Lecture 2: Foundation for General Neuro-Based Interventions Flashcards
Our goal in Neuro is to optimize functional competence.
* The ability to perform daily activities in a variety of environments, under different conditions, with a minimal expenditure of physical and cognitive resources. We want them to get to the point where they don’t feel like they have to put so much effort into every single action. This includes the cognitive realm (thinking about not falling for instance)
This is kind of like a new normal. Some people have all their normal functions come back after a stroke and they feel like they’re “normal” again. While others dont
4 principles of neuro rehab - don’t memorize these
1) Effective neuro rehab involves a continuous cycle of deductive and inductive reasoning
2) The goal of neuro rehab is functional competence
3) Functional competence is promoted by basing rehab strategies on embedded models of motor behavior and neuro rehab
4) Functional competence requires motor learning and self efficacy
* Self efficacy = the condifence in yourself to do something. The more confident you are in doing something the better its going to turn out
*
Use of theories or models to guide interventions is inductive or deductive reasoning?
Deductive
Use of patient releated data to support or reformulate theories is inducted or deductive reasoning?
Inductive
these are more our obsevrations
How models can affect what we do
* movement science
* Medical Science
* Rehabilitation science
Coordinate that deductive reasoning w/ our observations (inductive reasoning)
how you view something is everything. Your lense / interpretation makes everything different
You can see the other 3 pictures show different treatment styles. Using different techniques to get the same outcome to decrease tone. Different ways we will approach one pt. Theres no one set way, but there are things you shouldnt do. Not every therapist sees things from the same POV
Different approaches for neuro rehab: - probs mix and match
1) muscle reeducation - theoredical basis is on the physiology of the muscle. Importance of pt knowledge and and motivation. Conscious activation and relaxiation of the muscles. Assumes that increased strength and endurance improves function - however this isnt true, and we know we might not be able to strengthen a m after an injury - however, they can learn techniques to work around that
2) Neurofacilitation - looking at reflex and heirachical models of motor contorl - here they want normal posture and tone - then work w/ them so fix these details first
3) Motor learning - mostly base don healthy individuals is the problems w/ these studies. Emphasis on patient driven approach to motor planning, error detection, and problem solving. Emphasis on importance of task and environment; Use of task and environment set-up information delivery, and structured practice for motor learning. Motor learning is the process of acquiring and refining skilled movements through practice and experience
Which of our 3 theraories (muscle reeducation, neurofacilitation, motor learning) is focused on the use of strengthening exercises and conditioning activities to promote the performance of functional activities with the least energy cost to the pt.
In this theory we increase the strength and contorl of areas of the body beliebed to be spared by a pathology, rather thant rying to restore lost functions
Muscle reeducation
Assumption: increase in strength will directly translate into improved function
Principles: anatomy, kinesiology, exercise science
Which neuro therory focuses on specific exercises, not actual tasks and environment
Muscle reeducation
In which of our neuro theries should pts relearn functional activities through practice and repetition of the normal movement patterns used by healthy individuals?
Manual guideance and sensorimotor stimulation were used to eleicit and strengthen motor responses, and specific movement progressions where utilized to promote the restoration of skilled motor behavior
* these will help you form that skill
Allowing erroneous or compensatory movements was beleieved to interfere w/ the restoration of skilled motor control - so we want to normalize/correct the abnormal movement
Principles: reflex, feedback, hierarchial models of motor contorl.
Neurofacilitation
Get them in that normal pattern and only focus on that normal pattern.
Which neuro theroy says: Motor behavior of patients with neurological pathology reflected their best attempts to carry out functional tasks with a limited motor capacity
Patients needed to learn to regain their motor function as independently as possible through structured exploration of motor tasks, self assessment, information processing, self-correction, and practice
Principles: biomechanics, neuroscience, cognitive and behavioral psychology, cybernetics and human ecology.
Motor learning
remember motor learning is in everything we do, not just neuro
In the neuro setting we need to
* Promote neuroplasticity
* Function based therapy
* integrate multiple components of the therories
10 principles of neuro plasticity
Which principle of neurplasticity is failure to drive specific brain function can lead to functional degradation
Use it or lose it
Which principle of neuroplasticity is training that drives a specific brain function can lead to an enhancement of that function
Use it and improve it
Train that function to better that function
Which principle of neuroplasticity is the nature of the training experience dictates the nature of the plasticity
* has to be specific to what the goal is
Specificity
Which principle of neuroplasticity is induction of plasticity requires sufficient repetition
Repetition matters
Which principle of neuroplasticity is induction of plasticity requires sufficient training intensity
Intensity matters
Which principle of neuroplasticity is different forms of plasticity occur at different times during training
* think someone had a stroke and didnt get therapy for a while. That time that wasnt spent healing will be a major factor in not getting back to prior level of function
Time matters
Which principle of neuroplasticity is the training experience must be sufficiely salient (releates to pt) to induce plasticity
Salience matters
needs to be meaningful and important
Which principle of neuroplasticity is plasticity in response to one training experience can enhance the acquisition of similar behaviors
Transference
Which principle of neuroplasticity is plasticity in response to one experience can interfere with the acqusition of other behaviors
* think if someone was going through rehab and stopped, that could interfere w/ their progression or if something else happened at that time (think another event)
Interference
Knowledge check: What kind of reasoning would be more pt releated information?
