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
Control of movement progresses:
Gross to fine
Proximal to distal
Brunnstrom’s 7 Stages of Motor Recovery:
1) flaccidity
2) synergies some spasticity
3) marked spasticity
4) out of synergy, less spasticity
5) selective control of movement
6) isolated/coordinated movement
stage 1: Flaccidity
Characteristics: Complete absence of voluntary movement and muscle tone in the affected limb. The limb is flaccid and unresponsive to voluntary commands.
Therapy Focus: Preventing contractures with passive range of motion (PROM) exercises, positioning, and supporting limb mobility.
stage 2: Synergies with Some Spasticity
Characteristics: Involuntary movement patterns (synergies) emerge with increasing spasticity. Movements are largely confined to these synergy patterns.
Therapy Focus: Facilitating movement within synergy patterns and beginning to introduce voluntary movement control.
stage 3: Marked Spasticity
Characteristics: Spasticity is pronounced and affects motor control significantly. Movement is predominantly in synergy patterns with less voluntary control.
Therapy Focus: Managing spasticity through stretching and inhibition techniques, and promoting movement within synergies.
stage 4: Out of Synergy with Less Spasticity
Characteristics: Movement begins to occur outside of the original synergy patterns. Spasticity decreases, and voluntary control improves.
Therapy Focus: Encouraging movements outside of synergy patterns and working on improving overall motor control.
stage 5: Selective Control of Movement
Characteristics: Further reduction in spasticity. The patient gains the ability to control movements more selectively, though some abnormal patterns may still be present.
Therapy Focus: Enhancing the ability to perform isolated movements and working on coordination and functional activities.
stage 6: Isolated and Coordinated Movements:
Characteristics: Movements become more isolated and coordinated. Spasticity is minimal, and the patient can perform complex and refined motor tasks.
Therapy Focus: Fine-tuning movement coordination, strengthening, and integrating movements into functional tasks.
stage 7: Normal Motor Function
Characteristics: Full restoration of motor control. Movements are smooth, coordinated, and no longer affected by spasticity or abnormal patterns. Some patients may not fully reach this stage.
Therapy Focus: Continuing to enhance strength, endurance, and functional integration of movements.
Bobath- Neurodevelopmental Treatment (NDT)
Need to understand normal movement
Hands-on intervention to guide patient towards normal posture and movement patterns
Adapts activities based on patient’s performance and needs
Postural analysis is key component of physical exam
Movement analysis
Therapeutic handling (key points of control) are graded and withdrawn as patient progresses
Continual assessment and evaluation of pt movement = Adapting intervention as needed
Incorporates sensory system (Rood)
Active participation
Key Principles of NDT:
Normalizing Muscle Tone: Use techniques like manual handling, weight-bearing, and specific positioning to influence muscle tone and facilitate normal motor responses
Employ manual guidance, sensory stimulation, and therapeutic activities that encourage the use of normal movement patterns
Use therapeutic techniques to adjust body positioning and handling to promote optimal alignment, balance, and motor control
Engage patients in functional activities that are meaningful and relevant, integrating therapeutic exercises with real-life tasks
Key Techniques in NDT:
Facilitation: Techniques such as tapping, stroking, or weight shifting to promote muscle activation and normal movement.
Inhibition: Methods like deep pressure or prolonged stretch to reduce spasticity and abnormal muscle tone.
Sensory Stimulation: Using sensory inputs to influence motor responses, such as using visual or tactile cues to guide movement.
Functional Activities: Engaging patients in task-specific practice to improve their ability to perform everyday activities.
NDT Therapeutic Goals:
Improving Motor Control: Enhance the patient’s ability to control and coordinate movements.
Enhancing Postural Control: Improve balance and stability through effective handling and positioning.
Facilitating Functional Independence: Support patients in achieving greater independence in daily living activities.
Clinical Application- NDT:
Patient- R CVA with impaired sensation, trunk and L sided weakness, L inattention
Postural analysis- thoracic kyphosis, L lateral and posterior trunk lean, posterior pelvic tilt (sacral sitting)
Activity of Session- UE dressing EOB
Initial goal- midline sitting balance and neutral pelvic position - How could we do this?
