Historical Perspectives and Intervention Principles Flashcards
Remediation (Recovery) vs. Compensation: goals and treatment
Goal is improved function – movement, QoL, independence
Treatment should encompass attempts at restoration of lost function/skills AND/OR teaching of compensatory strategies = Maximize skills while learning new ways of performing tasks/activities
A neurological rehabilitation program is designed to:
meet the needs of the individual based on their specific movement dysfunction, injury/disease considerations, and personal goals
Neurologic Injuries (e.g., Stroke, TBI) Remediation (Recovery)
aims to restore lost function by promoting neuroplasticity—the brain’s ability to reorganize and form new connections
early intervention in the rehabilitation process focuses heavily on recovery
intensive therapies (e.g., physical, occupational, speech therapy) target the damaged areas of the brain or spinal cord to regain motor, cognitive, and sensory functions
exercises may aim to improve strength, coordination, balance, speech, and cognition.
Neurologic Injuries (e.g., Stroke, TBI) Remediation (Recovery) examples
Post-stroke physical therapy to restore limb function through task-specific repetition and motor learning.
Cognitive therapy to help patients recover memory or problem-solving skills after a TBI.
Neurologic injuries are often:
acute and non-progressive
meaning the brain or nervous system can recover to some degree if the right interventions are applied early
While some damage may be permanent, there is often potential for improvement, especially in the first few months post-injury
Neurologic Injuries (e.g., Stroke, TBI) Compensation
When full recovery is not possible, compensatory strategies are introduced to help individuals adapt to residual deficits
may involve teaching patients to use their unaffected limbs, modify tasks, or incorporate assistive devices to maintain independence and functionality
If certain functions cannot be fully recovered, compensation allows the individual to return to daily life and activities as independently as possible
Neurologic Injuries (e.g., Stroke, TBI) Compensation examples
Using a cane or brace to assist with walking if full recovery of gait is not achievable.
Adapting daily tasks like using one hand for dressing or grooming if the other hand is permanently weakened or paralyzed.
Neurodegenerative Diseases (e.g., Parkinson’s Disease, Multiple Sclerosis)
Remediation (Recovery):
remediation can be used in the early stages of neurodegenerative diseases to maintain or restore function, its effectiveness is often limited as the disease progresses
exercises may slow the rate of decline but do not reverse damage
focuses on maintaining motor function, flexibility, and coordination through specific exercises, medication management, and lifestyle changes
goal is to maximize current abilities for as long as possible
Neurodegenerative diseases are:
progressive, meaning function gradually declines over time
Therefore, while recovery of lost abilities is not usually possible, remediation efforts may aim to delay functional decline.
Neurodegenerative Diseases (e.g., Parkinson’s Disease, Multiple Sclerosis)
Remediation (Recovery) examples:
Exercise programs to maintain muscle strength and motor control in early Parkinson’s disease.
Balance and gait training in early multiple sclerosis to address motor symptoms before they worsen.
Neurodegenerative Diseases (e.g., Parkinson’s Disease, Multiple Sclerosis)
Compensation:
increasingly important as neurodegenerative diseases progress and the loss of function becomes more permanent - helps patients adapt to their changing abilities and maintain independence
Adaptive devices, environmental modifications, and compensatory techniques help individuals manage daily tasks despite the progression of their condition
often teach compensatory strategies early to prepare for future declines
neurodegenerative diseases are chronic and progressive, compensation is essential for maintaining quality of life = emphasis is on finding long-term solutions to manage day-to-day activities as the disease advances
Neurodegenerative Diseases (e.g., Parkinson’s Disease, Multiple Sclerosis)
Compensation examples
Use of mobility aids (e.g., walkers, wheelchairs) as walking becomes more difficult in advanced Parkinson’s disease.
Energy conservation techniques for individuals with MS who experience fatigue, helping them prioritize tasks and use energy efficiently.
Voice amplifiers or communication devices in later stages of Parkinson’s disease when speech becomes impaired.
Neurologic Injuries (Stroke, TBI): summary
Remediation: Focuses on restoring lost function and capitalizing on the brain’s capacity for neuroplasticity. Significant gains are often made in the early stages of recovery, particularly within the first few months post-injury.
