Neurological Physiotherapy Practice Week 1-11 Notes

Neurological Physiotherapy Practice Week 1: Intro & Background Principles

• Acknowledging the Kaurna people as the original custodians of the Adelaide Plains.

• Lecture aims:

  • Familiarity with conceptual frameworks and guiding principles for neurological physiotherapy and rehabilitation.

  • Understanding the application of these frameworks to stroke management.

Assumed Prior Knowledge

• Anatomy and Neuroanatomy.

• Biomechanics of Normal Movement (Gait).

• Normal Human Development.

• Pathophysiology.

• Pharmacology.

• Physiotherapy skills (assessment AROM/PROM, strength, muscle length, exercise prescription).

• WHO Classification of Function (ICF).

Neurological Physiotherapy – History

• Neurodevelopmental (Bobath) Approach:

  • Developed in 1940-50s by Karel (Neurophysiologist) and Berta (Physiotherapist) Bobath.

  • Uses facilitation, inhibition and stimulation through handling techniques to influence postural tone.

• Brunnstrom Approach:

  • Developed in 1940s by Signe Brunnstrom (Swedish Physiotherapist).

  • Reflexes should be used; the CNS reverts to an earlier stage of development due to brain damage.

• Sensorimotor (Rood) Approach:

  • Developed in the early 1950s by Margaret Rood (OT/PT).

  • Motor function is directly related to sensory mechanisms. Uses sensory stimulation/facilitation.

• Proprioceptive Neuromuscular Facilitation (PNF):

  • Developed in 1940s by Herman Kabat (American Neurophysiologist).

  • Uses proprioceptive, cutaneous and auditory input to improve gross movement in “functional” directions.

• Motor Relearning (Optimising Skill Acquisition) Approach:

  • Developed in 1980s by Janet Carr and Roberta Shepherd (Australian Physiotherapists).

  • Focus on practice of specific task-related activities. Move away from “neurofacilitation”.

What is Rehabilitation and Neurological PT?

• World Health Organisation – Definition of Neurological Rehabilitation (WHO, 2017):

  • Rehabilitation is a set of measures that assist individuals to achieve and maintain optimal functioning.

• Carr and Shepherd (2010):

  • Neurorehabilitation enables individuals with brain lesions to function effectively by regaining optimal motor performance.

  • Includes Individual (person, family, carers), Injury/illness, and Regain/maintain/enhance function - participation

Conceptual Framework to Guide Neuro PT

• Understanding the concepts guides practice and facilitates evidence-based interventions.

• Permits tailored interventions for individual patients.

• Provides a structure for the logical development of treatment strategies.

Conceptual Framework - Guiding Principles

1. WHO International Classification of Functioning, Disability and Health (ICF).

2. Team Work + Shared Goal Setting.

3. Patient Centred Care.

4. Prediction.

5. Neural Plasticity.

6. Systems model of motor control.

7. Retraining functional movement.

8. Skill acquisition/motor learning.

9. Self-efficacy/management.

10. Prevention – Promoting health.

    • (Lennon, 2018, Figure 1.2, page 5)

Guiding Principle 1: ICF Framework

• The WHO ICF has been accepted as a universal framework for describing neurological functioning and disability.

• Provides a systematic way of understanding the multiple levels at which patients may experience problems.

• 5 Categories:

  • Body Functions and Structures.

  • Activities.

  • Participation.

  • Environmental Factors.

  • Personal Factors.

  • Interactions are bi-directional.

Guiding Principles – ICF Health Condition: Stroke

• Stroke and the ICF

  • Anatomical Parts and Function  Impairment (Weakness).

  • Activities performed by Person  Limitation (Poor walking).

  • Participation in Life Roles  Restriction (Walk to Shop).

  • Environmental factors (Home with multiple steps, aids or equipment).

  • Personal Factors (Gender, Age, Culture, Education, etc).

Guiding Principles 2: Teamwork

• Teamwork should involve:

  • Patient.

  • Family.

  • Health/Social Care Professionals.

• Teams can be Multidisciplinary or Interdisciplinary.

• Team / collaborative goal-setting is a core component of neuro-rehabilitation.

• Stroke Foundation Guidelines.

