Neuro I - Week 1 Lecture (Theoretical Foundations of Neurological Rehabilitation)

What are the 3 major motor control theories?

-reflex

-hierarchial

-systems

What is the reflex theory based on?

the classic experiments of Sir Charles Sherrington (“reduced” cat preparations)

What are the assumptions of the reflex theory?

-sensory inputs control motor outputs

-sensations is necessary for movement s

-movement is a summation of reflexes

Limitations of the reflex theory

-De-afferented animals show coordinated movement (no sensation in UEs example)

-open-loop control demonstrated (contacts example)

-anticipatory, feed-forward control (opening door example)

Clinical Implications of reflex theory

-use of reflexes to facilitate movement

-reflexes can enhance voluntary movement (ex. tapping on muscle you want them to use)

What is the hierarchical theory based on?

-English neurologist Sir Hughlings Jackson

-formed basis for clinical neurology up to today

What are the assumptions for the hierarchical theory?

-organization is top down

-central programs/reflexes control muscle activation patterns

-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 (start with easier things and work towards more difficult things)

What are the limitations of the hierearchal theory?

-locomotion in spinal cats (low level of control)

-central pattern generators

-development not step-like following CNS damage

-blurred distinctions between voluntary and reflex

clinical implications of hierarchical theory

-lesions disrupt high level control of lower level reflexes

-goal of therapy is to facilitate normal mature reflex action and inhibiting more primative reflexes

What is the systems theory based on?

-Russian neurologist Nicoli Bernstein (1932)

What are the assumptions of the 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 a task

What are synergies?

patterned, programmed movements our bodies use to reduce the amount of processing needed for each movement

What are the limitations of the systems theory?

-lack of consensus on terminology and definitions

-difficult for scientific study

-relation of neuroanatomy to systems unclear

what are the clinical implications of the systems theory?

-movement organized around behavioral goals (ex. weight shifting)

-motor deficits following brain damage not only reflex lack of neural control but also the best attempt by remaining system to accomplish task or goal

What are neurologic rehab philosophies influenced by?

Theories of motor control

What are neurologic rehab philosophies used to build?

framework for treatment

What are the 3 main neurologic rehab philosophies?

-muscle reeducation

-neurotherapeutic facilitation

-contemporary task oriented

Who came up with the muscle reeducation theory and why?

-Sister Kenny for the treatment of poliomyelitis

What did patients do prior to the muscle reeducation philosophy?

-waited in bed to see what outcome would be

What is the muscle reeducation philosophy based on?

isolated muscle function (NOT systems model of motor control)

Therapeutic aims of the muscle reeducation philosophy

-isolate muscle actions by focusing on individual muscles

-maximize strength and use of motor units remaining

-teach functional activities

provide orthopedic support

Dissatisfactions of muscle reeducation theory

-CNS plasticity not considered

-cannot isolate muscle action in UMN lesions

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

Why was the Neurotherapeutic facilitations philosophy developed?

-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 joint s

Which motor control theories is the neurotherapeutic facilitation philosophy based on?

-reflex and hierarchical

Therapeutic aims of neurotherapeutic facilitation philosophy

-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

Dissatisfactions of neurotherapeutic facilitation philosophy

-little function carryover

-patient passive recipients of therapy

-does not look at biomechanical, musculoskeletal, and environmental constraints

-inhibiting abnormal reflexes does not necessarily allow normal movement

What theories of motor control is the contemporary task-oriented philosophy based on?

-reflex, hierarchical, and systems theories

What does the contemporary task-oriented philosophy target?

-both peripheral (musculoskeletal environment) and Central (CNS) systems

Therapeutic aims of contemporary task-oriented philosophy

-treatment centered around achievement of task/goal

-”teach” problem solving skills (adaptable to diff contexts)

-be aware of musculoskeletal and environmental factors

Dissatisfactions of contemporary task-oriented philosophy

-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 therapists)

What are the specific treatment approaches?

