Evidence based treatment HB - strength (MS) Flashcards
Neuro rehabilitation conceptual framework
ICF participation Patient centred care Team work Predication Neural plasticity Motor control Functional movement re-education Skill acquisition Self management Health promotion
International classification of functioning disability and health
Provides understanding for patients with problems with activities and aim to improve quality of life
Team work
Rehabilitation requires physio patients relationship and family social workers etc
SMART goals
Patient centred care
Develop their knowledge and skills so they can make a decision about their health
Prediction
Rehabilitation teams must make discharge recommendations soon after initial assessment
Neuro plasticity
Changes that occur in structure and function as a result of experience and therapy following brain damage
Spontaneous recovery can also occur however this can be enhanced by neuro plasticity.
Cortical maps can be modified by a variety of inputs; sensory inputs, experience, learning and therapy.
It is time dependent therefore early intervention is better, repetition and greater intensity produce neural changes, enhances sensory, cognitive, motor and social stimulation facilitate increased neural plasticity.
Task-specific training, aerobic exercise, problem solving and all essential to promote neural plasticity and to optimise functional recovery.
Motor control
Motor control is how the nervous system interacts with the body parts and environment to produce purposeful, coordinated actions. There are many subsystems and multiple connections that work in parallel to produce the movement therefore functional tasks have a greater beneficial effect on improving the quality of movement. Compensation strategies may be used to achieve the task. The therapist should aim to reduce impairments and compensatory strategies to promote functional recovery and return to participation.
Functional movement re education
A key aim is to restore movement and function in people with neurological damage. It is not always possible to achieve normal movement therefore relearning optimal movement is important. This can be achieved via recovery, adaptation, maintenance and prevention. By understanding prognosis and pathology, and working in partnership with the patient regarding their goals it can help determine which one of these aims should be the focus focus the physical intervention.
Skill acquisition
This is the principle that underpins motor learning and control which is essential to improve aspects of skilled performance.
What elements should be considered when structuring a therapy session
practice specificity of training transfer of training (generalisability) feedback modelling mental practice
Tasks specific practice
Task orientated practice =performance of the functional task that are meaningful to the patient.
The task can be broken down and the patient can practice the different parts before practicing the whole sequence of activity.
Whole and part practice
Feedback
Feedback can be visual verbal and manual (sensory).
The amount of practice is important and current evidence indicates ‘more is better’. Therefore aiming for large numbers of repetitions should be incorporated into the therapy sessions.
How can you enhance the patients intrinsic motivation
Motor learning is also enhance by improving the patient’s intrinsic motivation.
This can be enhanced by increasing confidence with positive feedback, ensuring a level of choice with activities (learning autonomy), and using external focus e.g. ‘stand tall’ rather than ‘straighten you spine’.
Self management
Self-efficacy is the individual’s belief and knowledge about their own capabilities to influence their lives.
Education and knowledge = on their long-term conditions helps them to develop the skills and confidence to manage their own health.
Health promotion
Primary prevention seeks to prevent the onset of disease via healthy living.
Secondary prevention aims to stop or slow the disease progression and prevent complications.
Tertiary prevention is focused upon reducing impairments and activities restrictions.
It is important to encourage fitness through participation in activities and to limited the effects of non-communicable disease via exercise; this can be achieved via identifying, modifying and encouraging appropriate, enjoyable activities for patients.
Muscle strengthening
Patients with a neurological problem will often present with varying degrees of muscle weakness and incoordination.
The subsequent decrease in activity will lead to a further reduction of strength within the muscles.
Elderly people and muscle strength
Elderly individuals will have associated age related neuromuscular changes; as will a sedentary lifestyle leading to deconditioning. Immobility is associated with neural and muscular adaptations such as secondary atrophy, disuse leads to reduce muscle volume and cross-sectional area.
What is muscle strength affected by
- Structural – cross-sectional area of muscle, density of fibres
- Biomechanical – efficient mechanical leverage across joints, effects of dynamic intersegmental interactions
- Functional – number, type and frequency of motor units recruited during contraction and efficient cooperation between muscles in a synergy
Improving Muscle strength
Strength is a function of the properties of the muscle, neural control mechanisms and context.
Therefore strength can be improved by increasing muscle size, mechanical efficiency and neural function.
Strength training can increase strength, improve functional performance, as well as decrease muscle stiffness, co-contraction and hyperreflexia. Task-orientated exercises and training may decrease stiffness by improving the neural control of muscle and maintain muscle extensibility; co-contraction may decrease as a result of improved limb control.