Guiding Principles 2: Teamwork + Goals

• Facilitators of goal-setting:

  • Early, frequent, active communication with patient and family.

  • Individually tailoring the goal-setting process.

  • Effective, confident and encouraging staff.

  • Education of patients and families.

  • Provision of supporting, educational materials.

  • Adequate resources.

• Barriers to goal-setting:

  • A mismatch between patients’ and staff’s perspective.

  • Staff lack of confidence to manage patient expectations.

  • Patients’ stroke related impairments.

  • Insufficient time and ineffective organizational systems.

Guiding Principles 3: Patient Centred Care

• A partnership-based approach with shared decision-making.

• Team discussion with patient/family/carer regarding treatment options leads to their choice.

Guiding Principles 4: Prediction

• Discharge and future planning must begin at the first meeting.

• Avoid prediction bias by using predictors that are evidence-based.

• Allows the therapist to be realistic with patient and carers.

• Outcome measure (OM) scores are strong predictors of discharge destination among patients with stroke.

• OM provide an objective means of early discharge planning.

• Discharge decisions should consider patient-specific biopsychosocial factors.

Guiding Principles 4: Prediction in Stroke

• G/h Abd and digit Extension  better arm recovery.

• Early static sitting  ambulation recovery.

• Paretic LL strength and mobility are predictors of physical health-related quality of life.

• Faster mobility, lower age, and comorbidities predicted better social integration.

• Poor recovery of strength and mobility affects community reintegration poststroke.

Guiding Principles 5: Neural Plasticity

• Neural Plasticity: “The capacity of the nervous system to modify itself, functionally and structurally, in response to experience and injury.”

• A key component of neural development and normal functioning of the nervous system.

• Not all neural plasticity is helpful:

  • Adaptive – improvements in outcome (not compensation).

  • Mal-adaptive – negative outcome (persistent pain, spasticity).

• Priming can lead to a greater neuroplastic response – preparing the motor system.

• Aerobic exercise enhances neuroplasticity.

10 Principles of Experience-Dependent Plasticity

1. Use It or Lose It: Failure to drive specific brain functions can lead to functional degradation.

2. Use It and Improve It: Training that drives a specific brain function can lead to an enhancement of that function. competitive plasticity

3. Specificity: The nature of the training experience dictates the nature of the plasticity.

4. Repetition Matters: Induction of plasticity requires sufficient repetition/dosage.

5. Intensity Matters: Induction of plasticity requires sufficient training intensity.

6. Time Matters: Different forms of plasticity occur at different times during training. Initiate rehab early.

7. Salience Matters: The training experience must be sufficiently salient to induce plasticity.

8. Age Matters: Training-induced plasticity occurs more readily in younger brains.

9. Transference: Plasticity in one set of neuronal circuits promotes concurrent/subsequent plasticity.

10. Interference: Plasticity in one neural circuit can impede the induction of new plasticity in the same circuit.

Guiding Principles 6: Motor Control

• Systems Model of Motor Control:

  • A field that explores how the NS interacts with the body, task and environment to produce movement.

  • Dynamic systems model suggests that the solution varies according to individual, task, and environment.

• The systems model predicts that changes to individual resources due to stroke will affect movement control.

• May involve compensatory strategies, which solve immediate problems but aren't ideal long-term.

• Working to improve individual resources will improve movement control.

• Therapy may involve altering the environment and/or task characteristics.

Guiding Principles 7: Retraining Functional Movement

• Aims of Neurological Physiotherapy (RAMP):

  • Restore “normal” functional movement - Ideal.

  • Adapt (Compensate).

  • Maintain – especially in degenerative disorders or with normal ageing.

  • Prevent complications (disuse atrophy, contracture).

Guiding Principles 8: Motor Learning / Skill Acquisition

• Principles of motor skill learning:

  • Practice (Amount, Frequency, Duration, Variety, block v random).

  • Specificity of Training (task, context specific, functional practice).

  • Transfer of Training (Impairment-focused training does not generalise).

  • Feedback (Frequency, Timing, Delivery mode, Extrinsic).

  • Modelling / Demonstration (in addition to verbal instruction).

  • Mental Practice (When to use it).

