Theoretical Foundations of Neurologic Rehabilitation

what is a THEORY

is a speculation, general idea + notion

- not directly testable

- abstract

what can a THEORY be used to generate

testable hypotheses

in principle, what are SCIENTIFIC THEORIES always classified as

tentative + subject to corrections/inclusions in a wider theory

what are 2 REASONS why we need THEORIES

1. framework for interpreting behavior

2. guide for clinical action

what are 2 CHARACTERISTICS that THEORIES should always be

1. changing

2. dynamic

what are the 3 MOTOR CONTROL THEORIES

1. reflex

2. hierarchical

3. systems

what is the REFLEX THEORY based on

classic experiments of Sir Charles Sherrington ("reduced" cat preparations)

what does the REFLEX THEORY state

all movements are based on simple reflexes + there's a stimulus that causes a response

what are 3 ASSUMPTIONS of the REFLEX THEORY

1. sensory inputs control motor outputs

2. sensation in necessary for movement

3. movement is a summation of reflexes

what are 3 LIMITATIONS of the REFLEX THEORY

1. de-afferented animals show coordinated movement

2. open-loop control demonstrated

3. anticipatory, feed-forward control

what is the CLINICAL IMPLICATIONS of the REFLEX THEORY

use of reflexes to facilitate movement

what is the HIERARCHICAL THEORY based on

top-down structure

regarding the HIERARCHICAL THEORY, what does TOP-DOWN STRUCTURE state

that the higher centers are always in charge of the lower centers

who was the key figure in proposing the HIERARCHICAL THEORY

Sir Hughlings Jackson (english neurologist)

what has the HIERARCHICAL THEORY formed a basis for

clinical neurology up to current

what are 4 ASSUMPTIONS of the HIERARCHICAL THEORY

1. central programs/reflexes control muscle activation patterns

2. organization is top down

3. motor control emerges from reflexes + nested in a hierarchy of levels in CNS

4. recovery from injury follows a pattern similar to child development

regarding the HIERARCHICAL THEORY assumptions, recovery from injury follows what PATTERN

follows step like pattern similar to CHILD DEVELOPMENT

what are 4 LIMITATIONS associated with the HIERARCHICAL THEORY

1. locomotion in spinal cats (low level of control)

2. central pattern generators (CPGs)

3. development not step like following CNS damage

4. blurred distinctions between voluntary + reflex

what do CENTRAL PATTERN GENERATORS (CPGs) generate

reciprocal movements linked to optimizing energy expenditure

where are CENTRAL PATTERN GENERATORS (CPGs) mainly located

in spinal cord

what are 2 CLINICAL IMPLICATIONS associated with the HIERARCHICAL THEORY

1. lesions disrupt high level control of lower level reflexes

2. goal: facilitate normal mature reflex action + inhibit more primitive reflexes

regarding the HIERARCHICAL THEORY, what is the THERAPY GOAL

facilitate normal mature reflex action + inhibit more primitive reflexes

what is the SYSTEMS THEORY of MOTOR CONTROL based on

task goals is the center of treatment + movements aren't solely controlled by a central command, but rather by interactions among multiple systems

who first proposed the SYSTEMS THEORY of MOTOR CONTROL in 1932

nicoli bernstein

what are 3 ASSUMPTIONS associated with the SYSTEMS THEORY of MOTOR CONTROL

1. adaptive anticipatory mechanisms

2. reflexes + synergies are normal strategies to limit degrees of freedom

3. interactive systems on same level control motor behavior to achieve task

what are 3 LIMITATIONS associated with the SYSTEMS THEORY of MOTOR CONTROL

1. lack of consensus on terminology + definitions

(dynamic action, distributed control + ecological theory)

2. difficult for scientific study

3. relation of neuroanatomy to systems unclear

what are 2 CLINICAL IMPLICATIONS associated with the SYSTEMS THEORY of MOTOR CONTROL

1. movement organized around behavioral goals

(e.g. weight shifting)

2. motor deficits following brain damage not only reflect lack of neural control but reflect best attempt by remaining system to accomplish task/goal

("abnormal" synergy hierarchical vs systems)

what is the purpose of using NEUROLOGIC REHABILITATION PHILOSOPHIES

to build frame work for treatment

what should NEUROLOGIC REHABILITATION PHILOSOPHIES be based on

latest research + scientific knowledge in many areas (i.e. motor)