Compensation: Used when recovery is incomplete or plateaued. Adaptive strategies and devices help individuals cope with permanent deficits.
Neurodegenerative Diseases (PD, MS): summary
Remediation: Aims to maintain function and slow functional decline in the early stages. True recovery is typically limited due to the progressive nature of these diseases.
Compensation: Becomes the primary approach as the disease progresses, helping individuals adapt to worsening symptoms and maintain independence despite declining function.
___ is more central to recovery following neurologic injuries, whereas ___ becomes the dominant strategy in managing the progressive loss of function in neurodegenerative diseases.
remediation
compensation
ICF - health condition (neuronal) motor recovery
restoring function in neural tissue that was initially lost after injury
may be seen as reactivation in brain areas previously inactivated by the circulatory even
although this is not expected to occur in the area of the primary brain lesion, it may occur in areas
ICF - body functions/structure (performance) motor recovery
restoring the ability to perform a movement in the same manner as it was performed before injury
this may occur through the reappearance of premorbid movement patterns during task accomplishment (voluntary joint range of motion, temporal and spatial interjoint coordination)
ICF - activity (functional) motor recovery
successful task accomplishment using limbs or end effectors typically used by nondisabled individuals
ICF - health condition (neuronal) motor compensation
neural tissue acquires a function that it did not have prior to injury
may be seen as activation in alternative brain areas not normally observed in nondisabled individuals
ICF - body functions/structure (performance) motor compensation
performing an old movement in a new manner
may be seen as the appearance of alternative movement patterns (recruitment of additional or different degrees of freedom, changes in muscle activation patterns such as increased agonist/antagonist coactivation, delays in timing between movements of adjacent joints) during the accomplishment of a task
ICF - activity (functional) motor compensation
successful task accomplishment using alternate limbs or end effectors
for example, opening a package of chips using 1 hand and the mouth instead of 2 hands
Remediation/Restoration
focuses on returning a function or ability to its previous state, often by addressing the underlying cause of the impairment
aims to recover lost skills or improve the functional capacity of affected areas
primary aim is to restore the individual’s original capabilities or to achieve a level of function as close as possible to what was present before the impairment
Compensation
adapting to the impairment by using alternative strategies, techniques, or assistive devices
focuses on enabling the individual to perform tasks and maintain independence despite functional limitations
aim is to manage and mitigate the impact of the impairment by finding ways to achieve tasks or activities despite the functional loss
58-year-old female with left hemiplegia following a recent stroke, the focus was on restoring strength and mobility through both in-patient and out-patient rehabilitation:
UE:
- HEP focused on open-chain strengthening exercises
- Task-specific movement patterns to regain functional use
LE:
- Closed-chain strengthening exercises, including weight-bearing activities
- Gait training to improve walking ability
- Balance training to address both static and dynamic stability
58-year-old female with left hemiplegia following a recent stroke
Outcomes:
- Significant improvements in both static and dynamic balance, which helped her regain confidence in movement
- Strength in her left leg increased, enabling her to progress in mobility
- She initially used a walker, transitioned to a quad cane, and ultimately was able to ambulate independently by the end of rehabilitation
Remediation/Restoration - Restoring a lost function/skill:
Therapy capitalizes on the spontaneous recovery process
Therapy services continued after discharge at the outpatient level
Compensatory strategies were not the focus since independent ambulation occurred within 3 months of recovery
40 yo woman with a non-operable GBM in right occipital lobe. Compression of the optic nerve compromised 90% of her vision in the left eye
compensatory approach focuses on optimizing function despite the visual impairment
Adjust the home/work environment to ensure safety
Introduce visual aids such as magnifiers or screen readers for reading and computer use
Teach compensatory scanning techniques to help her compensate for the left-sided visual field loss. This would involve learning to actively move her head and eyes to scan her environment
Encourage the use of the right eye for activities like reading, writing, and cooking
40 yo woman with a non-operable GBM in right occipital lobe
Outcomes:
Increased Independence: With the appropriate compensatory strategies, she can maintain greater independence in daily activities
Safety Improvements: Reduced risk of accidents at home or in the community due to environmental adjustments and mobility training
Enhanced Quality of Life: By relying on her functional vision and adapting her lifestyle, she can continue to engage in meaningful activities despite her vision loss
50 yo male suffered T12 ASI A SCI after MVA
Teach him to navigate different terrains, transfer in and out of the wheelchair independently, and perform tasks like ascending/descending ramps and curbs
If he lacks upper body strength or endurance, consider a power wheelchair for longer distances or activities that require extended mobility
Adapt techniques for dressing, bathing, grooming, and toileting using assistive devices such as a grab bar, dressing aids, or a shower chair
Introduce a standing frame for weight-bearing to promote circulation, prevent osteoporosis, and reduce the risk of pressure ulcers
50 yo male suffered T12 ASI A SCI after MVA
Outcomes:
Maximized Independence: Mastery of wheelchair skills, ADL adaptations, and home modifications will enable him to live more independently.