Guiding Principles 9: Self-efficacy/management

• Self-efficacy: Belief about the capability to influence key events that affect one’s life.

• Cornerstone of Self-management: Knowledge, skills/ability, confidence to manage one’s own heath and care.

  • Self efficacy  better health, higher achievement, more social integration, higher motivation.

  • Self-efficacy  compliance with therapy.

Guiding Principle 9: Self efficacy / Management

• Self-management in Stroke:

  • SM Programs may be of benefit to people in the community post-stroke:

    • Improved QoL and self-efficacy.

    • Trend of improvement in mood and independence.

Guiding Principles 10: Prevention / Health Promotion

• Primary Prevention: Prevent disease onset.

• Secondary Prevention: Stop/slow disease progression.

• Tertiary Prevention: Reducing impairments and activity limitations.

Guiding Principles 10: Prevention / Health Promotion

• Stroke Foundation Guidelines – Secondary Prevention includes:

  • Adherence to pharmacotherapy.

  • Blood pressure lowering therapy.

  • Management of atrial fibrillation.

  • Antiplatelet therapy.

  • Cholesterol lowering therapy.

  • Carotid Surgery, patent foramen ovale management.

  • Cervical artery dissection management, cerebral venous sinus thrombosis Mx.

  • Diabetes management.

  • HRT, Oral contraception.

  • Lifestyle Modification (Diet, Physical Activity, Obesity, Smoking, ETOH).

Neurological Physiotherapy Practice Week 1: Motor Control & Motor Learning

• Lecture aims:

  • What is motor control?

  • Theories of motor control.

  • What is motor learning?

  • Theories and key principles of motor learning.

  • Motor learning neurological physiotherapy.

• Relevance: Performing movement-based skills is a prominent feature of the human experience.

What is Motor Control?

• Processes related to activating, coordinating and regulating the production of quality functional movement.

• Relates to how the motor system is organized and how it produces and executes movement.

• Several major theories of motor control exist.

• Motor control is not the same as motor learning.

Theories of Motor Control

1. Reflex Theory – a series of reflex responses to a stimulus which combine to form the basis for functional movement.

2. Hierarchical Theories – motor control is organised in a top-down structure.

3. Motor Programming Theories – movement is produced by a central motor pattern.

4. Systems Theory – movement is produced by the synergistic interaction of multiple systems.

5. Dynamic Action Theories – movement results from the interaction between components of the motor system.

6. Ecological Theories – detecting information in the environment relevant to movement will guide actions.

Motor Control in Voluntary Movement

• Planning

  • Prefrontal cortex and Posterior parietal cortex:
    Decision to move is created and converted into possible motor commands

• Initiation

  • Premotor and supplementary motor areas
    Motor commands are devised and maintained until needed

  • Basal Ganglia
    Motor commands are refined and unsuitable movements prevented

• Execution

  • Motor cortex and spinal cord
    Motor commands are released and transmitted via descending pathways

Motor Control Hierarchy

• Research suggests hierarchy and parallel loops – allows a level of redundancy.

• Higher levels control decision making + strategy, e.g. association areas, basal ganglia.

• Lower levels control motor execution, e.g. brainstem, spinal cord.

What is Motor Learning?

• “the study of the acquisition and/or modification of skilled action.”

• A set of processes associated with practice / experience leading to more permanent changes.

• Learning is a process of acquiring capability for skilled action.

• Learning results from experience or practice.

• Learning cannot be measured directly. Inferred from behaviour.

• Learning produces permanent changes (performance ≠ learning).

• Includes interaction of individual with task of environment to find a solution.

Motor Learning – Definitions

• Motor Learning (2-part operational definition):

  • Skill acquisition

  • Skill maintenance

What Motor Learning is Not?

• A learnt cognitive process – although there is an interplay of cognition.

• Performance.

Motor Learning - Adaptation

• Adjustment of well-practiced action in response to change in environment or body.

• Recalibration of actions – required due to changed dynamics of environment or body.

• Explicit adaptation (Sensory Prediction Error).

• Implicit adaptation (Success or Failure of Movement).

Motor Learning – Physiological Mechanisms

• Brain regions that contribute to motor learning

Role of Neuroplasticity in Motor Learning

• The reorganisation of structure or function through responding to intrinsic and extrinsic stimuli.