Inductive
Remember, deductive is the models
Principle 2: The goal of neuro rehab is functional competence
Activities that are meaningful and important to the pts life motivates and engages the pt
* think salience
Goals of body structure and function are part of this, but should not supersede the goal of functional competence
Setting ROM/MMT goals wouldnt supercede standing and getting out of a chair for a neuro pt
* Function first - link everything to function
Through movement strategies/patterns were trying to create coordination (also known as schema)
We are coordinated individuals, the halves of our body work together. However, in neuro injuries the halves of the body don’t work togther properly
* so our schema after a neuro energy is damaged
Another word for coordination mode?
Schema
What we use to carry out a motor task. Its a plan
Movement strategies
The actual kinematics employed to perform the task?
Movement patterns
General form of actions that can be adapted to specific tasks and environments
* EX: how to perform sit to stand
Coordination mode (schema)
pts need to generate a variety of movements with flexible coordination modes when carrying out activities, not just performing a specific set of movement patterns
* so you need to know how to do a sit to stand in multiple different environments
* Not just a specific set of movement patterns
Principle 3: Functional competence is promoted by basing rehab strategies on embedded models of motor behavior and neuro rehab
* rehab works when we can give our pt a well designed functional task that quires the use of desired movements in a meaningful context
* so were designing a program where a pt is able to use tools / what they learned and be sucessful in their lives
Promote spontaneous use of the pattern within functional tasks (carryover)
Increase availability of movement patterns to increase strategies
* have more tools in the toolbox
Embedding - meaningul tasks that require performance of the targeted movement pattern
* EX: supination impaired after CVA - incoporate into opening a book, carrying dinner plate
Meaningful task that require performance of the targeted movement pattern
Embedding
EX: supination impaired after CVA - incorporate into opening a book, carrying dinner plate
* things that are meaningful to the pt
A = traditional ICF model
B = we want to also make sure were opening our eyes to see the ICF as an imbedded model.
* think about the impairment being at the core and were building around it
* especially if that health condition isnt going away
Principle 4: Functional competence requires motor learning and self efficacy
Choose interventions and use rehab strategies that promote retention and transfer of skills, not just initial performance
An important key to learning is to optimize patient engagement by manipulating the conditions for pt experiences and practice and building the confidence of pts in their abilities
* give them the environment to build confidence to make errors then advance it
Should always incooperate aerobic EX in w/ pts
Promotes:
* Greater capacity for motor learning and neuroplasticity
* Improved executive function
* Improved cardiovascular health and physical performance
Recent advances in the study of neuroplasticity show aerobic EX as low as 30 minutes of exercise at 60% of maximum heart rate increases production of brain derived neutrophic factor, an important facilitator of motor learning and neuroplasticity
Pt w/ gratest potential
* Motivated, confident in their abilities, and wiling to meet the challenges they encounter when performing functional tasks
One of the most commonly reported barriers to EX and mobility for pts at home in the community is low self-efficacy
* Self-efficacy = belief in self that task can be accomplished or goal can be achieved
Motor learning: Learning the mechanics of their new self-organized system, how to utilize mechanisms of control at various levels of their system, and how to use a variety of strategies and mvoements to carry out their desired activities with the least cost to their system
* so its all about efficiency and how to self organize efficiently
* initially after some big event (think a stroke) their energy usage will be through the roof because they are inefficent (think not being able to use half their body) - however, w motor learning they adapt to the new normal and will decrease their total energy expenditure
motor learning abilities among individuals vary across three main foundational categories of abilities:
1) cognitive abilities
2) Perceptial speed ability
3) Psychomotor ability
factors to be aware of: alertness, anxiety, memory speed of processing information, speed and accuracy of movements, and uniquness of the setting
Recovering patients may vary in their learning potential according to the pathology present, the number and type of impairments, recovery potential and general health status, and comorbidities
NOTE: we set the goals to their prior level of function before the event
* if the were non ambulatory we dont want to set gait goals
main principle of motor learning: optimize pt engagement
* what two things make this up
Acqusition of new behavior + retention and transfer of that behavior
So motor learning = acquire skill –> keep the skill –> transfer the skill
What are the 3 stages of motor learning?
