Intervention Strategies for the Neuro Patient (neuro)

Improving Sensory Selection & Utilization for Balance

3 sources of input maintain balance: Somatosensory inputs Visual inputs Vestibular inputs Training should vary these inputs to best challenge the patient How might you vary the somatosensory inputs when treating your patient with balance deficits? How might you vary the treatment environment and/or make treatment more functional to promote balance?

What type of patient may not be appropriate for task-oriented training?

Cognitive deficits, patients with profound weakness, and/or patients with perceptual deficits

Improving Sensory Selection & Utilization for Balance cont'd

Compensatory training strategies will be required for those patients with significant sensory loss Example: LE PPC loss and bilateral amputations - will need to focus more on visual inputs

Balance & Coordination Training: Precautions

FALL RISK Impaired balance with instability Use gait belt & close guarding Use assistive device Orthostatic Hypotension Monitor blood pressure & signs of cardiopulmonary stress

Increasing Aerobic Capacity: Aerobic Training

Improved CV and peripheral endurance ↓ anxiety, depression Enhance physical function Enhance sense of well-being

Gait/Locomotion Training: Indications & Contraindications

Indications Decreased functional ambulation ability / gait Decreased functional ability with wheelchair mobility Decreased balance Impaired protective & reactive balance Decreased endurance Contraindications Unstable fracture of weight bearing bone Unstable vital signs Unsafe response to balance activities

Hypotonia modalities

Quick icing Vibrational stimulation Electrical stimulation muscle reeducation EMG biofeedback - muscle contraction awareness

Enhancing Flexibility: Serial Casting

Recommended for patient who have or are at risk for contracture Therapists positions the limb in end range Layer of thin foam and white cotton wrap is applied, followed by casting material Typically changed every 7-10 days and used for 1-6 weeks

AFO - Foot Control

Solid ankle AFO or plastic hinged solid ankle AFO Controls medial / lateral ankle motion Can control frontal & transverse plane foot motion

AFO - Foundation / Stirrup

The traditional foundation for the AFO & can be solid or split Steel stirrup, U-shaped fixture is the center portion of which is riveted to the shoe through the shank The arms of the stirrup join the brace uprights at the level of the anatomical ankle Solid Stirrup A one piece attachment that provides maximum stability of the orthosis on the shoe Split Stirrup Simplifies donning because wearer can detach the uprights from the shoe If the central piece is riveted to other shoes, then shoes can be interchanged It is bulkier and heaver than a solid stirrup or foot plate Not recommended for the more active patient as it is easier to dislodge the side piece from the receptacle

Enhancing Muscle Strength: Benefits of Strength Training

↑ production of maximal force due to changes in neural drive- increased motor unit recruitment, increased rate and synchronization of firing patterns of motor units , improved reaction time Changes in muscle (hypertrophy, muscle fiber type, ↑ size and # of myofibrils) ↑ in connective tissue tensile strength and BMD( bone, mineral density) Improved function Improved sense of well-being and self-confidence

Range of Motion: Indications & Contraindications

Indications Loss of joint flexibility Prevention of a contracture Used to maintain joint motion Lack of active control (weakness/innervations) Contraindications Unstable fracture Joint infection Bone cancer

Stretching indications/prec/contraind

Indications Potential for contracture Decreases in passive ROM Contraindications Acute muscle injuries Surgical incisions Precautions Avoid inflicting pain Bone fragility Do not over stretch (too aggressively)

Functional Training techniques

Shift is away from more traditional "hands on" approach to recovery -Active movements are the overall goal Therapist is a coach, structuring practice, providing challenge and feedback Counteracts immobility and effects, prevents learned nonuse

AFO - Superstructure

Superstructure consists of: uprights a shell or band or brim

Neurodevelopmental Training (NDT Bobath) cont'd

Inhibition of abnormal motor patterns Does not reinforce the development of synergy movement patterns with activity or exercise Sensory feedback is critical in treatment of sensory & motor deficits including •Weakness •Limited ROM •Impaired tone & coordination Postural control utilizes both feedback & feed forward mechanisms to support postural control Postural control is the foundation for all skill learning

Neuromuscular Facilitation

"The facilitation, activation or inhibitions of muscle contraction and motor response" (O'Sullivan) Facilitation: " enhanced capacity to initiate a movement response through increased neuronal activity and altered synaptic potential." (O'Sullivan) Activation: "the actual production of a movement response and implies reaching a critical threshold level for neuronal firing." (O'Sullivan) Inhibition: "the decreased capacity to initiate a movement response through altered synaptic potential." (O'Sullivan)

Aerobic Training: Precautions

Beta Blockers - inaccuracy of HR monitoring Severe fatigue - proceed slowly with close monitoring Metabolically fragile patients Diabetes mellitus Dialysis patients Patients with extensive surgery and/or trauma Monitoring Close monitoring of VS w/ gradual progression of activities Keep running records of assessment

Functional Training skills/specifics

Task specific, based on examination of motor function and activity performance Basic Activities of Daily Living (BADL) -Feeding, dressing, hygiene Functional Mobility Skills (FMS) -Bed mobility, transfers, locomotion Instrumental Activities of Daily Living (IADL) -Home chores, shopping Community mobility Work activities

Functional Training cont'd

Effective in treatment of the secondary effects of immobility -Weakness, loss of flexibility, psychosocial situation/needs Focuses on early training following neurologic-damage Takes into account individuality of the patient [age, interests, etc.] & targets skills important to patient and family

Orthotic, Protective or Supportive Devices Indications

Impaired motor control Abnormal tone Decreased strength Decreased ROM

Enhancing Flexibility: ROM Exercises

Manual therapy = PROM; joint mobilization Therapeutic exercise = AROM and AAROM Functional multi-joint movement PNF Patterns Functional movement patterns (push, pull, reach)