Position the patient at the edge of the bed or in a supportive chair. Use pillows, cushions, or rolled towels to support the trunk and pelvis - Place a pillow behind the patient’s back to support the thoracic spine and reduce kyphosis
engage the patient in exercises that promote trunk stability and alignment - Seated Marches: Have the patient lift one knee at a time while sitting, encouraging trunk stabilization
Use mirrors or visual markers to help the patient see and correct their posture - Place a mirror in front of the patient so they can visually monitor and adjust their trunk position and alignment.
Incorporate activities that require maintaining midline balance and neutral pelvic position - Reaching Tasks: Have the patient reach for objects placed at different angles while maintaining sitting balance
Proprioceptive Neuromuscular Facilitation (PNF)
Musculoskeletal & neuro-muscular dysfunction
Therapist focuses & capitalizes on patient’s strengths and not on the observed deficits (“untapped existing potential”)
Enhance appropriate movement patterns & postural responses; used to complement other manual skills
Diagonal movement patterns
Proprioceptive Neuromuscular Facilitation (PNF) Techniques –
promote better kinesthetic awareness & more efficient neuromuscular control
Increase patient mobility/stability
Guide/initiate patient movements
Facilitate more efficient & coordinated movement through normal timing/muscle activation
Increase ROM, strength, endurance
- Promote Better Kinesthetic Awareness & More Efficient Neuromuscular Control:
Improve awareness of movement patterns and coordination.
Perform the movement passively, then actively, and with resistance to help the patient learn the correct movement patterns and enhance proprioceptive feedback
- Increase Patient Mobility/Stability:
Contract-Relax: Increase range of motion (ROM) and flexibility by using muscle contractions followed by stretching
> patient contracts the muscle group against resistance, then relaxes, allowing for a deeper stretch of the target muscle group
Hold-Relax: Enhance flexibility and reduce muscle tightness, contributing to better stability
> patient holds a stretch position while performing an isometric contraction of the opposing muscle group, followed by a relaxation phase to increase the range of motion
- Guide/Initiate Patient Movements:
manual contact: Provide physical guidance to initiate and control movement
> Use hands-on techniques to guide the patient’s limbs through specific movement patterns, enhancing proprioceptive feedback and movement initiation
Facilitated Stretching: Promote active movement by facilitating muscle activation through stretch reflexes
> gentle stretch to the muscle group to stimulate the stretch reflex, encouraging the patient to initiate the movement actively
- Facilitate More Efficient & Coordinated Movement Through Normal Timing/Muscle Activation:
Stabilizing Reversals: Improve stability and control by alternating resistance
> Apply resistance to one side of a joint, then switch to the opposite side, which helps in developing balanced muscle activation and coordination
Alternating Isometrics: Enhance strength and stability by engaging muscle groups in an alternating fashion
> Apply isometric resistance alternately to different muscle groups around a joint to improve muscle endurance and stability
- Increase ROM, Strength, Endurance:
contract-Relax and Hold-Relax Techniques: Increase ROM and muscle flexibility.
> Use these techniques to stretch the muscles by leveraging isometric contractions followed by relaxation and stretching
Dynamic Reversal and Rhythmic Initiation: Increase strength and endurance through resisted movements.
> Perform movements with resistance to enhance muscle strength and endurance, while ensuring the use of proper movement patterns.
Key Principles of PNF:
utilizes diagonal and spiral movement patterns that mimic natural movement, integrating multiple joints and muscle groups
employs various techniques to facilitate muscle contractions and improve neuromuscular function: stretch reflexes, resistance, and manual contact
proprioceptive (sensory) inputs such as stretching, resistance, and tactile cues to enhance motor responses and coordination
UE D1 Flexion
Shoulder girdle-anterior elevation
Shoulder- flexion, adduction, ER
*Elbow- flexion
Forearm- supination
Wrist- flexion, radial deviation
Finger- radial flexion
Thumb- adduction
Upper Extremity D1 Flexion Pattern:
Movement Sequence:
Shoulder Flexion: The arm moves from a position of abduction and external rotation to flexion.
Shoulder Adduction: The arm moves across the body towards the midline.
Shoulder External Rotation: The shoulder maintains or slightly increases external rotation during the movement.
Elbow Flexion: The elbow flexes as the arm moves towards the body.
Wrist Flexion: The wrist also flexes and rotates, often ending with the fingers in a grasping or closed position.