Improved Quality of Life: Compensatory strategies can reduce the physical and emotional barriers, fostering a sense of autonomy.
Prevention of Secondary Complications: Through proper skin care, positioning, and bowel/bladder management, complications like pressure sores, infections, or contractures can be minimized.
Compensatory Approach
Learning how to develop “work arounds” for a functional task
Patient taught to change the environment or change their approach
Combined Remediation and Compensation
Combined process of restoring and learning adaptive techniques for improved functioning
ncorporates both rehabilitation techniques (remediation) to improve a patient’s function and compensatory strategies to work around current limitations
Combined Remediation and Compensation
Case: 30 yo male dx with Guillain-Barré syndrome presents with significant weakness and tingling throughout the B LE.
remediation:
Gradual, low-resistance exercises to rebuild muscle strength in the lower extremities as motor function returns
Proprioception and coordination exercises to improve stability, especially as sensation recovers
Passive or active-assisted ROM exercises to prevent joint stiffness and improve flexibility
compensation:
Assistive Devices
Ankle-foot orthosis (AFO) for foot drop or other motor control deficits, providing stability during ambulation
Environmental Modifications: Adjustments like grab bars, raised seating, or ramps to ease daily activities until strength improves.
Combined Remediation and Compensation: Rehabilitation
Initial compensatory strategies- transferring with slide board, head/hips
With disease progression and tx, patient able to regain ambulation ability with use of SPC at discharge from inpatient rehab
Compensation needed initially and progress into restoration
Which to Choose When?
Return of motor capacity is often a combination of recovery & compensation, thus both remediation & compensatory techniques are commonly used
Factors to consider: an individual’s capacity (brain & muscle structure or function, genetics, etc.), neurological condition, time post-injury, patient & family goals
Example 1: You may focus on remediation tx strategies early post-stroke to capitalize on spontaneous recovery mechanisms, with minimal use of compensatory strategies
goal is to restore as much function as possible by:
Neuroplasticity Training: Intensive, task-specific exercises (e.g., reaching, grasping) that promote rewiring of the brain.
Strength and Coordination Exercises: Targeting weakened or paralyzed muscles to regain motor control.
Mirror Therapy: Using the unaffected limb to stimulate recovery in the affected one.
Constraint-Induced Movement Therapy (CIMT): Encouraging the use of the affected limb by restricting movement of the unaffected one.
In this phase, compensatory strategies (like using adaptive tools or one-handed techniques) are minimized to encourage the patient to relearn skills, rather than adapting to their deficits. The focus is on maximizing the potential for functional recovery rather than bypassing the impairments.
Example 2: You may focus on compensatory strategies for a person with primary-progressive MS to optimize efficiency and minimize fatigue
compensatory strategies are often prioritized to manage ongoing, progressive symptoms, optimize efficiency, and minimize fatigue:
Energy Conservation Techniques: Educating the patient to plan tasks ahead, take frequent breaks, and use strategies like sitting during activities to avoid fatigue.
Assistive Devices: Using mobility aids such as canes, walkers, or wheelchairs to reduce the effort needed for walking and maintain independence.
Adaptive Equipment: Modifications like grab bars, dressing aids, and electric-powered tools to assist with daily tasks and conserve energy.
Task Simplification: Breaking down complex activities into smaller, more manageable steps to reduce the cognitive and physical demands.