Cognitive - What to do
Associative - How to do (physically doing it)
Autonomous - How to succeed
* environment is very variable, and they should be very independent and ready to take on new tasks
* errors should be minimal and they should have good carry over to lots of environments
When breaking down motor learning
Think about:
* Task (general task and demands)
* Individual (body functions)
* Environment (physical features)
“TIE”
Knowledge check: in what stage of motor learning would require the least amount of cueing and be good in the most variable environment
Autonomous
True motor learning = retention of the motor skill
* they can replicate it in any environment
* Factors liek fatigue, anxiety, poor motivation, boredom, or drugs can cause performance to deterorate during practice while learning may still be occured
Defined as a leveling off of performance after a period of steady performance
* Is learning still happening?
Plateau
Characterize normal practice and can be expectued
During pleastus, learning may still be going on, whereas performance is not changing much
* spin the narrative and maybe tell the pt that they need to go home and work on things and come back later
The patient who is able to engage in active introspection and self evaluation of performance and reach decisions independently about how to improve performance demonstrates an important element of learning
* if you can reach your own decisions on what you need to do, thats awesome
Much of the necessary learning of functional skills occurs after discharge and during outpatient episodes of care
The therapist cannot possibly structure practice sessions to meet all of the functional challenges the patient may face
* set your goals wisely
* pt may take a break or come back later
The acquisition of independent problem soliving/decision making skills ensures that the ginal goal of rehabilitation can be achieved
* having the pt be more independent and thinking about their own body is best
out patient works more on skills
in patient is more about getting them moving / discharged
Is our goal restoration or compensation?
Its both
Of course we want to restore as much function as possible, but some times thats not possible so thats why we add compensation techniques when they plateu or have total paralysis
A sequence of practice and rest times in which the rest time is much less than the practice time
Massed practice
Spaced practice intervals in which the practice time is equal to or less than the rest time
Distributed practice
A practice sequence organized around one task performed repeatedly, uninterrupted by practice or any other task
Blocked practice
So again, this is the pt repeating the same skill loads of time in a row before moving on to another skill
* think shooting 50 free throws in a row before moving to some other skill
* Good for beginners because they have less time to forget
A practice sequence in which a variety of tasks are ordered randomly across trials
Random practice
The gain (or loss) in the capability of task performance as a result of practice or experience on some other task
Transfer training
components parts of a task are practiced before practice of the whole task
part/whole practice
A practice strategy in which performance of the motor task is imagined or visualized without overt physical practice
Mental practice
Feedback can be
* Extrinsic
* Intrinsic
* Knowledge of results - task success - external focus
* Knowledge of performance - how to task was perfomed - internal focus
Environment can be:
* Closed - think working on eye movements in a dark room where theres not much going on
* Open - think being in a gym with lots of things going on. This can just be some changing things.
* Variable - this can also be the gym and you can’t contorl for a lot of things happening
how the task was performed is knowledge of results or knowledge of performance?
* internal or external focus?
Knowledge of performance
internal focus
Task sucess is knowledge of performance or knowledge of results?
* internal or external focus?
Knowledge of results
External focus
While you were walking you dragged your feet. Knowledge of results or knowledge of performance
Knowledge of performance
Wow, you just walked 200 feet is knowlege of performance or results?
Results
Different constrains (on motor learning I think)
All of this overalps on individual to impact their ability to learn - based on their diagnosis this will obviously shift
Therapists design the intital plan of rehabilitation by:
* Understanding the pathology, impairments and functional limitations of patients and the ways tasks and environments, information delivery and practice can be used to optimize pt engagement
* Optimize pt engagement, if they’re just coming in 1 time a week they’re not getting better. espically in a neuro setting.
Considerations include:
* Interactions that occur between the intrinsic biomechanical, psychological and neuromuscular constrains of pts
* Extrinsic spatial and temporal constrains of tasks and environments - what is their environment like?
* How the interal information processing of pts can be enhanced
* Optimal strategies for practice - how do we make them excited and give them the tools they need.
Theraputic progression model three categories
1) Those releated to motor learning
* What do they need to learn
2) Those releated to characteristics of the movement or task
* impairment level stuff you need to do
3) Other considerations such as equipment used and the level of physical assistance provided
* Equipment that lets them reah goals
Progression
Start w/ less advanced tasks –> more advanced
Think starting in hallway w/o people –> hallway w/ people
I like how high you picked up your feet when stepping over the cones is knowledge of performance or results?
