Intro to Neuromuscular Re-education Flashcards
what is motor control?
the ability of the neuromuscular system to regulate or redirect the mechanisms essential to move
ability of the system to produce output
what is motor learning?
set of processes associated with practice or experience which leads to relatively permanent changes in the capability of producing skilled action
way in which we adapt/change/relearn
motor learning is a direct result of what?
neuroplastic change
what is neuroplastic change?
the expansion and/or reorganization of the cortical map
what drives fxnal recovery after a stroke?
cortical plasticity and reorganization mechanisms
how long can reorganization take?
years
t/f: reorganization after a stroke can be positive or negative
true
what are the 3 mechanisms of neuroplasticity?
1) injury driven change
2) neuronal modification
3) experience driven change
what is involved in injury driven change in neuroplasticity?
cellular level changes
recovery following CNS injury
what is involved in neuronal modification in neuroplasticity?
stimulus driven change
synaptogenesis for the development of new neural pathways
activation of parallel neural pathways (opposite hemisphere)
activation of silent and redundant neural pathways
what is involved in experience driven change in neuroplasticity?
experience-expectant plasticity
experience-dependent plasticity
what is experience-expectant plasticity?
in reference to critical periods of developmental change (important in growing babies)
what is experience-dependent plasticity?
motor learning is an example of this
use-dependent, fxn-dependent, task-dependent
t/f: in the performance of a motor task/activity, brain activity is linked to the phase of motor learning
true
during the initial phases of neuroplastic changes (skill acquisition), what is happening in the brain?
there are large and diffuse areas of the brain that are active
immediate reorganization due to unmasking of previously nonfxnal synaptic connections in neighboring areas.
during the autonomous phases, what is happening in the brain?
when tasks are repeated, the # of active areas of the brain are reduced
during the skilled phase, when tasks are learned, what is happening in the brain?
smaller, more distinct areas of the brain show an increased activity
brain areas neighboring the lesion take over those parts of the map that were occupied by damaged cells
during what phase of neuroplasticity is less attention required to perform the task resulting in the brain regions becoming more focal as skilled performance increases?
during skilled phases
what is dendritic aborization?
branching out of dendrites to take over damaged parts of the brain
what are regenerative and reactive synaptogenesis?
ways of neurons taking over damaged parts of the brain
neuro rehab should result in _____ ______
brain change
TMS or fMRI shows that what kind of training and environment produces long-lasting cortical reorganization?
task-specific training in enriched environments
t/f: the tasks need to be fxnal to lay down a fxnal map
true
recovery of neuronal fxn after brain injury is influenced by what?
the type, intensity, and timing of rehab relative to surgery
t/f: early rehab is necessary for improved outcomes
true
t/f: during days 1-5, intensity needs to be monitored carefully
true
would you want to do forced use for the involved UE at day 3? why or why not?
nope bc it is probably too intense and will be counterproductive
t/f: being too rigorous too early can be counterproductive
true
what are the 10 neuroplastic principles?
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
what does the neuroplastic principle of use it or lose it mean?
failure to drive specific brain fxns can lead to fxnal degradation
what does the neuroplastic principle of use it and improve it mean?
training that drives a specific brain fxn can lead to an enhancement of that fxn
what does the neuroplastic principle of specificity mean?
the nature of the training experience dictates the nature of the plasticity
what does the neuroplastic principle of repetition matters mean?
induction of plasticity requires sufficient reps
what does the neuroplastic principle of intensity matters mean?
induction of plasticity requires sufficient training intensity
what does the neuroplastic principle of time matters mean?
different forms of plasticity occur at different times during training
what does the neuroplastic principle of salience matters mean?
the training experience must be sufficiently salient to produce plasticity
what does the neuroplastic principle of age matters mean?
training-induced plasticity occurs more readily in younger brains
what does the neuroplastic principle of transference mean?
plasticity in response to one training experience can enhance the acquisition of similar behaviors
what does the neuroplastic principle of interference mean?
plasticity in response to one training experience can interfere w/acquisition of other behaviors
what is motor recovery?
the re-acquisition of mov’t skills lost through injury
variable and individualized
cortical representation of mov’t can be changed in what 3 ways?