UE D1 Extension
Shoulder girdle-posterior depression
Shoulder- extension, abduction, IR
*Elbow- extension
Forearm- pronation
Wrist- extension, ulnar deviation
Finger- ulnar extension
Thumb- abduction
Upper Extremity D1 Extension Pattern:
Shoulder Extension: The arm moves backward from the flexed position, extending the shoulder.
Shoulder Abduction: The arm moves away from the body, spreading out to the side.
Shoulder Internal Rotation: The shoulder rotates inward as the arm moves.
Elbow Extension: The elbow extends as the arm moves away from the body.
Wrist Extension: The wrist also extends, ending with the fingers in an open position.
UE D2 Flexion
Shoulder girdle- posterior elevation
Shoulder- flexion, abduction, ER
*Elbow- extension
Forearm-supination
Wrist- extension, radial deviation
Finger- radial extension
Thumb- extension
Upper Extremity D2 Flexion Pattern:
Movement Sequence:
Shoulder Flexion: The arm moves from an extended position to flexion, lifting the arm upward and outward.
Shoulder Abduction: The arm moves away from the body, spreading out to the side.
Shoulder External Rotation: The shoulder rotates outward during the movement.
Elbow Extension: The elbow extends as the arm reaches the end position.
Wrist Extension: The wrist extends with the fingers open, finishing in a position as if reaching to the side or up.
UE D2 Extension
Shoulder girdle-anterior depression
Shoulder- extension, adduction, IR
*Elbow- extension
Forearm- pronation
Wrist- flexion, ulnar deviation
Finger- ulnar flexion
Thumb- opposition
Upper Extremity D2 Extension Pattern:
Movement Sequence:
Shoulder Extension: The arm moves from a flexed position to extension, moving backward and downward.
Shoulder Adduction: The arm moves towards the midline of the body, narrowing the angle between the arm and torso.
Shoulder Internal Rotation: The shoulder rotates inward during the movement.
Elbow Flexion: The elbow bends as the arm moves downward.
Wrist Flexion: The wrist flexes, often ending with the fingers closed or in a grasping position.
LE D1 Flexion
Pelvic girdle- anterior elevation
Hip- flexion, adduction, ER
*Knee- flexion
Ankle- dorsiflexion, inversion
Toe- extension
Lower Extremity D1 Flexion Pattern:
Movement Sequence:
Hip Flexion: The leg moves from an extended position to flexion, bringing it forward.
Hip Adduction: The leg moves towards the midline of the body, narrowing the angle between the leg and torso.
Hip External Rotation: The hip rotates outward as the leg moves.
Knee Flexion: The knee bends as the leg moves forward.
Ankle Dorsiflexion and Toe Extension: The ankle dorsiflexes (moves upward) and the toes extend (move upward).
LE D1 Extension
Pelvic girdle- posterior depression
Hip- extension, abduction, IR
*Knee- extension
Ankle- plantar flexion, eversion
Toe-flexion
Lower Extremity D1 Extension Pattern:
Movement Sequence:
Hip Extension: The leg moves from a flexed position to extension, moving backward and away from the body.
Hip Abduction: The leg moves away from the midline of the body.
Hip Internal Rotation: The hip rotates inward during the movement.
Knee Extension: The knee extends as the leg moves backward.
Ankle Plantarflexion and Toe Flexion: The ankle plantarflexes (moves downward) and the toes flex (curl downward).
LE D2 Flexion
Pelvic girdle- posterior elevation
Hip- flexion, abduction, IR
*Knee- flexion
Ankle – dorsiflexion, eversion
Toe- extension
Lower Extremity D2 Flexion Pattern:
Movement Sequence:
Hip Flexion: The leg moves from an extended position to flexion, lifting it forward and upward.
Hip Abduction: The leg moves away from the midline of the body.
Hip External Rotation: The hip rotates outward during the movement.
Knee Extension: The knee extends as the leg moves forward.
Ankle Dorsiflexion and Toe Extension: The ankle dorsiflexes (moves upward) and the toes extend (move upward).
LE D2 Extension
Pelvic girdle- anterior depression
Hip- extension, adduction, ER
*Knee- extension
Ankle- plantar flexion, inversion
Toe- flexion
Lower Extremity D2 Extension Pattern:
Movement Sequence:
Hip Extension: The leg moves from a flexed position to extension, moving backward and towards the midline of the body.
