Neurological Physiotherapy Practice - Week 1

Introduction to Neurological Physiotherapy

Conceptual Frameworks and Guiding Principles

• Neuroplasticity: The brain's ability to reorganize itself by forming new neural connections throughout life. This allows the brain to compensate for injury and adjust to new situations or changes in the environment.
• WHO ICF Framework: A framework by the World Health Organization that provides a standard language and framework for the description of health and health-related states. It emphasizes functioning and participation in life roles.
• Motor Control: How the central nervous system organizes movement.
• Skill Acquisition/Motor Learning: The process of acquiring and refining motor skills through practice and feedback.
• Retraining of Functional Movement: Focuses on restoring or compensating for lost motor function to improve the ability to perform everyday tasks.

Example: Stroke

• The condition of stroke will be used to provide examples of how these frameworks and guidelines can be applied in practice.

Presumed Prior Knowledge

• Anatomy and Neuroanatomy
• Biomechanics of Normal Movement (especially gait)
• Normal Human Development
• Pathophysiology
• Pharmacology
• Physiotherapy skills (assessment of active/passive range of motion, strength, muscle length, exercise prescription)
• Familiarity with the WHO ICF framework

History of Neurological Physiotherapy

• Prominence grew with the Polio epidemics in the 1950s.
• Developed alongside the understanding of the central nervous system's role in controlling movement.

Early Approaches (1940s)

• Sensory Input for Motor Output: Using sensory input to improve motor output.
• Bobath Approach: Focuses on facilitation, inhibition, and stimulation through handling to influence postural tone and activity. Still used today with further development.
• Brunnstrom Approach: Based on the idea that reflexes are a basic stage of development and that the central nervous system reverts to this level after injury. Focuses on using these reflexes to enhance movement.
• Margaret Rood Approach: Based on the reflex and hierarchical model, therapeutic exercises are enhanced by cutaneous stimulation and extra receptive techniques like brushing to facilitate or inhibit activity.
• Proprioceptive Neuromuscular Facilitation (PNF): Developed by Hermann Kabat, utilizes agonist and antagonist muscle work with reflexive movement as its basis for learning volitional movement. Focuses on mass diagonal movement patterns. Uses a multi-sensory approach (auditory, visual, tactile).

Modern Approaches

• Models from Psychology and Sports Training: Focus on motor control, motor learning, and repetitive task practice.
• Carr and Sheppard's Motor Relearning Approach: A movement science-based and task-oriented approach. Focuses on practicing functional tasks, with practice being key to success.

Common Approaches in Clinics

• Bobath Approach
• Skill Acquisition/Functional Task Practice
• PNF (to some extent)

Key Takeaway for Students

• Understand the theoretical basis of therapeutic techniques, regardless of what the therapy is called. This will allow for logical, evidence-based application and modification of techniques to suit the individual patient.

Defining Neurological Rehabilitation

• WHO Definition: A process that assists individuals with disability to maintain or regain optimal function and health in interaction with their environment.
• Carr and Sheppard's Description: Enabling people with neurological injuries to function effectively by regaining optimal motor performance towards independence in critical tasks.

Key Aspects

• Individuals (patient, family, carers)
• Neurological illness or injury affecting the nervous system
• Assistance to regain, maintain, or enhance function and participation
• Active partnership between patient, family, and healthcare professionals

Importance of a Conceptual Framework

• Interventions must be guided by theory and theoretical assumptions.
• Allows for hypothesis generation and assessment.
• Beliefs influence care, and evidence should inform these beliefs.
• Evidence changes, so beliefs must be reviewed and challenged.
• Personal preferences should be guided by clinical guidelines and evidence, but also rationalized by clinical experience.
• Few absolutes in neurological rehabilitation; patients are not one-size-fits-all.
• Framework ensures a holistic, patient-centered approach.

Reasons to Use a Conceptual Framework

• Facilitate evidence-based practice.
• Help develop new interventions and initiatives.