1) spontaneous recovery
2) task/fxn-induced recovery
3) learned non-use recovery
what is spontaneous recovery?
the initial neural repair processes that occurs immediately after injury
what is task/fxn-induced recovery?
use of dependent cortical reorganization
the NS modifies itself
includes forced paradigms such as CIMT
what is learned non-use recovery?
non-use resulting in faulty/poor mov’t patterns
complete recovery may not be possible, but rather skills may be modified in what 2 ways?
compensation and substitution
what is compensation/substitution?
adaptation of remodeling motor or use of alternative motor elements
adoption of alternative strategies to complete a task
t/f: motor relearning is impaired w/sensory impairments
true
while motor and sensory processing are independently adaptive, what is the driving factor of fxnal neural adaptation?
the interaction bw them
what is an important input to motor learning and skill acquisition?
proper sensory input
what is the Brunnstrom theory to motor recovery?
heirarchical
using primitive, synergistic patterns to facilitate mov’t
a damaged CNS regresses to an older pattern of mov’t
which approach to motor recovery theorizes that primitive reflexes, synergies, and abnormal mov’ts are a part of recovery b4 normal mov’t occurs?
Brunnstrom
what is the technique for Brunnstrom’s approach?
facilitate synergies and primitive reflexes
progress through developmental (fxnal) positions
walking delayed
what is the NDT (Bobath) theory to motor recovery?
normalize tone, inhibit primitive patterns of mov’t, facilitate automatic , voluntary motor responses and subsequent normal patterns
what approach is the opposite to Brunnstrom?
NDT
what are the techniques of NDT?
therapeutic handling
key points of control to stop reflexes
facilitate normal and inhibit abnormal inputs
what is the Rood approach theory to motor recovery?
sensorimotor
modify muscles tone and motor activity using cutaneous sensorimotor stimulation
what is the technique of the Rood approach?
proprioceptive, exteroceptive, vestibular, vision, auditory, olfactory, gustatory inputs selected
what is the PNF theory of motor recovery?
stimulation of nerve, muscle, and sensory receptors through manual stimulation
what approach to motor recovery uses diagonal mov’t patterns that are fxnally relevant?
PNF (Kabat, Knott, and Voss)
what are the techniques of PNF?
facilitation of mov’t patterns using key manual contact and techniques
resistance, irradiation/reinforcement, stretch, verbal commands, traction/approximation, timing, body position/mechanics
what is the MRP (motor relearning programme) approach to motor recovery?
task-oriented approach
dynamical systems
ecological model
what is the theory of the MRP approach to motor recovery?
appropriate sensory input will modulate motor output
eliminate all unwanted motor activity w/in a task performance
NO developmental positions
want mov’t as normal as possible
which approach to motor recovery aims to eliminate all unwanted motor activity w/in task performance?
MRP
what are the techniques of MRP?
task analysis
performance of whole tasks (task specific training)
performance of task component using normal mov’t patterns
transference of learning
what is the neuro IFRAH approach to motor recovery?
sensorimotor, task oriented approach similar to MRP
what is the neuro IFRAH theory to motor recovery?
a combo of the approaches focused on normal fxnal task performance
what are the techniques of neuro IFRAH?
similar to MRP, NDT
unique tools are utilized
proprietary technique
which approach to motor recovery must you be trained in?
neuro IFRAH
what is the CIMT (constraint induced mov’t therapy) approach to motor recovery?
forced use
repetitive, task-specific practice (RTP)
what is the CIMT theory of motor recovery?
repeated “forced use” of an extremity results in cortical reorganization to restore normal mov’t
what are the techniques of CIMT?