what 5 AREAS should the NEUROLOGIC REHABILITATION PHILOSOPHIES be based on

1. motor control

2. motor learning

3. recovery of function

4. nervous system plasticity

5. psychology + sociology

what are 3 NEUROLOGIC REHABILITATION PHILOSOPHIES

1. muscle re-education

2. neurotherapeutic facilitation

3. contemporary task-oriented

who FIRST ADVOCATED for MUSCLE RE-EDUCATION

sister kenny

why did SISTER KENNY advocate for MUSCLE RE-EDUCATION

for treatment of poliomyelitis + felt patients would benefit from activity

what 2 MOTOR CONTROL THEORIES is MUSCLE RE-EDUCATION not really based on

1. hierarchical theory

2. reflex theory

PRIOR to MUSCLE RE-EDUCATION, what would the patients do

patients waited in bed to see what their outcomes would be

what is MUSCLE RE-EDUCATION based on

ISOLATED MUSCLE FUNCTION not systems model of motor control

what are the 4 THERAPEUTIC AIMS associated with MUSCLE RE-EDUCATION

1. isolate muscle actions by focusing on individual muscles

2. maximize strength + use of motor units remaining

3. teach functional activities

4. provide orthopedic support

what are 3 DISSATISFACTIONS associated with MUSCLE RE-EDUCATION

1. CNS plasticity not considered

2. can't isolate muscle action in upper motor neuron lesions

3. not lack of muscle activation but abnormal patterns often a problem

what 2 MOTOR CONTROL THEORIES is NEUROTHERAPEUTIC FACILITATION based on

1. reflex theory

2. hierarchical theory

who developed NEUROTHERAPEUTIC FACILITATION in the 1950s

therapists + physicians dissatisfied with muscle re-education model of rehab

what did the therapists + physicians who developed NEUROTHERAPEUTIC FACILITATION want

to affect nervous system itself rather than secondary effects of change to muscles + joints

what are the 4 THERAPEUTIC AIMS associated with NEUROTHERAPEUTIC FACILITATION

1. facilitate normal movement through proprioceptive input

2. modify CNS by allowing patient to experience "normal movement"

3. inhibit abnormal tone, primitive reflexes + synergies

4. don't allow CNS to learn abnormal patterns of movement

what are 4 DISSATISFACTIONS associated with NEUROTHERAPEUTIC FACILITATION

1. little functional carryover

2. patients passive recipients of therapy

3. doesn't look at biomechanical, musculoskeletal + environmental constraints

4. inhibiting abnormal reflexes doesn't necessarily allow normal movement

what is the NEWER THEORY of NEUROLOGIC REHABILITATION

contemporary task-oriented

what 3 MOTOR CONTROL THEORIES is CONTEMPORARY TASK-ORIENTED based on

1. reflex theory

2. hierarchical theory

3. systems model of motor control

what does CONTEMPORARY TASK-ORIENTED target (2)

1. peripheral nervous systems (musculoskeletal + environment)

2. central nervous system

what are 3 THERAPEUTIC AIMS associated with CONTEMPORARY TASK-ORIENTED

1. treatment centered around achievement of task/goal

2. "teach" problem solving skills (so adaptable to different contexts)

3. be aware of musculoskeletal + environmental factors

what are 4 DISSATISFACTIONS associated with CONTEMPORARY TASK-ORIENTED

1. no scientific consensus on definitions + terminology

2. requires cognitive processing by patient

3. hard to provide time consuming practice of skills

4. no specific techniques + requires creativity + thinking by therapist

what are 6 THERAPEUTIC TREATMENT APPROACHES

1. neuromuscular development treatment (NDT)

2. Brunnstrom

3. proprioceptive neuromuscular facilitation (PNF)

4. Rood

5. Johnstone

6. task-oriented

who developed the NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT)

karl + berta bobath

what 2 MOTOR CONTROL THEORIES is NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT) based on

1. reflex theory

2. hierarchical theory

what belief is the NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT) based on

"spasticity" is due to release of gamma system from higher control which releases abnormal reflexes

what are 9 TREATMENT EMPHASIS associated with NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT)

1. inhibit abnormal reflex patterns

2. special handling techniques used to facilitate movement patterns of higher control

3. avoid reinforcing abnormal movements

4. don't use associated reactions

5. treatment should be active + dynamic

6. need to establish righting + equilibrium reactions to allow foundation for normal movement

7. rotation is important to separate upper + lower trunk control

8. use sensory input to give patient a more normal sensation of movement

9. patient will learn midline only by moving in + out of it

what should the treatment be like for NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT)

active + dynamic

regarding NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT), what reflex patterns should be inhibited

abnormal reflex patterns

regarding NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT), what motion is important to separate upper + lower trunk control

rotation

regarding NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT), what will a patient learn

MIDLINE by moving in + out of it

regarding NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT), what needs to be established to allow foundation for normal movement

righting + equilibrium reactions

what 5 KEY TERMS is associated with NEUROMUSCULAR DEVELOPMENT TREATMENT (NDT)

1. inhibition

2. facilitation

3. reflex inhibiting postures

4. key points of control (clavicle + lower back)

5. trunk control

who developed BRUNNSTROM

signe brunnstrom

what 2 MOTOR CONTROL THEORIES is BRUNNSTROM based on

1. hierarchical theory

2. reflex theory

what belief is BRUNNSTROM based on

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

regarding BRUNNSTROM, what is the necessary MILESTONE for further recovery

synergistic movements

regarding BRUNNSTROM, what is considered the primitive spinal cord pattern

basic limb synergies

regarding BRUNNSTROM, what is EVALUATION + PROGRESS based on

six stages of recovery

what is STAGE 1 of RECOVERY regarding BRUNNSTROM

no volitional movement initiated (flaccid)

what is STAGE 2 of RECOVERY regarding BRUNNSTROM

appearance of basic limb synergy (beginning of spasticity)

what is STAGE 3 of RECOVERY regarding BRUNNSTROM

synergies are performed voluntarily (spasticity increases)