Hip Adduction: The leg moves towards the midline of the body.
Hip Internal Rotation: The hip rotates inward during the movement.
Knee Flexion: The knee flexes as the leg moves backward.
Ankle Plantarflexion and Toe Flexion: The ankle plantarflexes (moves downward) and the toes flex (curl downward).
What is the Current Research Saying?
Utilizes principles of motor control, motor learning, & neuroplasticity
Interventions:
Task-specific
Intensive
Engaging & meaningful to patient
Clinical practice in neurorehabilitation needs to be individualized
Interventions must be supported by evidence AND objective measurements
Cardiovascular endurance training
Collaboration with community
Active participation
What is motor control?
Ability to regulate or direct the mechanisms essential to movement
What is motor learning?
A set of internal processes associated with practice or experience leading to relatively permanent changes in the capacity for producing skilled action
What is neuroplasticity?
Ability of nervous system to adapt and reorganize, often as a result of injury, learning and/or experience
Principles of Neuroplasticity
1) use it or lose it
2) use it and improve it
3) specificity
4) repetition matters
5) intensity matters
6) time matters
7) salience matters
8) age matters
9) transference
10) interference
Use It or Lose It
failure to drive specific brain functions can lead to functional degradation
Neural circuits that are not actively used can weaken or be lost. Active engagement strengthens and maintains neural connections
Application: Regular practice of skills or activities helps preserve and enhance neural pathways.
Example: After a stroke, if a person stops using their affected limb, the neural pathways related to that limb can weaken. To prevent this, regular practice and use of the limb in daily activities or therapy can help maintain and strengthen these pathways.
Use It and Improve It
training that drives a specific brain function can lead to an enhancement of that function
Engaging in challenging and relevant activities can enhance neural function and abilities.
Application: Tasks that are challenging but achievable drive neural improvements, promoting skill development and recovery.
Example: An individual with brain injury engages in targeted cognitive exercises, such as problem-solving tasks or memory drills. This challenging practice helps improve cognitive functions and promotes neural improvements specific to the tasks being practiced.
Specificity
the nature of the training experience dictates the nature of the plasticity
type of training or experience leads to specific changes in the brain
Application: Training should be tailored to the specific skill or function you want to improve to achieve targeted neural changes.
Example: A person recovering from a spinal cord injury practices specific movements required for walking, like hip flexion and knee extension. This targeted practice enhances the specific neural pathways involved in walking rather than focusing on unrelated movements
Repetition Matters
induction of plasticity requires sufficient repetition
Repeated activation of neural circuits leads to more significant and lasting changes
Application: Frequent practice and repetition are necessary to solidify and maintain neural improvements.
Example: A musician practices a new piece of music repeatedly. The repetitive practice strengthens the neural connections involved in finger dexterity and coordination, leading to improved performance and skill over time.
Intensity Matters
induction of plasticity requires sufficient training intensity
extent of plastic changes is influenced by the intensity of the training or stimulation
Application: Effective interventions often require an appropriate level of intensity to drive meaningful changes.
Example: In rehabilitation for a sports injury, a therapist uses high-intensity interval training (HIIT) to improve strength and endurance. The intensity of the training promotes more significant and effective neural adaptations compared to low-intensity exercises.
Time Matters
different forms of plasticity occur at different times during training
There are critical periods during which plasticity is more pronounced. The timing of interventions can affect their efficacy
Application: Early and well-timed interventions can leverage periods of heightened plasticity for better outcomes.
Example: During the critical period after a brain injury, intensive therapy is provided. Early intervention capitalizes on this period of heightened plasticity, which can significantly improve recovery outcomes compared to starting therapy later.
Salience Matters
the training experience must be sufficiently salient to induce plasticity
The training or experience must be relevant and meaningful to the individual to be effective
Application: Personalizing tasks to align with the individual’s interests and goals enhances engagement and effectiveness.
Example: A therapy program for a stroke survivor incorporates tasks that are personally meaningful, such as cooking a favorite meal. The relevance and personal interest in the task enhance engagement and effectiveness of the therapy.
Age Matters
training-induced plasticity occurs more readily in younger brains
capacity for neuroplasticity varies with age, with younger individuals often showing more rapid changes, though plasticity can still occur in older individuals
Application: Interventions should consider age-related differences in plasticity but recognize that neuroplasticity can benefit individuals of all ages.