• Adaptive neuroplasticity (improvements in outcomes, not compensation).

• Maladaptive ‘negative’ outcomes e.g. persistent pain.

• Use dependent and specific, “Use it or lose it”.

• Repetition and intensity matter.

• Relevance/importance of tasks (salience), feedback is important, attention to task influence learning.

Role of Memory in Learning

• Storage of material that results from activities of information processing – reattain / use

• Sensory Memory – short time (fraction of second) – e.g. sound, sight, etc

• Short Term Memory – 15-30 seconds, working memory, capacity limit (7 items +/- 2)

• Long Term Memory – stored/accessible for future use, limitless capacity, long lasting

• Declarative/explicit – for facts, events, personal exp e.g., dates, telephone numbers

• Non-declarative/implied/procedural – motor skills learned through practice

• Encoding - process to get from short term to long term memory  storage

• Decoding – taking from memory and re-using  retrieval

• Forgetting causes - don’t pay attention, don’t elaborate, if not meaningful, failure to encode, consolidation failure, decay, interference, motivated forgetting, retrieval failure

Motor Learning & Implicit and Explicit Learning

• Implicit (nondeclarative) learning

  • Nonassociative learning (reflex pathways).

    • Habituation – decrease in responsiveness.

    • Sensitisation – increased response following threatening/noxious stimuli.

  • Associative learning (predict relationships/associations).

    • Classical conditioning (pairing one stimulus to another). Pavlov’s dogs experiment

    • Operant conditioning (relationship of one’s behaviour to a consequence).

  • Procedural learning: “habit”. Movement Schema

• Explicit (declarative) learning: Relevant for functional skills e.g. steps to get dressed.

Implicit and Explicit Learning in Therapy

• Use depends upon:

  • Location and type of CNS pathology.

  • Declarative/Explicit learning requires ‘verbal’/cognitive expression.
    *Declarative/explicit learning could be useful to rehearse mentally, that allow increased practice without pain/fatigue.

  • Declarative/explicit learning utilises neural circuitry of sensory association cortices.

ML Theories related to Stages of Learning

• Fitts and Posner 3-Stage Model (1967):

  • Cognitive stage.

  • Associative stage.

  • Autonomous stage.

• Bernstein’s Three-Stage Approach to Motor Learning: Mastering Degrees of Freedom (DOF)Emphasis on controlling degrees of freedom of body segments.

• Gentile’s Two-Stage Model (1972):

  • Develop understanding of task dynamics/requirements of movement to goal.

  • Fixation/diversification: refine, adapt to changing tasks and environmental demands.

  • Open v Closed skill.

Stages of Motor Learning

• Task in context, explanation – what and why, use demonstration / guidance / facilitation. Positivefeedback in chunks. Trial+Error.

• Practice: speed, settings, variability, self-analysis. Remove support.

• Minimal intervention, use internal processes, set new goals, learning can continue, maintenance.

Motor Learning Variables

• Amount of practice/practice levels.

• Feedback (Content, type, frequency, timing, focus).

• Instructions (internal / external) and attention.

• Active participation and motivation.

• Practice conditions (Task breakdown, practice variability, structure/order of practice, & distribution of practice).

• Specificity and context of practice

Motor Learning Factors

• Amount of Practice/Practice Levels  Dosage  Neuroplasticity (FITT Principles).

• Feedback is essential Intrinsic/inherent & Extrinsic/augmented.

• Focus of instructions (internal / external) – Attention.

• Active participation, motivation (salience) and active problem-solving (errors).

Motor Learning Practice Conditions

• Massed (more practice : rest) v Distributed Practice (more rest).

• Constant v variable (leads to more generalisability).

• Random v serial v blocked Practice.

• Whole v part training.

• Specificity of practice  task and context.

• Transfer – dependent on how similar.

Motor Learning in Neuro Summary

• Individualised & Task and context specificity.

• Dosage+ Repetition with variation “repetition-without-repetition”.

• Feedback on performance and results provided frequently (verbal / non-verbal).

• Fragment complex movements, whole practice for automatised movements.

• Involve active problem-solving.

