#6 Treatment Methods in Neurological Rehabilitation

What are the motor control models?

1. Reflex

2. Hierarchical

3. Systems

What are the neurologic rehabilitation models?

1. Muscle reeducation

2. Neurotherapeutic facilitation

3. Contemporary task-oriented

What are the different frameworks of current neuro-rehabilitation interventions?

1. Restorative interventions

2. Compensatory interventions

3. Impairment specific interventions

4. Augmented interventions

When are augmented interventions most helpful?

For patients with lack of voluntary movement control

- Hands-on approach!

- Neuromuscular/sensory stimulation to 'jumpstart' recovery'

When are augmented interventions contraindicated?

Patient with active movements

What are examples of currently used augmented interventions?

1. Neurodevelopmental treatment (NDT)

2. Proprioceptive neuromuscular facilitation (PNF)

3. Sensory integration (SI)

What are the main concepts of NDT?

1. Handling techniques

2. Key points of control

3. Facilitation/inhibition via sensory stimuli: joint approximation/traction, tactile cueing

What are the main concepts of PNF?

1. Resistance

2. Quick/prolonged stretch

3. Joint approximation/traction

4. Tapping

What are the main concepts of SI?

1. Calming effect

2. Muscle facilitation

3. Muscle inhibition

What are examples of calming effect of SI?

1. Slow stroking

2. Constant pressure

3. Warmth

4. Slow vestibular stimulation

What are examples of muscle facilitation of SI?

1. Light touch

2. Quick stroking with ice

3. Rapid vestibular stimulation

What are examples of muscle inhibition of SI?

Prolonged cooling

What technique defined the term synergy (abnormal synergies)?

Brunnstorm techniques

What other concepts/reactions are from the Brunnstorm techniques?

1. "Six stages of recovery"

2. Homolateral synkinesis

3. Raimiste's phenomenon

4. Souque's phenomenon

What is homolateral synkinesis?

Flexion in involved UE facilitates flexion of involved LE

- Involuntary

What is Raimiste's phenomenon?

Resisted abd/add in unaffected side will result in abd/add on affected side

- Seen well with LE, not with UE

- Involuntary

What is Souque's phenomenon?

> 100 degrees of flexion in involved shoulder with elbow extension results in extension and abduction of fingers

- Seen well with UE

- Involuntary

What are Brunnstrom's 6 Stages of Recovery?

Historical model, we don't follow these anymore:

1. Patient is completely flaccid, no voluntary movement, pt confined to bed

2. Basic limb synergy develops, no voluntary movement, can be done as spasticity appears but is not marked

3. Basic limb synergy develops voluntary and is marked, spasticity is marked (stage of max spasticity)

4. Spasticity begins to decrease, certain movement combos deviate from basic limb synergies and become available

5. Relative independence of basic limb synergies, spasticity is waning, some isolated movements can be performed

6. There are isolated joint movements

What are the key concepts from Brunnstrom?

1. Practice synergy patterns early in CVA in order to develop combos of movement outside of synergy during later course of rehab

2. Focus on reflexes which provide the components of normal movement

3. Proprioceptive (resistive) and exteroceptive (tactile) stimulation are used to elicit reflexes in the recovering adult hemiplegic

*This concept has evolved and is not contemporary practice

What are the key concepts from NDT?

1. Handling and positioning

2. Key points of control (proximal to distal)

3. Facilitation and inhibition via proprioceptive and tactile input

4. Analysis of motor problems

5. Integration of motor learning principles

6. Functional activites

What are key concepts of PNF?

1. Stronger parts of body utilized to strengthen weaker body parts

2. Use of neuromuscular mechanisms that stimulate proprioceptors

What are the key principles of PNF?

1. Diagonal extremity patterns

2. Trunk and head patterns

3. Combined patterns

4. Overflow or irradiation

5. Manual contacts

6. Therapist positioning

7. Verbal commands

What are key techniques of PNF?

1. Rhythmic initiation

2. Reversal of antagonist

3. Timing for emphasis

4. Repeated stretch

5. Repeated contractions

6. Slow reversals

7. Rhythmic stabilization

8. Contract/relax and hold/relax

What are Rood's sensory modulation techniques for facilitation?

1. Tapping of muscle belly

2. Quick stretch

3. Joint compression/approximation

4. Quick ice

5. Resistance

6. Traction

7. Vibration of agonist

What are Rood's sensory modulation techniques for inhibition?

1. Deep pressure

2. Prolonged stretch

3. Warmth

4. Prolonged ice

5. Vibration of antagonist

What is sensory integration designed to treat?

Hyper and hyposensitivity

What is used in sensory integration?

- Sensory modalities: rocking, spinning, brushing, music to address different senses

- Used widely in treatment of autism (more effective in children vs adults)

What were major theories during the 1940s-1970s?

1. Neurological rehabilitation

2. Recovery of function

What were the major theories during the 1980s?

Understanding of neural, physical, and behavioral aspects of movement

- Motor control

- Motor learning

What is normal vs abnormal movement from an integrative approach?