In this case, since PPMS often involves continuous decline, compensatory strategies help the patient maintain function and quality of life by working around limitations, rather than focusing on restoration of abilities.
4 Traditional Neurorehabilitation Approaches
Sensory Stimulation Techniques- Rood
Stages of Motor Recovery- Brunnstrom
Neurodevelopmental Treatment (NDT)
Proprioceptive Neuromuscular Facilitation (PNF)
Sensory Stimulation Techniques- Rood
involve using sensory inputs to facilitate or inhibit motor responses, aiming to improve motor control and muscle function
combines sensory stimulation with motor activities to elicit desired responses based on the idea that motor output can be influenced by sensory input
Facilitation Techniques
Inhibition Techniques:
Facilitation Techniques:
used to activate or stimulate muscle contraction
Light Touch: application of quick light strokes to the skin over a muscle using either fingers, cotton, or a brush to activate superficial muscles
Tapping: brisk taps with fingertips over the tendon or muscle belly of the involved muscle to facilitate phasic contraction of the muscle
Quick Stretch: A brief, rapid stretch to a muscle to activate a reflexive contraction. (often applied at lengthened range)
quick ice: Applying quick, short bursts of cold (icing) to stimulate muscle activity.
traction: manually applied distraction force to a joint or limb segment causes muscle relaxation and promotes movement
approximation: compression of a joint or body segment stimulates cocontraction of muscles around the body segment and promotes stability
resistance: manual application of force away from the axis of motion at the joints as the patient is asked to move or stabilize
Inhibition Techniques:
used to reduce excessive tone or calm overactive muscles
Prolonged Stretch: Holding a stretch for an extended time to reduce muscle tightness or spasticity. (application of a slow passive lengthening to inhibit contraction)
Deep Pressure: Applying firm, steady pressure to tendons or muscle bellies (longitudinal axis of muscle tendon) to inhibit muscle contraction.
Slow Stroking: slow stroking with the hand along the midline of the back, near posterior rami, for 3 to 5 minutes leading to calming of patient
prolonged cold: application of an ice pack or ice massage over a muscle leads to its relaxation and reduction of pain
Margaret Rood
Motor development sequences
Sensory stimulation techniques
Phasic muscles- function in voluntary movement
Tonic muscles- provide stability
*reflex driven approach
Motor Development Sequences:
Reciprocal Inhibition: The basic movement pattern where agonists contract and antagonists relax (e.g., simple reflexes).
Co-contraction: Simultaneous contraction of agonists and antagonists, providing stability around a joint (e.g., standing still).
Heavy Work: Movement of proximal muscles over a fixed distal segment, allowing for weight-bearing and controlled mobility (e.g., crawling, lifting).
Skill: The most advanced stage, where distal segments move freely while proximal parts stabilize (e.g., fine motor tasks like writing).
Sensory Stimulation Techniques:
These are applied to either facilitate (activate) or inhibit (calm) motor responses, which align with the developmental sequences.
Facilitation: Quick stretch, brushing, tapping, or icing to activate phasic muscles.
Inhibition: Deep pressure, prolonged stretch, and slow stroking to calm hyperactive tonic muscles.
Phasic Muscles:
responsible for voluntary, dynamic movement
typically more superficial, fatigue quickly, and are activated for brief periods during activities like walking, reaching, or grasping
Muscles like the biceps, triceps, and quadriceps are phasic, involved in quick, voluntary movements
Facilitating these muscles using sensory inputs like quick stretch or vibration to enhance their activation in movement
Tonic Muscles:
provide stability and postural control
deeper, more fatigue-resistant, and maintain contractions for prolonged periods to support static positions like sitting or standing
Muscles such as the erector spinae, abdominals, and gluteals are tonic, involved in stabilizing the body
Inhibiting overactive tonic muscles with techniques like prolonged stretch or deep pressure, especially in cases of spasticity or rigidity.
Brunnstrom- Stages of Motor Recovery
Describes process of movement recovery after stroke
Position of head and/or body will affect synergies
Individual must move through each stage of motor recovery and gain active movement in both flexion/extension synergies before movements outside of synergy can be performed