Neurological Physiotherapy Practice Week 1: Subjective Assessment

• Lecture aims:

  • ICF in Neuro PT Ax.

  • Components of a Neuro PT Subjective Ax.

  • Tips for patients with Communication Issues.

  • Tips for patients with Cognitive Issues.

  • Goal setting in neuro rehabilitation.

  • Documenting the Neuro PT Subjective Ax.

Assessment in Neurological Physiotherapy

• Assessment is the starting point for clinical reasoning & planning based on the WHO International Classification of Functioning, Disability and Health (ICF) Framework.

• A comprehensive assessment:

  • Facilitates decision making, treatment planning, determining prognosis.

  • Assists consideration of other disciplines or services.

• No standardised process for neurological assessment.

Assessment consists of:

• Subjective Assessment

  • Medical record / obs chart / referral.

  • Other members of the team.

  • Interview with patient / family / carers.

  • Subjective outcome measures.

• Objective Assessment:

  • Observations.

  • Physical Examination.

  • Standardised measurement tools and outcome measures.

• Assessment may be completed at baseline, to monitor for change + post intervention.

Subjective Assessment

• Prior to meeting patient / family / carers: Review all client information including:

  • 3 Identifiers

  • PC / HxPC, Imaging/tests, Medical stability (medical obs) and precautions/limitations.

  • PMHx, PSHx, medications

  • SHx and Home Environment

  • FHx

  • Handedness

  • Driving

  • Other professionals involved.

Subjective Assessment Includes

• Safety First! – Check Medical Stability/Observations + Precautions/Contraindications.

• Introduce self, role, gain consent, check 3 ID.

• Confirm information gathered from other sources.

• Look at PC/Main Problem/current symptoms - their knowledge/understanding PC and HxPC and Other Rx.

• Look at PM(+S)Hx, tests/imaging, medications, ?precautions. SHx and Home environment, FHx, Handedness, driving.

• Collect information about Goals, expectations, perceptions/beliefs, Pain, fatigue, vision, hearing, Sensory problems, Chest/Respiratory, Mobility, Falls Hx, Continence, Vertigo, dizziness, nausea.

Additional Notes

• Throughout Subjective Assessment, take note of:

  • Insight, attitudes/beliefs, knowledge/understanding.

  • Communication issues – receptive and/or expressive.

  • Cognitive issues - Understanding information and Q’s, & Following commands.

  • Mood, behaviour.

  • Signs pain, discomfort or fatigue

  • Breathing, chest, cough, sputum, saliva control.

  • Medical stability and medical observations, deteriorating patient.

Components of Neurological Subjective Assessment

• 3 Identifiers: Name, DOB, Address, MRN  correct person?

• PC/Main problem: What are the current issues patient is facing?

  • Check their knowledge/understanding - may be difficult in the acute stage

  • May be different to what you think, what referred for

  • Direct focus of Assessment or Management

• HxPC (Diagnosis, Date onset, Change so far).

• Check Ix Imaging/tests, Medical precautions/instructions.

Medical Stability, History

• Medical Stability – BP, HR, RR, Temp, ECG, ABG, Hb, BGL

• PMHx / PSHx

  • Co-morbidities that may impact Ax or Mx/Rx.

  • Medications, SHx + Home environment, FHx etc.
    *Work / Hobbies / Pre-morbid activities related to goals, and objectives for Ax and Rx?
    *Need Supports (formal and informal), and to need Social Work assistance?

Components of Neurological Subjective Assessment

• What able to complete - Usually/Recently v’s Currently?

• Home environment – usual access / mobility requirements

  • Steps or stairs, Supports.
    *Driving, Orientation to TPP, Goals, expectations, What about previous treatment etc?
    *Pain, Fatigue, Chest and Respiratory +Mobility.
    Check the history for problems about Continence, Vertigo, dizziness, nausea

Tips for Communication or Cognitive issues

• Simplify your questions (Use Yes and No questions when speech is impaired).

• Discuss communication strategies with a speech pathologist.

• Discuss cognitive challenges with SP, OT, Medical.

• Give patients more time to process and respond Use gestures, written word, pictures, or other assistive devices.

• Change own voice volume or speed of talking Consider an interpreter as ESL.