non-affected extremity is constrained in a mitt and the pt uses the involved extremity for a majority of the day, for an extended period of time
what is the mirror therapy approach to motor recovery?
repetitive, task-specific practive (RTP) with use of a mirror for feedback
what is the theory of the mirror therapy approach to motor recovery?
viewed mirror image of the non-affected limb activates pathways of normal mov’t in the affected limb
what are the techniques of the mirror therapy approach to motor recovery?
non-affected extremity performs mov’t and reflection is watched in the mirror
involved extremity is similarly moved
when is error augmentation appropriate to use?
in pts who are cerebellar dependent so they can correct/refine mov’t
when is error augmentation not appropriate to use?
in pts who are cerebellar deficit bc they can’t correct/refine mov’t
what is the theory behind error augmentation for motor recovery?
using erroneous sensory feedback to enhance adaptation to a new environment
when is errorless learning appropriate to use?
in pts who are cerebellar deficient bc they can’t correct/refine mov’t
when would we maybe not want to use errorless learning?
when a pt is cerebellar dependent bc they can be challenged to correct mov’ts
t/f: there is overlap bw the different approaches to motor recovery?
true
t/f: there is evidence that one technique for motor recovery is better than another
false
t/f: there is limited evidence surrounding the use of the motor recovery techniques
true
what does current evidence on approaches to motor recovery support?
using a mix of components from dif approaches appears best for promoting fxnal independence following a stroke
some treatments show promise for improving motor recovery, esp those that focus on high-intensity and repetitive task-specific practice
there is most promise for improving motor recovery for approaches that do what?
focus on high-intensity and repetitive task-specific practice
what are some commonalities among PNF and neuroplasticity principles?
use it or lose it
use it and improve it
specificity
reps matter
intensity matters
salience matters
what are the 4 principles of therapeutic handling?
1) decrease the amount of force the client uses to stabilize body segments
2) direct (facilitate) initiation of mov’t efficiency and effectiveness of recruitment
3) guide/redirect the direction, force, speed, and timing of muscles activation for successful task completion
4) grade the input
how do we decrease the amount of force the client uses to stabilize the body segments?
provide external support where/when needed to decrease effort
support (provide stability) or change alignment of the body w/respect to gravity (treatment position) if needed
how do we direct (facilitate) initiation of mov’t efficiency and effectiveness of recruitment?
contrain or increase degrees of freedom needed to stabilize or move
how do we grade input?
recognize when the client can recruit/fxn independently of the therapist’s input and take over control of posture and mov’t
what part of the Brunnstrom approach do we accept now?
the Brunnstrom recovery stages are correlated w/neurophysiologic measures and highly correlated w/the MMAS (motor assessment scale) regarding the eval of motor recovery in pts following stroke
the recovery stages can be used for the assessment of pts w/post-stroke hemiplegia
which approach may use reflexes, associated, rxns, or overflow moves to initiate mov’t?
Brunnstrom
which approach may use synergistic mov’t to facilitate mov’t, particularly using stronger proximal segments to facilitate weaker distal mov’ts?
Brunnstrom
which approach may use primitive reflexes and equilibrium rxns to achieve active motor responses to weak/absent muscles?
Brunnstrom
t/f: in Brunnstrom’s approach, treatment must progress developmentally from reflex response to voluntary response to fxnal response
true
which approach states that fxnal training and walking is delayed until the transition from developmental reflexes to voluntary responses has occurred?
Brunnstrom
resistance to flexion of the uninvolved LE causes ___ of the ___ extremity
extension, involved
resistance to extension of uninvolved LE causes ___ of the ____ extremity
flexion, involved
what is mirror synkinesis?
resisted grasp by the uninvolved hand causes a grasp rxn in the involved hand
an attempt to flex the involved leg or resistance to leg flexion causes a ____ response in the ____ arm
flexor, involved
what is homolateral synkinesis?
an attempt to flex the involved leg or resistance to leg flexion causes a flexor response in the involved arm
what is Souque’s phenomenon?
active or passive raising of affected arm over 100 degrees w/elbow extension causes the fingers to extend and abd
what is Raimiste’s phenomenon?
resistance to add/abd of the uneffected LE results in a similar response to the opposite LE
what are the 4 basic principles of Rood sensorimotor approach?
