Perspectives Flashcards
what’s the goal of remediation (recovery) vs compensation
goal is improved function - movement, QoL, independence
what is a neurological rehabilitation program designed to
meet the needs of the individual based on their specific movement dysfunction, injury/disease consideration, and personal goals
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/actiities
example of recovery as a health condition (neuronal)
restoring function in neural tissue that was initially lost after injury.
may be seen as reactivation in brain areas previously inactivated. by the circulatory event. although this is not expected to occur in the area of primary brain lesion, it may occur in areas surrounding the lesion and in the diaschisis
recovery as a body function/structure (performance)
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 ROM, temporal and spatial inter joint coordination, etc)
recovery as an example of activity (functional)
successful task accomplishment using limbs or end effectors typically used by non disabled individuals
compensation as an example of health condition (neuronal)
neuronal 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 non disabled individuals
compensation as an example of body functions/structures (performance)
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 etc) during the accomplishment of a task
compensation as an activity (functional)
successful task accomplishment using alternative limbs or end effectors
for example opening a package of chips using 1 Hand and mouth instead of 2 hands
what is remediation/restoration
restoring a lost function/skill
what is the compensatory approach
learning how to develop “work arounds” for a functional task
example: patient taught to change the environment or change their approach
example of compensatory approach
40 yo woman with a non operable GBM in right occipital lobe. compression of the optic nerve compromised 90% of her vision in left eye
50 yo male suffered T12 ASI A SCI after MVA
what is combined remediation and compensation
combined process of restoring and learning adaptive techniques for improved functioning
ex: 30 yo male dx with Guillain-barre syndrome presents with significant weakness and tingling throughout B LE. Rehab: initial compensatory strategies - transferring with slide board, head/hips. with disease progression and tx, pt able to regain ambulation ability w SPC at discharge
- compensation needed initially and progress into restoration
which to choose
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
Example 2: You may focus on compensatory strategies for a person with primary-progressive MS to optimize efficiency and minimize fatigue
traditional neurorehabilitation approaches
sensory stimulation techniques - Rood
stages of motor recovery - brunnstrom
neurodevelopment treatment - NDT
proprioceptive neuromuscular facilitation - PNF
Margaret Rood
Motor development sequences - Stages of motor control
Sensory stimulation techniques
Phasic muscles- function in voluntary movement
Tonic muscles- provide stability
Brunnstrom - stages of motor recovery
Describes process of movement recovery after stroke
Position of head and/or body will affect synergies
Control of movement progresses:
- Gross to fine
- Proximal to distal
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
Brunnstrom - stages of motor recovery stroke spasticity
- flaccidity
- synergies some spasticity
- marked spasticity
- out of synergy less spasticity
- selective control of movement
- isolated/coordinated movement
Bobath - Neurodevelopment treatment
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
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?
Continuous readjustment of trunk
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
Techniques – promote better kinesthetic awareness & more efficient neuromuscular control
Techniques
Increase patient mobility/stability
Guide/initiate patient movements
Facilitate more efficient & coordinated movement through normal timing/muscle activation
Increase ROM, strength, endurance
UE D2 flexion
Shoulder girdle- posterior elevation
Shoulder- flexion, abduction, ER
*Elbow- extension
Forearm-supination
Wrist- extension, radial deviation
Finger- radial extension
Thumb- extension
UE D1 flexion
Shoulder girdle-anterior elevation
Shoulder- flexion, adduction, ER
*Elbow- flexion
Forearm- supination
Wrist- flexion, radial deviation
Finger- radial flexion
Thumb- adduction
UE D2 extension
Shoulder girdle-anterior depression
Shoulder- extension, adduction, IR
*Elbow- extension
Forearm- pronation
Wrist- flexion, ulnar deviation
Finger- ulnar flexion
Thumb- opposition
UE D1 extension
Shoulder girdle-posterior depression
Shoulder- extension, abduction, IR
*Elbow- extension
Forearm- pronation
Wrist- extension, ulnar deviation
Finger- ulnar extension
Thumb- abduction
LE D1 Flexion
Pelvic girdle- anterior elevation
Hip- flexion, adduction, ER
*Knee- flexion
Ankle- dorsiflexion, inversion
Toe- extension
LE D1 extension
Pelvic girdle- posterior depression
Hip- extension, abduction, IR
*Knee- extension
Ankle- plantar flexion, eversion
Toe-flexion
LE D2 flexion
Pelvic girdle- posterior elevation
Hip- flexion, abduction, IR
*Knee- flexion
Ankle – dorsiflexion, eversion
Toe- extension
LE D2 extension
Pelvic girdle- anterior depression
Hip- extension, adduction, ER
*Knee- extension
Ankle- plantar flexion, inversion
Toe- flexion
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
principles of neuroplasticity
use it or lose it
use it and improve it
specificity
repetition matters
intensity matters
time matters
salience matters
age matters
transference
interference
take home points
Value our past and appreciate the science and clinical practice evolution in any healthcare profession
Embrace the discomfort of challenging ideas, reflect, and lean into forward momentum
Movement/task analysis are key to what we do as PTs
Facilitation/handling techniques still have their place, albeit differently than with historical approaches
Principles of neuroplasticity!
Cannot be confined to one approach – there is no “one size fits all” rehabilitation intervention for persons with neurological injury or disease