Lennon and Basil's 10 Guiding Principles (Chapter 1 of Textbook)

1. WHO International Classification of Functioning, Disability and Health (ICF framework)
2. Teamwork
3. Patient-Centered Care
4. Prediction
5. Neuroplasticity
6. Systems Model of Motor Control
7. Functional Movement Reeducation
8. Skill Acquisition
9. Self-Management/Self-Efficacy
10. Health Promotion and Prevention

1. WHO ICF Framework

• Developed in 2001
• Focuses on functioning and participation, not just disability and impairment.
• Describes a person's level of function within their environment.
• Systematic way of considering ability and disability as an interaction of health condition and contextual factors.
• Important for assessment and management of neurological conditions.
• Enhances clinical reasoning by facilitating assessment, goal setting, intervention selection, and outcome measurement.

Five Categories:

1. Body Functions and Structures: Anatomical structures and systems and how they function. Negative aspect is impairments.
2. Activities: Tasks a person completes. Negative aspect is activity limitations.
3. Participation: Broader areas of life within society. Negative aspect is participation restrictions.
4. Environmental Factors: External factors that affect functioning.
5. Personal Factors: Internal factors such as age, gender, culture.

Example: Stroke

• Health Condition: Stroke.
• Body Structures and Functions: Muscle weakness (impairment).
• Activity: Difficulty walking.
• Participation: Restriction in walking to the shops.
• Environmental/Personal Factors: Home environment, support, age, health literacy, culture.

2. Teamwork

• Collaboration between healthcare workers, patient, family.
• Multidisciplinary (sharing discipline-specific information) or interdisciplinary (collaborative assessment, communication, decision-making).
• Collaborative goal setting is essential.
• Organized stroke unit care leads to preferential outcomes.

Goal Setting

• Motivates the team and patient.
• Considers patient wishes, priorities, values, and expectations.
• Written and shared with the patient.

Facilitators of Goal Setting

• Early, frequent communication with the patient and family
• Tailoring the goal setting process
• Effective and encouraging staff
• Education of patients and families
• Supporting educational material
• Adequate resources

Barriers to Goal Setting

• Mismatch between patient and staff perspectives
• Staff lacking confidence to manage patient expectations
• Patient-related impairments (cognition, communication)
• Insufficient time
• Ineffective organizational systems

3. Patient-Centered Care

• Partnership between patient, carer/family, and healthcare team.
• Shared decision-making.

Characteristics of Person-Centered Care

• Respect for clients' values, priorities, and perspectives.
• Respect for their rights to autonomy and choice.
• Equalizing power (avoiding top-down approach).
• Client-oriented information for informed choices.
• Enabling clients to identify priorities, needs, and goals.
• Facilitating their participation in the rehabilitation process.
• Striving for collaboration and partnership in achieving client goals.
• Individualizing service delivery.
• Assessing outcomes that matter to the client.
• Ensuring service provision is useful and relevant.

4. Prediction

• Prediction and discharge planning start from the first encounter.
• Knowledge of prediction literature aids in providing an evidence base.
• Awareness of prediction literature allows for realistic information sharing.
• Outcome measures can provide objective means of predicting discharge destinations.
• Biopsychosocial factors play a significant role.
• Always maintain hope.

Examples (Stroke)

• Shoulder abduction and finger extension predict good arm recovery.
• Early static sitting is linked to ambulation recovery.
• Leg strength and mobility predict quality of life.
• Barthel Index Score at six months after stroke
• Total Trunk Impairment Score

5. Neuroplasticity

• The capacity of the nervous system to modify itself functionally and structurally in response to experience or injury.
• Forms the basis of neurophysiotherapy and rehabilitation.
• Potential to improve movement by making demands on the system.
• Not all neuroplasticity is helpful (adaptive vs. maladaptive).

Priming

• Actions to prepare the motor system (sensory stimulus, environmental stimulus, mental imagery).