1) sensory input is required for normalization of tone and facilitation of desired motor responses
2) sensorimotor control is developmentally based
3) mov’t is purposeful; engagement in activities is required to produce a normal response
4) repetition of mov’t is necessary for learning
which approach uses sensory stimulation to muscles and jts to normalize tone and facilitate muscles responses?
Rood
which approach uses superficial cutaneous stim using stroking, brushing, tapping, icing, vibration to elicit voluntary muscle activation?
Rood
t/f: cutaneous stimulation in Rood’s approach can be applied to the agonist or antagonist
true
what are the techniques that can be used in the Rood sensorimotor approach?
neutral warmth
gentle rocking/shaking
slow rolling (rhythmic rotation) (low trunk rotation)
deep tendon pressure (bicipital tendon, ant tib tendon)
jt compression and WB (heavy jt compression)
maintained (prolonged) stretch vs quick stretch
light moving or quick touch
quick icing
fast brushing
tapping
vibration
which approach to motor recovery focuses on the practice of missing task components and whole tasks, as well as transference of learning?
MRP (motor re-learning programme)
what are the 4 steps of MRP (motor re-learning programme)?
1) analyze mov’t or task components
2) practice missing components of mov’t/task
3) practice part to whole mov’t or task
4) transference of learning
when analyzing mov’t or task components in MRP, what kind of activities and environment should be used?
real-world activities and environment
what do we do when practving missing components of mov’t/task in MRP?
prevent unwanted mov’t or compensations
provide feedback, manual guidance to the mov’t
which technique is based upon the inhibition of abnormal reflexes and tone, undesired mov’t prior to mov’t?
NDT (neuro-developmental treatment)
which approach theorizes that abnormal reflexes and mov’t interfere w/acquisition of normal mov’t patterns?
NDT
t/f: we have to manage the UE to do any fxnal training
true
how do we practice NDT?
abnormal tone is reduced by use of reflex-inhibiting postures allowing for pts to feel normal mov’t while preventing use of compensatory motions
once inhibited, the body is ready for mov’t and normal mov’t patterns are facilitated
incorporate sequential developmental positions one following by the other
what are reflex inhibition postures/patterns (RIPs)?
a position that is used to inhibit spasticity by lengthening shortened muscles
what are the foundations of facilitation in NDT?
1) using both sides of the body (symmetry)
2) preventing abnormal mov’t (compensations), abnormal reflexes and clinical hypertonicity during facilitation
3) avoiding use of ADs
4) using key points of control
what are the key points of control?
head and trunk
humeral head
thumb
hip and femur
sternum and low back
how do we use the head and trunk as key point of control?
head and trunk flexion decreases shoulder retraction, trunk and limb extension
how do we use the humeral head as a key point of control?
humeral head ER and flexion to 90 degrees decrease flexion tone of the UE
why does flexion synergy of the UE cause spasticity?
bc in flexion synergy, the humeral head is pushed anterior onto the biceps tendon causing a quick stretch increasing spasticity
how can we use the humeral head to decrease UE flexion synergy?
in supine, put force down on the humeral head while holding the UE in ER and ext
how do we use the thumb as a key point of control?
thumb abd and ext w/forearm sup decreases flexion tone of the wrist and fingers
how do we use the hip and femur as key points of control?
femoral ER and abd decreases extensor/add tone of the LE
how do we use the sternum and low back as key points of control?
facilitates anterior pelvic tilt/postural extension or posterior pelvic tilt/trunk flexion
how can we break extension synergy in the LE?