- get through most ROM in a synergistic pattern

what is STAGE 4 of RECOVERY regarding BRUNNSTROM

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

- isolate some movement out of synergies

what is STAGE 5 of RECOVERY regarding BRUNNSTROM

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

- more functional movements

what is STAGE 6 of RECOVERY regarding BRUNNSTROM

isolated joint movements are performed with coordination

what are 4 SYNERGY PATTERNS

1. upper extremity flexion

2. upper extremity extension

3. lower extremity flexion

4. lower extremity extension

what 2 SYNERGY PATTENS are UMN PROBLEMS dominated by

1. upper extremity flexion

2. lower extremity extension

what are the 2 STRONGEST SYNERGY PATTERNS

1. UE flexion

2. LE extension

what are 5 FLEXOR SYNERGIES of the UPPER EXTREMITY

1. retraction (of scapula)

2. external rotation

3. abduction

4. elbow flexion

5. supination

what is the WEAKEST UE FLEXOR SYNERGY PATTERN

abduction

what is the STRONGEST UE FLEXOR SYNERGY PATTERN

elbow flexion

what are 5 EXTENSION SYNERGIES of the UPPER EXTREMITY

1. protraction (of scapula)

2. internal rotation

3. adduction

4. elbow extension

5. pronation

what is the WEAKEST UE EXTENSOR SYNERGY PATTERN

elbow extension

what are the 2 STRONGEST UE EXTENSOR SYNERGY PATTERNS

1. adduction

2. pronation

what are 6 FLEXION SYNERGIES of the LOWER EXTREMITY

1. hip flexion

2. hip abduction

3. hip external rotation

4. knee flexion

5. ankle dorsiflexion/inversion

6. toe dorsiflexion

what is the STRONGEST LE FLEXION SYNERGY PATTERN

hip flexion

what are the 2 WEAKEST LE FLEXION SYNERGY PATTERNS

1. hip abduction

2. knee flexion

what are 5 EXTENSION SYNERGIES of the LOWER EXTREMITY

1. hip extension

2. hip adduction/internal rotation

3. knee extension

4. ankle plantarflexion/inversion

5. toe plantarflexion (great toe may extend)

what is the WEAKEST LE EXTENSION SYNERGY PATTERN

hip extension

what are the 2 STRONGEST LE EXTENSION SYNERGY PATTERNS

1. hip adduction/internal rotation

2. knee extension

what are the 6 TREATMENT EMPHASIS associated with BRUNNSTROM

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

2. limb synergies are necessary milestones for recovery

3. encourage + assist patient in using limb synergies + associated reactions initially then out of synergy

4. all patients will follow stage of recovery but may not attain all 6

5. functional training (bed mobility + transfers) should utilize associated reactions + limb synergies if needed early on

6. associated reaction can be elicited during treatment even if patient is flaccid

regarding the TREATMENT EMPHASIS for BRUNNSTROM, what should STRENGTH TESTING focus on

PATTERNS OF MOVEMENT rather than isolated joint motions

regarding the TREATMENT EMPHASIS for BRUNNSTROM, what is a necessary MILESTONE for RECOVERY

limb synergies

regarding the TREATMENT EMPHASIS for BRUNNSTROM, what is a patient ENCOURAGED + ASSISTED IN

using limb synergies + associated reactions initially then out of synergy

regarding the TREATMENT EMPHASIS for BRUNNSTROM, what will all PATIENTS FOLLOW

stages of recovery (but may not attain all 6)

regarding the TREATMENT EMPHASIS for BRUNNSTROM, what should FUNCTIONAL TRAINING utilize

associated reactions + limb synergies (if needed early on)

regarding the TREATMENT EMPHASIS for BRUNNSTROM, what can be ELICITED during treatment if a patient is FLACCID

associated reaction

what are 3 KEY TERMS associated with BRUNNSTROM

1. limb synergies

2. associated reactions

3. stages of recovery

who were the 3 INDIVIDUALS that developed PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)

1. kabat

2. knott

3. voss

what is PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF) based on

idea that stronger parts of body movements are used to facilitate the weaker parts

regarding PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF), what does NORMAL MOVEMENT + POSTURAL CONTROL rely on

balance between agonist + antagonist

regarding PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF), what is there GREAT EMPHASIS ON

manual contacts + proper hand positioning to stimulate proprioceptors

what are 6 TREATMENT EMPHASIS for PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)

1. use diagonal patterns of movement (rarely move in straight planes of motion)

2. techniques must have accurate timing, specific commands + correct hand placement

3. verbal commands must be short + concise

4. repetition is essential for motor learning

5. give greater resistance if trying to achieve stability

- less resistance for mobility

6. techniques should be used that cause irradiation of strength from stronger to weaker muscles

regarding TREATMENT EMPHASIS for PNF, what should be USED

diagonal patterns of movement

(as we rarely move in straight planes of motion)