Aerobic Exercise

• Enhances neuroplasticity due to increased blood flow to nerve cells.

Kleeman & Jones (2008) - 10 Principles of Experience-Dependent Neuroplasticity

1. Use it or Lose it: Failure to drive specific brain functions leads to functional degradation.
2. Use it and Improve it: Training that drives a specific brain function can enhance that function.
3. Specificity: The nature of the training experience dictates the nature of the plasticity. If we practice swimming, we get better at swimming, but not running.
4. Repetition Matters: Induction of plasticity requires sufficient repetition or dosage.
5. Intensity Matters: Induction of plasticity requires sufficient training intensity.
6. Time Matters: Different forms of plasticity occur at different times during training. Early rehab may be more effective.
7. Salience Matters: The training experience must be sufficiently important or meaningful to induce plasticity.
8. Age Matters: Training-induced plasticity occurs more readily in younger brains.
9. Transference: Plasticity in one set of neuronal circuits can promote concurrent or subsequent plasticity.
10. Interference: Not all plasticity is beneficial. Plasticity in one neural circuit can impede the induction of new plasticity in the same circuit (e.g., learning non-use of an affected arm).

6. Motor Control

• How the nervous system interacts with the body and environment to produce movements.
• Systems Model: Movement solution changes based on the interaction between the individual, task, and environment.
• Multiple neural systems work in hierarchies and parallel.
• Therapy focusing on functional and task-specific actions is important.
• Changes to the individual's resources (cognitive, sensory, action systems) affect movement control.
• Compensatory strategies can be detrimental (e.g., hiking at the shoulder to achieve arm elevation can lead to impingement).
• Therapy to restore systems and resources will improve motor control.

7. Retraining of Functional Movement

• Focuses on restoring normal function and optimizing movement.
• Return to function is influenced by the nature of the condition, constraints imposed by the disease process, type/degree/number of impairments.
• Adjustments to task completion may be needed (assistive devices).
• Therapy may focus on maintaining function or preventing complications.

RAMP Acronym

• Restore: Recovery (potential for normal functional movement).
• Adaptation/Compensation: Alternate movement strategies or equipment use (avoiding detrimental compensations).
• Maintenance: Maximizing independence and minimizing reduction in activity/participation.
• Prevention: Preventing complications (contracture, swelling, injury, disuse atrophy).

Example: Stroke

• Range of techniques may be used to provide the aims of RAMP.

Stroke Foundation Clinical Guidelines

• A "living document" with constantly updated information.

8. Skill Acquisition

• Uses evidence from motor learning.
• Important principles: amount of practice, specificity of training, transfer of training, feedback, modeling/demonstration, and mental practice.

Stroke Foundation Guidelines

• Strong recommendations for providing a large amount of therapy (2-3 hours per day).

9. Self-Efficacy/Self-Management

• Neurologic physiotherapy: training an athlete model and providing them with the resources, skills and knowledge also doing activities for themselves rather than a doing to patients model.
• Self-efficacy: belief about the capability to influence events that affect one's own life.
• Self-management: skills, knowledge, and confidence to undertake tasks to manage one's own health and healthcare needs safely and effectively.
• Self-efficacy is related to better health, higher achievement, more social integration, and higher motivation to act.
• Self-efficacy is correlated with adherence to therapy.
• Focus on how to promote self-efficacy and enhance patients' self-management skills.

10. Prevention and Health Promotion

Three Kinds of Prevention

1. Primary Prevention: Preventing disease onset (good nutrition, exercise).
2. Secondary Prevention: Stopping or slowing disease progression after onset.
3. Tertiary Prevention: Reducing impairments and activity limitations.

Physiotherapists Role

• Physiotherapists mostly deal with secondary and tertiary prevention.

Stroke Foundation Guidelines

• Secondary prevention includes medically related interventions and lifestyle modifications (diet, physical activity, obesity, smoking, alcohol).