Example: A young child with a brain injury may show rapid recovery due to higher neuroplasticity compared to an older adult. However, older adults can still benefit from rehabilitation with tailored interventions that consider their specific neuroplasticity capacity.
Transference
plasticity in response to one training experience can enhance the acquisition of similar behaviors
Learning or improvements in one area can transfer to other, related areas
Application: Skills learned or improved in one context can facilitate gains in other contexts, such as improving overall motor skills by training specific movements.
Example: Training in balance exercises for an elderly individual not only improves their balance but also enhances their overall mobility and gait. The improvement in balance transfers to other aspects of movement and daily functioning.
Interference
plasticity in response to one experience can interfere with the acquisition of other behaviors
New learning or experiences can interfere with previously learned skills or recovery processes
Application: Be mindful of how new interventions might affect existing skills or recovery, and plan accordingly to minimize negative interference.
Example: A patient with stroke recovery practices a new motor skill but also continues to perform an old, less efficient technique. The old technique may interfere with learning the new skill. Adjusting practice to minimize interference helps focus on improving the new skill effectively.
Prediction
personalized: neuroimaging
intervention: team work, partnerships
outcome: better health
Prevention
personalized: genes
intervention: exercises, health promottion
outcome: impairments prevented
Plasticity
personalized: classification
intervention: motor training, intensity
outcome: better motor
Participation
personalized: goals
intervention: self efficacy, virtual reality
outcome: goals achieved
Historical approaches-
not supported by research
Evidence supports experience-dependent neuroplasticity and high-intensity interventions for recovery after neurologic injury
Need model(s) to help guide future research on neuro-rehabilitation intervention
Justification for our practice, patients and payment
Traditional Medical Models
Historically, treatment for neurological injuries often focused on passive modalities, such as rest, immobilization, and medications, with limited emphasis on active rehabilitation
These approaches may not have effectively promoted functional recovery or neuroplasticity as they did not engage the patient actively in their recovery process
Evidence-Based Approaches:
Neuroplasticity is driven by experiences and activities that stimulate neural pathways. Targeted and meaningful activities promote functional recovery
Research shows that engaging in activities that are relevant and challenging to the individual can enhance neural adaptations and functional outcomes
Need for Models to Guide Research:
Developing comprehensive models that integrate principles of neuroplasticity, such as those addressing specificity, repetition, and intensity, can guide future research and practice
Models can help in identifying key variables and conditions that influence neuroplasticity and recovery, guiding the development of targeted research studies
Justification for Practice, Patients, and Payment:
Utilizing evidence-supported interventions ensures that treatments are based on current research, which improves patient outcomes and enhances the efficacy of rehabilitation
Evidence-based interventions that focus on neuroplasticity and high-intensity training offer the potential for better recovery and functional improvements, benefiting patients significantly
Demonstrating that high-intensity and targeted interventions lead to better outcomes can justify the costs of these treatments to insurers and funding bodies
walking recovery model for stroke
strong recommendations:
measurement
-10MWT
-6MWT
-Functional gait assessment
intervention
-tailored
-task-oriented
-repetitive practice
delivery methods:
-circuit class
-treadmill
-cardio-respiratory fitness training
walking recovery model for stroke
emerging innovations:
optimizing dosage
personalized interventions
targeted biomechanical factors
enhancing motor learning
neuro-modulation
behavior change technqiues
walking recovery model for stroke
personal factors:
motivation
age
mood
support
walking recovery model for stroke
performance capacity:
impairment
activity
participation
independence
speed
endurance
quality
walking recovery model for stroke
environmental factors:
load
distance
terrain
traffic
attention
doors/turns
speed
weather
walking recovery model for stroke
future roadmap: driven by stroke survivor needs, increase evidence-base
measurement:
-focus on performance measures
-biomarkers for prediction
-big data & data-sharing
intervention:
-large studies, global team development
- robust trial design
implement what we know:
apply a common language
recommended measures/interventions
invest in people
environments and service delivery pathways to promote recovery
support self-management
technology
____ are key to what we do as PTs
Movement/task analysis
_____ still have their place, albeit differently than with historical approaches
Facilitation/handling techniques