bring the LE into flexion and ER
which approach is generally thought to include elements of both PNF and NDT?
neuro IFRAH
t/f: there is currently no independent evidence validating the neuro IFRAH approach or demonstrating improved fxnal outcomes in stroke
true
what is involved in planning NMR interventions?
task-specific interventions
experience-dependent plasticity
during Brunnstrom phase 1, what is the goal of interventions?
normal active motor recruitment
during Brunnstrom phase 2, what is the goal of intervention
normal active motor recruitment
prevention of synergies when possible (may have to have them sit instead of stand)
during Brunnstrom phase 3, what is the goal of intervention?
use as many reflex inhibiting postures as possible
decrease the influence of any clinical hypertonicity
try to facilitate more normal active motor recruitment
during Brunnstrom phase 4, what is the goal of interventions?
trying to maximize fxn
active motor recruitment
may try to make mov’t “pretty” with error augmentation
when would we NOT want to try to implement error augmentation for intervention?
when a pt is in marked spasticity
during Brunnstrom phase 5, what is the goal of intervention?
strengthening
when can we start normal strengthening in interventions with stroke recovery?
when the pt is outside of synergistic influence
what are the 5 steps in changes structures though function?
1) prepare the brain (prime the pump)
2) prepare the body
3) promote e recovery (task specific training)
4) repeat, repeat, repeat (experience dependent plasticity)
5) transference and interference
5)
what is inhibition facilitation?
preventing or redirecting components of mov’t that are unnecessary and interfere w/intentional, coordinated mov’t
do we have more control over the underlying spasticity or the clinical hypertonicity?
clinical hypertonicity
when inhibiting tone, what steps do we have to take?
1) know what mov’t you want, ask for it, and make certain you get it (promote positive plasticity)
2) make every mov’t count in your session (and instruct the same for home) (avoid negative plasticity)
when inhibiting tone, if you don’t get what you want immediately, what should you do?
change what you’re doing (hands, technique, position, environment, task)
how do we do mov’t and task analysis?
break down (deconstruct) a fxnal activity into its component parts to understand and evaluate the demands of the task
what is involved in step 1, prepping the brain?
aerobic activity of moderate to high intensity to increase neurotrophin production and increase post stroke neuroplasticity and recovery of cognitive and motor processes
what are the 3 “ingredients” for increased neurotrophin production during moderate to high intensity aerobic exercise?
1) brain derived neurotrophic factor (BDNF)
2) insulin-like growth factor-I (IGF-I)
3) nerve growth factor (NGF)
what does brain-derived neurotrophic factor (BDNF) do?
synapse formation and neuronal growth
what does insulin-like growth factor-I (IGF-I) do?
promotes better recovery
what does nerve growth factor (NGF) do?
promotes growth and survival of sensory and sympathetic neurons
what is involved in increasing post stroke neuroplasticity and recovery of cognitive and motor processes?
synaptogenesis in multiple brain regions
dendritic branching or arborization (only with moderate intensity exercise)
what is involved in step 2, prepping the body?
biomechanical alignment (esp the pelvis and feet stable on the ground)
adequate stability
we need to ensure the pt has adequate stability to allow for what?
distal mobility
controlled mobility
transitional mobility
t/f: distal mobility requires proximal trunk stability
true
how do we get controlled mobility?
by controlling mov’t w/in a position
weight shifting to the limits of stability
how do we get transitional mobility?
by controlling as the COG changes from position to position or task to task
what is activities/positions are involved in transitional mobility?
sit to stands
tall kneeling and half kneeling
gait pattern control
how do we ensure appropriate muscular tone/activity?
inhibition of clinical hypertonicity
reduce the effects of spasticity or rigidity
facilitating normal muscle tonus or active motor output
why should we avoid “splinter” exercises like LAQ and SAQ in stroke rehab?
bc they are ortho focused interventions that are targeting muscle strength, while in stroke rehab we need to target normal motor recruitment