Performance
Talking about an aspect of the task
3 neurorehabilitation models
1) Neurofacilitation
2) Task-Oriented
3) Complementary Movement
Which neurorehabilitation model:
* is Based on reflex and hierarchial models of motor contorl
* Developed for individuals w/ abnormal sensorimotor function or muscle tone and were used to either inhibit abnormal movement or facilitate more normal motions
* Still in use today
Neurofacilitation
What are the 4 levels of motor contorl?
Mobility
Stability
Controlled mobility
Skill
What part of motor contorl is free, flexible motion that translates the body or body part in space and includes qualitites of range and speed?
Level 1: mobility
What part of motor control is cocontraction of agonists and antagonists that fixes parts of the body to allow for weight bearing and latear allow for dynamic holding in levels 3 and 4
Stability (level 2)
So agonist and antagonist are contracting
What part of motor contorl is the distal body parts are fixed on the support surface and the proximal segment moves over a fixed distal segment (weight shifting)
Controlled mobility (level 3)
think shifting in quadruped
* contorlled mobility
What part of motor contorl does is the distal part of the extremity is free from the support surface and coordinated movement of this segment is superimposed on proximal stability?
Skill (level 4)
Think alternating arm in leg in quadruped. think bird dog
Motor contorl levels:
Mobility –> Stability –> Contorlled Mobility –> Skill
This is showing mobility –> stability –> combined mobility and stability in weight-bearing –> skill
So its showing how they transfer
What does facilitation mean?
arousing / exciting / getting a contraction
think light touch, tapping, quick stretch etc… were trying to excite the muscle
Inhibitory means?
If someone has a tight muscle, we want to relax it. So think the opposite of muscle contraction
were inhibiting the tightness of that muscle
This is an example of how to manage high tone
Application of quick light strokes to the skin over a muscle using either fingers, cotton, or a brush facilitates contraction of the underlying muscle
* This is facilitation or inhibition
Light touch
facilitation
These just suck. Memorize the individual positions.
Explain an UE flexion abnormal synergy
Explain a UE extension abnormal synergy
Explain a LE flexion abnormal synergy
Explain an LE abnormal extension synergy
Doesnt know the risks associated w/ smoking. doesnt understand that it can releate to healing
* says she will do anything but still smokes
lots of things go into wellness
give them resources
how smoking gets easier w/ time
target these areas
PNF
Guides pts to reach better kinesthetic awareness and neuromuscular control
Facilitates improved efficiency of movement, timing and coordination
Increases ROM, strength, endurance
Procedures of PNF
Verbal Commands - For PNF
* clear
* Simple
* Appropriate timing
* Engaging - not boring
All encompasing patterns below
* movements are specific and the patterns are named for diagnals in flexion or extension
* Scapula and pelvis named for depression/elevation
* we do not have to use these exact cues that are below, those are for the purists - which we are not
Describe D1 flexion
Describe D1 Extension
exact opposite of D1 flexion
D1 flexion pattern
* notice its named flexion because you’re ending in flexion
D1 extension pattern
Describe D2 flexion
Describe D2 Extension
D2 flexion pattern
D2 extension pattern
Describe LE D1 flexion
Describe LE D1 extension
PNF LE D1 flexion
LE D1 extension pattern
Describe D2 LE flexion
Describe LE D2 extension
LE D2 flexion
LE D2 extension
all of the patterns compared to eachother
* repeating info from before
Describe the two movements here
Up arrow = Anterior elevation (moving up and forward)
Down arrow = posterior depression
this of it this way: if you kept going along the line would you elevate or depress? would you translate anterior or posterior?
Describe the directions the shoulder blade is moving
Up arrow = posterior elevation (sliding around the back of the rib cage being more posterior)
Down arrow = anterior depression (sliding forward around the rib cage)
This is the PNF patterm for scapula anterir elevation (note - you can sneak you hand under arm so it moves better)
PNF pattern for scapular posterior depression
PNF pattern for scapular anterior depression
PNF pattern for scapular posterior elevation
Describe the patterns at the hip (remember, the reference point is the top of the iliac crest)
Up arrow = anterior elevation
Down arrow = posterior depression
Describe what motion is happening at each arrow
Up arrow = Posterior elevation
Down arrow = Anterior depression
this one is confusing
PNF pattern for pelvic anterior elevation pattern
notice how knees are bent for all these
PNF pattern for posterior depression
PNF pattern for posterior elevation
PNF pattern pelvic anterior depression
PNF techniques:
For PNF
Is setting dependent, but even when getting someone into bed you can be working on this shit
In out pt its easy to do these w/ a medicine ball or a theraband.
however, in inpatient / neuro your focus is function so maybe work on them when getting into bed
* or use them to help them stand up
Contraindication for PNF:
* Recent surgery
* Orthostatic hypotension
* dislocation
* several more, we just came up w/ these in class