Task-related practice is important for improving strength as it improves the firing and synchronisation of the motor units and agonist-antagonist and synergic coordination as well as increasing muscle length and improved muscle mechanics.
What is the result of these exercises
- ↑muscle strength – increased ability to generate and time muscle forces appropriate to the task
- ↑ skill in performance of that task – increases coordination of muscle activations
- ↑ extensibility of muscle for the task – decreased resistance to movement
How are exercises selected
Exercises need to be selected in accordance to the individual’s needs and level of muscle activation.
All exercises need to be practice repetitively and with variations. Weight-bearing and non-weight-bearing exercises should be considered.
Consideration of both eccentric and concentric exercises are important in the re-education of normal functional and enhances recovery.
Transferability of exercises
To regain skill of functional performance it is important to both generate appropriate forces but to time these forces across multiple segmental links.
Once the basic movement has been regained the variations can be practiced to improve functional tasks for example the lower limb flexion – extension activity within sit-stand, walking, stair climbing; evidence has indicated that by practicing one task it can have a generalised improvement to another task.
Each individual task has a slight difference of focus of muscle recruitment so to achieve maximum improvement the goal task should be practiced.
Modification of practice is often essential to ensure that the movement is achieved. Within early training the exercise can be modified to provide graded practice.
Repetitions
To improve strength= continuous repetitions without rests working to fatigue.
Then a short rest 30 secs then repeat the same number of repetitions for repeated sets.
Speed of repetitions should also be considered as the ability to generate and time peak force affects many functional actions.
Increasing speed = should be incorporated into the exercise programme.
Consideration should be given to the intensity (how difficult), the duration (how long), frequency (how often) and the type of activities that are completed within the exercise programme.
The programme should be designed to meet the individual’s needs.
Physiological effects of strength training
Strength training can stimulate metabolic, mechanical and structural muscle fibre changes.
There can be improvements in muscle excitation, motor unit activation, efficiency of motor neuron recruitment, inhibition of antagonist muscles, improved synchronisation of motor unit firing patterns and evidence of enhanced supraspinal influence.
Guidelines for functional strength training
- Exercises should be task orientated
- Exercise as intensively as possible to the point of mild fatigue
- Grade the amount of resistance and number of repetitions to the individual’s ability
- The amount of resistance will depend upon the specific effects required and existing muscle control and strength
- Progressive resistance training should be approximately 6-12 repetition of 60-70% maximum possible load
- Very weak muscles can be facilitated muscle activity and force generation, simple exercises, biofeedback, mental practice and functional electrical stimulation
Repetitive, task-specific training
Good evidence base- especially for stroke
Task-specific training involves repetitive part and whole task practice that are meaningful to an individual patient.
Part practice involves undertaking the tasks through segmentation. The movement sequence is broken down into segment parts and practiced in isolation and separately before then ‘chaining’ these segments together to practice either a few segments together or the whole task.
There are five key elements for successful implementation of task-specific training include;
• Tasks that are relevant to the patient and context
• Random and changing tasks
• Repetitive tasks with massed practice
• Part and whole practice
• Reinforced with positive and timely feedback
There is debate within the literature regarding the number of repetitions that should be performed however the consensus of opinion is that the greater number of repetitions the better.
Neuromuscular electrical stimulation
NMES involves a low-dose electrical current to the peripheral motor nerves to improve motor performance and cortical excitability.
This can be used to promote functional tasks – Functional Electrical Stimulation FES) with or without activation from the patient.
Current evidence indicates that is the patient is able to produce the voluntary contraction this is more effective than passive stimulation. NMES has been shown to be effective to reduce post-stroke spasticity and hemiplegic shoulder pain.
Robotics
Aim towards restorative approaches.
Efficient approach to deliver an increased dose of therapy and provide practice and repetition.
May improve function and activities of daily living. The evidence indicates that predominately the improvements are at the shoulder and elbow with limited success at the hand.
Patient satisfaction and adherence is good possible due to the high quality gaming approach which increases engagement and motivation.
Therefore robotics maybe a useful adjunct to more conventional therapy as a means of achieving higher dose therapy.
Virtual reality and gaming strategies
Provide a computer-based, interactive, multisensory simulation environment that occurs in real time.
Goal directed, reward based which can be used to aid task-specificity and patient motivation.
Based on the principal of increasing activation of the neural areas by increasing the motor activity as well as the imagery within the task.
Engages the bilateral motor cortices. It is one method of increasing the therapy dose.