• Ask a family member or carer for clarification.

• Consider if information from patient is accurate and reliable.

Other Considerations and Communication Strategies

• ESL – Interpreter? Or Family? And other cultural considerations Language v Cognition.

• Look for Response - Verbal response? v’s Body movements, or request (simple request v’s multiple requests).

• Hearing aids? Glasses? (Also) Pain/comfort? Safety/Drowsy: Say pt name, touch patient shoulder.

• Deteriorating patient – monitor for S+S Religious or Cultural considerations?

Outcome Measures

A test or scale to measure accurately a particular attribute of health that is expected to be influenced by an intervention.
Use it to: - Identify a specific problem - Evaluate disease progression - Evaluate effect of intervention - Justify need for physiotherapy - Motivate patients.

• Provide feedback to patients - Evaluate cost effectiveness

Outcome Measures Considerations Including

• Construct you want to change/evaluate.

• Level of patient ability and Level of the WHO ICF.

• Reliability, Validity and Sensitivity + Practicalities.
  Include Subjective Outcome Measures – Neuro Physio Examples.

Goal Setting

• What is a goal?: “A desired future state achieved by a person with a disability as a result of rehabilitation activities. Rehabilitation goals are actively selected, intentionally created and are shared by people participating in the activities.

• Setting/planning: establishment or negotiation of rehab goals may improve patient outcomes.
  *SMART assessment with Hope - Key to Enhance Motivation (also assist with training and self determination)

Collaborative Goal Setting should

• Involve the patient their family / and the therapists: Enable active co-planner role.

Goal Setting Rehabilitation Should be

1)Achievable and Realistic set the bar at the right height.
2)Goal Commitment, Self-Efficacy and Hope with high value of Readiness.
Document Subjective Ax, with Typical Structure (and Core Components).

Week 2: Objective Assessment

• The ICF Neurological PT Objective (and subjective) Ax components.

• Focus - Regional / Metro Workplace etc to AROM/Strength (plus sensation, coordination and vision).
  *How managing tasks + What usually participate in compared what can do right now.

Neurological PT Objective Assessment Overview

• Source versus Problem oriented assessment framework

• Focuses on Systematic and all Impairments (related activities and function).
  Also Focuses on Activity based (appropriate + to observe and compare to normal). Also confirm or refute hypothesized contributing impairments .

Source v’s Problem-Based Ax

• No right or wrong way - dependent on setting, situation, priorities, patient, time, experience.

• A source based Ax is Assess/Test Impaired -- Observe Function Hypothesis. Problem Based goes Observe Function Hypothesize.Assess.

Core Components of Ax

• Observation, AROM, Strength, PROM, Tone. Sensation, Coordination, Vision, Functional Ax + Outcome Measures (+ Specific activity, & Specific presentations).

• Objective Ax starts – from beginning and through the whole session!. Take into account: Safety, Communication, Cognition.

• Assess as needed - From Bed versus Chair (Type) versus Walking Patients
  *Patient variability - Always ask a patient to demonstrate what they can do

Observation, General points

*Attach appropriate documentation and Attachments.

• Consider Severity with alertness, positions, movements as well as Wounds + Breathing.

Neurological PT Ax Overview - AROM / Strength

Unlike MSK Ax. Learn to systematically Assess, ‘whole’ body, in timely manner. Also look at: - UMNL versus LMNL for PROM + Tone + Sensory.
Proprioception, & Pain -- that also affects Ax’s like AROM. Consider coordination, and Ataxia.

Additional Considerations

*With vision we determine if the patient can see ALL of their environment and Ax what they can see.
This also effects Therapy. Also note: Bed positioning and transfers while taking Cognition and Observations into account!

Functional/Activity Ax - plus points

*Bed mob  mostly hospital patients, Bed mob: - Rolling - Up/Down -Side/Side - Bridge (Important Factors), Transfers (Lie to sit,Sit to stand and chair position).
Consider factors from previous slides

Sitting Balance (also considering Standing Balance) -- Before a Transfer.

*Consider observations, posture / Static, & Dynamic Balance Independence, Assistance, Endurance factors.
Before a Transfer

Mobility plus non core considerations too. Consider;.

