Theoretical Foundations of Neurologic Rehabilitation

theory

- speculation, general idea, notion

- not directly testable

motor control theories

- reflex

- hierarchical

- systems

reflex theory

based on the classic experiments of Sir Sherrington

assumptions of reflex theory

- sensory inputs control motor outputs

- sensation is necessary for movement

- movement is a summation of reflexes

limitations of reflex theory

- de-afferented animals show coordinated movement

- open loop control demonstrated

- anticipatory, feed forward control

clinical implications of reflex theory

- use of reflexes to facilitate movement

hierarchical theory

- english neurologist Sir Hughlings Jackson

- has formed basis for clinical neurology up to today

assumptions of hierarchical theory

- 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

limitations of hierarchical theory

- locomotion in spinal cats

- central pattern generators

- development not step like following CNS damage

- blurred distinctions between voluntary and reflex

clinical implications for hierarchical theory

- 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

- first proposed in 1932 by Russian neurologist Nicoli Bernstein, not translated until 1967

- what we use today

assumptions of systems theory

- 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

limitations to systems theory

- lack of consensus on terminology and definitions

- difficult for scientific study

- relation of neuroanatomy to systems unclear

clinical implications for systems theory

- movement organized around behavioral goals

- 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

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

- not really based on hierarchical or reflex theories

- prior to this patient waited in bed to see what their outcome would be

- felt patients would benefit from activity

- based on isolated muscle function not systems model or motor control

therapeutic aims of muscle reeducation

- isolate muscle actions by focusing on individual muscles

- maximize strength and use of motor units remaining

- teach strength and use of motor units remaining

- teach functional activities

- provide orthopedic support

dissatisifactions of muscle reeducation

- cns plasticity is not considered

- cannot isolate muscle action in UMN lesions

- not lack of muscle activation but abnormal patterns often a problem

neurotherapeutic facilitation

- 1950's developed therapists and 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

therapeutic aims of neurotherapeutic facilitaion

- facilitate normal movement through proprioceptive input

- modify CNS by allowing patient to experience "normal movement"

- do not allow CNS to learn abnormal patterns of movement

dissatisfactions of neurotherapeutic facilitation

- 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 theory

- newer theory of neuro rehab based on reflex, hierarchical and systems model of motor control

- targets both peripheral and central systems

therapeutic aims of contemporary task oriented theory

- treatment centered around achievement of task or goal

- "teach" problem solving skills

- be aware of musculoskeletal and environmental factors

dissatisfactions of contemporary task-oriented theory

- no scientific consensus on definitions and 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

- developed by Karl and Berta Bobath

- based on reflex and hierarchical theories of motor control

- based on the belief that "spasticity" is due to release of the gamma system from higher control which releases abnormal reflexes

treatment emphasis of neuromuscular developmental treatment

- 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

key terminology for neuromuscular development treatment

- inhibition

- facilitation

- reflex inhibiting postures

- key points of control

- trunk control

brunnstrom

- developed by signe brunnstrom

- 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 mile stones for further recovery

- basic limb synergies are primitive spinal cord patterns

- evaluation and progress based on six stages of recovery

stages of recovery

6

stage 1 recovery

no volitional movement initiated

stage 2 recovery

- appearance of basic limb synergy

- beginning spasticity

stage 3 recovery

- synergies are performed voluntarily

- spasticity increases

stage 4 recovery

- movement patterns no longer totally dictated by synergy

- spasticity tends to decrease

stage 5 recovery

- increased movement out of limb synergies

- spasticity continues to decrease

stage 6 recovery

isolated joint movements are performed with coordination

synergy patterns

- UE flexion

- UE extension

- LE flexion

- LE extension

most common synergy patters

- UE flexion

- LE extension

flexor synergy of UE

- retraction of scap

- ER

- abduction: weak

- elbow flexion: strong

- supination (will pronate bc of gravity but will actively try to supinate)

extension synergy of UE

- protraction of scap

- IR

- adduction: strong

- elbow extension: weak

- pronation strong

flexion synergy of LE

- hip flexion: strong

- hip abduction: weak

- hip ER

- knee flexion: weak

- dorsiflexion/inversion of ankle

- dorsiflexion of toes

extension synergy of LE

- hip extension: weak

- add/IR of hip: strong

- knee extension: strong

- plantar flexion/ inversion of ankle

- plantar flexion of toes

treatment emphasis of brunnstrom

- strength testing should focus on patterns of movement rather than isolated joint motions

- limb synergies are necessary milestones for recovery

- encourage and assist patient in using limb synergies and associated reactions initially then out of synergy

- all patient will follow the stages of recovery by may 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

key terminology of brunnstrom

- limb synergies

- associated reactions

- stages of recovery

proprioceptive neuromuscular facilitation

- developed by Kabat, Knott, and Voss in California

- based on the 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

treatment emphasis of PNF

- 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 movement

key terminology of PNF

- overflow/irradiation

- D1, D2

- rhythmic initiation/stabilization

- slow reversal

- hold relax

- timing for emphasis

- normal timing

rood (margaret rood)

- based on reflex and hierarchical motor control theories

- all motor output is the result of both past and present sensory input

- takes into account affect of autonomic nervous system and emotion

- introduced modes of sensory stim such as icing, brushing, neutral warmth, maintained pressure and slow rhythmic stroking

treatment emphasis of rood

- use of sensory stim to achieve motor output

- movement is considered automatic and noncognitive

- "heavy work" is exercise that occurs against gravity and/or resistance and is used for gaining control of postural muscles

- "light work" is used in the extremities without resistance and is used for gaining mobility and skilled movement

- tactile stim used to facilitate normal movement

key terminology for rood

- sensory stimulation

- heavy work

- light work

johnstone

- developed by margaret johnstone

- based on facilitation theory of neurorehabilitation

treatment emphasis of johnstone

- uses developmental sequence for treatment based on child development

- inhibiting tone through positioning very important

- developed air splints for decreasing tone and providing stabilization

key terminology for johnstone

- air splints

- developmental sequence

- tone inhibiting postures

task-oriented

- carr and sheppard from australia 1987

- based on task-orientation theory of neurologic rehabilitation and systems theory of motor control

- incorporates theories and research related to motor control, motor learning, and motor development

treatment emphasis of motor-control

- uses attainment of goal or task as motivation for 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 environment, biomechanical, and musculoskeletal factors better than the other approaches

key terminology for task-oriented

- motor learning

- motor control

- motor development

- goal directed

contemporary neurological rehabilitation

any intervention that uses the best available evidence to improve physical function through: physical skill and functional performance, muscle performance, cardiorespiratory function, balance and postural control