1. Normal = performer + task + environment

2. Abnormal = ineffective interaction between one or more of the systems controlling movement

What is the abnormal movement pattern from an integration approach?

The performer's best solution for task performance (given the functional abilities remaining after damage and not just the result of the lesion itself)

What is task specific training?

Movement is organized around a behavioral goal and is constrained by the environment

- AKA task-oriented neurorehabilitation

With task specific training, how do patients learn?

By actively attempting to solve problems inherent in a functional task rather than repetitively practicing normal patterns of movement

What are concepts under task specific rehabilitation?

1. Motor re-learning

2. Recovery of function: produced by plastic reorganization of undamaged control centers (neural plasticity)

3. Clinical implications: recovery best produced by practice of purposeful, goal-oriented tasks that are meaningful to pt

*Approach AKA task specific functional training

What are motor learning strategies in the cognitive stage?

1. Establish a reference of correctness

2. Direct attention to critical tasks elements

3. Have patient verbalize at different times

4. Select appropriate feedback method

5. KR: focus on specific and few errors

6. KP focus on success

7. Positive reinforcement

What are motor learning strategies in the associated stage?

1. KP: intervene, stop when errors occur

2. KR: assist learner to improve self-evaluation and self-correction

3. Stress relevance to functional outcomes

4. Avoid excessive augmented feedback!

5. Facilitation techniques, guided movements may be counterproductive

What are motor learning strategies in the autonomous stage?

1. Emphasize decision-making skills

2. Only occasional feedback (KP/KR)

3. Stress consistency

4. Massed practice

5. Variable environment

6. Focus on return to home/work/community

7. Focus on competitive aspects of SKILLS

What are categories of developmental/functional motor skills?

1. Transitional mobility

2. Static postural control (stability task, static equilibrium, static balance)

3. Dynamic postural control (controlled mobility, dynamic equilibrium, dynamic balance)

4. Skill

How does functional training look in the clinic?

Detailed task analysis, essential elements within the task and context of environment

- Therapist selects activities and modifies task demands based on this analysis to determine the POC

What is function induced recovery?

Ability of NS to modify itself in response to changes in activity and environment

- Repetitive LEARNING behaviors

- Improvements in functional outcomes are correlated with observed changes in neural adaptations

What are examples of evidence-based function induced recovery examples?

1. Constraint-induced movement therapy (CMT)

2. Task specific gait training

What are task modification strategies?

1. Initially selected tasks for patient success and motivation

2. Tasks continually modified to increase level of difficulty

3. Tasks modified to promote adaptation of skills and learning

4. Tasks modified to promote independence

What is the paradigm shift for neuro rehab treatment methods?

Shift away from

1. Extensive hands-on approach

2. Prevention of substitution learning

3. Rest for recovery and healing

Therapist is now a training coach, structuring practice and providing appropriate challenge and feedback

- Helped prevent learned non-use and immobility effects

What is NDT, PNF, SI today?

NDT, PNF, SI ADAPTED programs to include current theories of nervous system

- "Living concepts" -- examining the research from the movement sciences as supporting evidence

- Goal = individual's independence and quality of life

What does PNF look like in the clinic today?

1. Functional evaluation of:

- Stability tasks (assuming position and holding position)

- Mobility tasks (mobility on stability and pure mobility)

2. Pattern assessment:

- ROM, strength of individual components

- Timing, coordination

- Tone, irradiation (to trunk or other extremities)

- Any associated reaction

3. Treatment outline

What is the general structure of a PNF treatment plan?

1. Beginning exercises

2. Transition exercises

3. Main exercises

4. Transition exercises

5. Functional exercises

What does NDT look like in the clinic today?

1. Increased emphasis on interactive systems (so movements instead of RIPs), but original emphasis on handling techniques, symmetrical posture still remains

2. Pattern assessment:

- ROM, strength of individual components

- Timing, coordination

- Tone, irradiation (to trunk or other extremities)

- Any associated reaction

What is the general structure of a NDT treatment plan?

1. Decrease abnormal tone

2. Develop postural control

3. Main exercise

4. Functional exercise

What are assumptions of a task specific approach?

1. There is potential for recovery after CNS lesion

2. Neuromuscular system organizes itself in the context of desired goals (hence functional tasks) rather than specific movement pattern

3. Neural control operates within the constraints of the msk system and physical laws of motion

4. Rehab is an active process

What does the task specific approach look like in the clinic today?

Assessment of movement is the key to planning interventions:

1. Initial condition

2. Preparation

3. Initiation

4. Execution

5. Termination

What is the general structure of a task-specific treatment plan?

1. Beginning exercises

2. Beginning preparation

3. Main exercises

4. Motor learning principles

5. Functional exercises

What does the current neurorehabilitation model include?

1. Restorative interventions

2. Compensatory interventions

3. Impairment specific interventions

4. Augmented interventions

*Emphasis now on training functional skills and promoting motor learning