Gait incl; specific Ax (like UE and car) plus Respiratory + swallowing while considering PMHx. (Also reflex's including Spinal and Cranial aspects).
Spinal reflexes will be covered in MSK Yr 3 (with Neurological too).
Aprasia / Dyspraxia - plus the effect of bradykinesia and akinesia – may also be taken.
Be wary of signs and symptoms of Vestibular Ax to aid with referral.

Documenting the Neuro Objective Ax

*What to be in the plan (if on Ward / with NS / at night if those recommendations are different?). If cues etc required, that is documented + the basics as always.
With CORE Impairments and Chart the non core points.
What test completed and where if from normal area (to chart).

Activity and Functional Components Documentation. Consider points including Endurances.

How completed? Which abilities are done? Also how's their Independence / Assistance? What's the equipment needed or other considerations during Documentation.

Week 2: Observation, AROM & Strength

Lecture aims: - How to complete observation in different settings and patient specific. - How to complete a Neuro PTAROM Ax - How to complete a Neuro PT Strength Ax - The relationship of AROM and Strength

Observation Considerations: Attach appropriate documentation and Attachments + Medical Stability etc.

Important points:

How is the (acute hospital setup verses the) patient's Home setup (including surface types) verses the Environment setup?
Throughout: note their alertness /responsiveness with posture and alignment through - Spontaneous movements and Other spontaneous observations
Also analyse the movement's Compensations (e.g Bed transfers and Gait).

Arom v Strength + Additional Ax

*Key factor - Safety + handling + Marked Muscle weakness and Communication challenges). Behavioral/Emotional challenges. Cognitive Challenges and how to make it best + Pain considerations. ++ Fatigue with Time ++ and Position .
as is the order/level needed to achieve desired result + vision assessment..
Arom needs AROM AND strength as affected as 2 different phases).
Mmt is subjective but essential (with possible variations including - isometric, - “make” verse “break”). Consider level/severity when considering the grades.

AROM and Strength (including Mmt considerations).

*Also know safety/ handling if there has to bed based strengthening too.++ Use video demonstrations). Quality remains important.

Clinical Reasoning, Problem Lists & Matrices

Clinical reasoning “therapist formulates health management strategies and plans of care based on clinical data, along with client choices and professional knowledge.
Effectiveness of Rx depends on an appropriately detailed Ax: Analysis of the information relating to each individual patient.
Holistic/comprehensive Ax based on ICF Framework is the starting point (Also consider activity Limitations).

Clinical Reasoning Framework (including problem v source based ax)

Consider :Cyclical Approach and continuous evaluation.
Problem Based Approach -- Review Activity/Participation Hypothesize contributing (Impairments) to test. Then a Treatment and plan in regards to all of that.
Source Based Approach -- Test (all) Impairments, then review Activity etc to assist treatment.

Problem Lists (in Neurology)

Are an integral tool for analysis, treatment planning and goal setting that focuses impairments, and - Continuous ongoing process: Ax–analysis–hypothesis–intervention–Ax-hypothesis = All from perspective of Participation.
Look for the key elements and follow an appropriate template, to achieve result.
You may need to modify as you go to achieve result).

Week 3: PROM, Tone, Spasticity & Contracture

Key aims-- Spasticity, contracture & hyper /hypoTonus
Factors for normal and abnormal + tone and UMN are main targets
Address what may develop with Hypertonicity, & spasticity.
Key components - PROM, Tone, Spasticity Relationship.
Learn ax and management.

Key Definitions include

1. Muscle tension.

2. UMNS = group of motor impairments including (positive and negative features)

Also Understand Neural and Muscle Changes Following UMNL (especially hypertonus) (to achieve mechanical treatment with stretching, splinting and casting.
Best Approach: Stretching, Splinting, Casting. Also with AROM FUNCTIONAL USE.

• Consider - - Hypertonia -- (and External Triggers -- Also remember high tone may = Weak).
  *Know Reduced resistance to passive movement and Rx aims hypotonia.
  also: Dystonia - Involuntary, sustained or intermittent muscle contractions.

• Definition spasticity AND Rigidity as well (sustained efferent AND effectors.

Additional key points

Decorticate and Decerebrate Rigidity (and posture descriptions).