend)

What is the weakest LE extension synergy pattern?

hip extension

What are the two strongest LE extensor synergy patterns?

hip ADD, IR; knee extension

Brunnstrom treatment emphasis

strength testing should focus on patterns of movement rather than isolated joint motions
limb synergies are necessary milestones for recovery
encourage/assist patient in using limb synergies and associated reactions initially then out of synergy
all patients will follow stages of recovery but not attain all 6
functional training such as bed mobility and transfers should utilize associated reactions and limb synergies if needed early on
associated reaction can be elicited during treatment even if patient is flaccid

proprioceptive neuromuscular facilitation (PNF)

specific treatment approaches; based on idea that stronger parts of the bodies movement are used to facilitate the weaker parts; normal movement and postural control relies on balance between agonist and antagonist; great emphasis on manual contacts and proper hand positioning to stimulate proprioceptors

proprioceptive neuromuscular facilitation (PNF) treatment emphasis

use diagonal patterns of movement as we rarely move in straight planes of motion
techniques must have accurate timing, specific commands and correct hand placement
verbal commands must be short and concise
repetition is essential for motor learning
give greater resistance if you are trying to achieve stability, less for mobility
techniques should be used that cause irradiation of strength from stronger to weaker muscles

rood

based on reflex and hierarchical motor control theories; all motor output is the result of both past and present sensory input, taking into account affect of ANS and emotion; introduced modes of sensory stimulation such as icing, brushing, neutral warmth, maintained pressure, and slow rhythmic stroking

rood treatment emphasis

use of sensory stim to achieve motor output
movement is considered automatic and non-cognitive
"heavy work"
"light work,"
tactile stim used to facilitate normal movement

heavy work

treatment emphasis of rood; exercise that occurs against gravity and/or resistance and is used for gaining control of postural muscles

light work

treatment emphasis of rood; used in the extremities without resistance and is used for gaining mobility and skilled movement

Johnstone

specific treatment approaches; based on Facilitation Theory of Neurorehabilitation

Johnstone treatment emphasis

used developmental sequence for treatment based on child development
inhibiting tone through positioning very important
developed air splints for decreasing tone and providing stabilization

task-oriented

specific treatment approaches; based on Task-Oriented Theory of Neurologic rehabilitation and systems theory of motor control; incorporates theories and research related to motor control, motor learning, and motor development;

task-oriented treatment emphasis

uses attainment of goal or task as motivation for treatment
more emphasis on "teaching" patients to solve motor problems as opposed to facilitating through hands on treatment techniques
takes into account environmental, biomechanical, and musculoskeletal factors better than the other approaches