-Neuromuscular Developmental Treatment (NDT)

-Brunnstrom

-Proprioceptive Neuromuscular Facilitation (PNF)

-Rood

-Johnstone

-Task-Oriented

What belief is NDT based on?

“spasticity” is due to release of the gamma system from higher control which released abnormal reflexes

What theories of motor control is NDT based on?

reflex and hierarchical theories

Treatment emphasis on NDT

-inhibit abnormal reflex patterns

-special handling techniques used to facilitate movement patterns of higher control

-avoid reinforcing abnormal movement s

-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 pt. a more normal sensation of movement

-patient will learn midline only by moving in and out of it

What theories of motor control is the Brunnstrom treatment approach based on?

hierarchical and reflex theories

what belief is the Brunnstrom treatment approach based on?

patients in early recovery from CVA should be assisted to gain use of limb synergy movement patterns

What type of movements are necessary mile stones for further recovery based on the Brunnstrom treatment approach?

synergistic movement

What are the 6 stages of recovery associated with the Brunnstrom treatment approach?

1- no volitional movement associated

2- appearance of basic limb synergy (beginning of spasticity)

3-synergies are performed voluntarily (spasticity increases)

4-movement patterns no longer totally dictated by synergy (spasticity begins to decrease)

5- increased movement out of limb synergies (spasticity continues to decrease)

6- isolated joint movements are performed with coordination

What type of patterns are basic limb synergies? (Brunnstrom)

primitive spinal cord patterns

What are the 4 synergy patterns?

-upper extremity flexion

-upper extremity extension

-lower extremity flexion

-lower extremity extension

What is the flexor synergy pattern of the upper extremity (5)

-retraction

-ER

-abduction (weak)

-elbow flexion (strong)

-supination

What is the extension synergy pattern of the upper extremity?

-protraction

-IR

-adduction (strong)

-elbow extension (weak)

-pronation (strong)

What is the flexion synergy pattern of the lower extremity?

-hip flexion (strong)

-hip abduction (weak)

-Hip ER

-knee flexion (weak)

-dorsiflexion with inversion of ankle

-dorsiflexion of toes

Extension synergy pattern of lower extremity

-hip extension (weak)

-adduction/IR of the hip (strong)

-knee extension (strong)

-plantar flexion/inversion of ankle

-plantar flexion of toes (great toe may extend)

Which synergy patterns are seen most often?

-upper extremity flexion

-lower extremity extension

Treatment emphasis on Brunnstrom treatment approach

-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 patients will follow the stages of recovery but may not obtain 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 pt. is flaccid

What idea is the proprioceptive neuromuscular facilitation (PNF) treatment approach based on on?

stronger parts of the bodies movement are used to facilitate the weaker parts

What does normal movement and postural control rely on based on the PNF treatment approach?

balance between agonists and antagonists

What does the PNF treatment approach put great emphasis on?

manual contacts and proper hand positioning to stimulate proprioceptors

Treatment emphasis on the PNF treatment approach

-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

What control theories of movement is the Rood treatment approach based on?

-reflex and hierarchical motor control theories

What did the Rood treatment approach introduce?

modes of sensory stim

(icing and brushing, neutral warmth, maintained pressure, and slow rhythmic stroking)

What does the Rood treatment approach take into account?

affect of autonomic nervous system and emotion

What is all motor output the result of based on the Rood treatment approach?

both past and present sensory input

Treatment emphasis on the Rood treatment approach

-use of sensory stim to achieve motor output

-movement is considered automatic and non-cognitive

-”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

What is the Johnstone treatment based on?

facilitation theory of neurorehabilitation

Treatment emphasis on Johnstone treatment approach

-uses developmental sequence for treatment based on child development

-inhibiting tone through positioning is very important

-developed air splints for decreasing tone and providing stabilization

What does the task-oriented treatment approach incorporate?

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

What is the task-oriented treatment approach based on on?

task-oriented theory of neurologic rehab and systems theory of motor control

Treatment emphasis on task-oriented treatment approach

-uses attainment of goal/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