Improving Dynamic Postural Control

Therapist should select an appropriate weight bearing position Start with smooth directional changes engaging the antagonist action (weight shifting) Challenge the patient's LOS Practice in a variety of environments Incorporate various functional activities (reaching, stepping, etc.) and potentially PNF Redirect patient's cognitive attention

Strength Training: Exercise Guidelines

Type of muscle contraction Isometric, eccentric, concentric •When is each appropriate? Why? Mode of exercise training Open chain vs. Closed chain Circuit training Aquatics Type of resistance Free weights, pulleys, bands, machines, manual resistance, body weight, water resistance, PNF w/resistance Intensity What is important about intensity? What principle is this based on? Parameters Number of sets, repetitions( 3 sets of 10 to 15 reps) •How do you determine this is appropriate for your patient? Duration- 15 to 30 minutes per session or as tolerated Frequency- 2 to 3 days/week Warm up and cool down periods

Improving Static Postural Control cont'd

--Initially, focus should be on achieving symmetrical, balanced weight bearing. Example: Patient with right sided hemiplegia after stroke - how might this patient's stance appear? What would you do to correct this stance? Initial goal is to maintain this "balance" independently and for longer durations. Therapist may begin with decreasing support in positions, progressing to resisted isometric contractions to promote strength in stabilizing muscles. Additional strategies include use of resistance bands to promote proprioceptive loading and contraction of stabilizing muscles. Example: Seated with arms supported, band is placed around forearms and patient pushes forearms away from one another - promote scapular stabilization Standing with band around lower thighs, patient keeps thighs apart against band resistance - promotes stability of the hips Progressions: Change the surface •What is in your lab that you might use to promote improved postural control? Decrease the BOS Consider aquatic therapy

AFO - Foundation / Insert

A plastic or metal component (insert) or foot plate foundation Provides good control of the foot & can be modified internally Can be worn in different shoes Facilitates ease of donning Less costly shoes, i.e. sneakers can be worn Lightweight Must be worn with a shoe with proper heel height or can produce knee instability

Functional Training

Because movement is normally goal directed, functional tasks are thought to be a natural way to achieve or promote motor control. The task oriented model is based on the idea that the movement system must solve problems to accomplish motor tasks. (Horak, 1991) This model assumes that movement control is organized around goal-directed functional behaviors rather than specific muscles or movement patterns. (Bertoti, page 192)

Functional Training Examples

Bed Mobility (supine/sit, rolling, moving in bed) -Strengthen the trunk, lower extremities, upper extremities Unsupported static and dynamic sitting -Strengthen trunk and neck for upright activities -Rotation exercises stimulate the vestibular system and prepare for turns Standing and weight shift activities, pre-gait activities -Strengthen trunk, LEs and balance, proprioception •Bathroom hygiene, kitchen activities Functional transfers Strengthen trunk, LEs, UEs, dynamic balance Progressive ambulation training Strengthen trunk, LEs, UEs, dynamic balance

Functional Training: Indications and Precautions Bed Mobility/Transfers

Bed Mobility/Transfers Indications •Decreased independence with bed mobility &/or transfers Precautions •Orthostatic hypotension •Monitor blood pressure •Avoid increases in hypertonia •Increase assistance •Increase surface support

Neurodevelopmental Training (NDT Bobath)

Belief that abnormal patterns of posture & movement are caused by Abnormal tone Primitive reflexes patterns Mass synergies Resulting in interference in normal recovery & function Belief: Peripheral sensory information influences motor response and output Patient can learn/relearn motor behavior with the use of body and limb posture Neurofacilitation techniques Neuroinhibition techniques Both

Other Considerations for Patient with Low Endurance

Breathing techniques Airway clearance techniques Chest mobility Energy conservation techniques Activity pacing Lifestyle changes Regular rest periods Improved sleep -Relaxation techniques or medications Consider an activity log -Rate activities using Borg Rating of Perceived Exertion (RPE) Stress management

Orthotic, Protective or Supportive Devices contraind/prec

Contraindications Skin breakdown - Avoid use if skin shows signs of breakdown or undue pressure; Monitor for signs of pain or discomfort with device Precautions Reddened pressure areas - monitor closely; report & document carefully Fluctuating edema - monitor very closely; minimize skin &/or bone contact

Improving Coordination and Agility Definitions

Coordination: "ability to execute smooth, accurate and controlled movements" (O'Sullivan) Agility: "ability to perform coordinated movements combined with upright standing balance" (O'Sullivan) Ataxia: "uncoordinated movement that manifests when voluntary movements are attempted." (O'Sullivan) Principle cause - cerebellar disease or lesion

Neurodevelopmental Training (NDT)

Developed by Berta Bobath, PT & Karel Bobath, MD - (late 1940s) Based on treatment for patients with neurological dysfunction (CP/CVA) who demonstrated Abnormal tone & postural reflexes Loss of normal postural reflex mechanism including •Righting, equilibrium, protective extension reaction

Functional Training Strategies

Emphasize early training Define the goals of task practice Determine the activities to be practiced Determine the parameters of practice Utilize behavioral shaping techniques Promote problem solving Structure the environment (open vs. closed) Establish parameters for practice outside PT Maintain focus on active learning Monitor recovery closely and document progress

Ankle Foot Orthoses (AFO)

Encompasses the shoe and terminates below the knee Composed of: •Foundation - (shoe + insert) •Ankle control •Foot control •Superstructure

Impairment Interventions:An Overview

Enhancing Muscle Strength, Power & Endurance Enhancing Aerobic Capacity Enhancing Flexibility Managing Muscle Tone Enhancing Postural Control and Balance Enhancing Coordination and Agility Improving Gait and Locomotion Relaxation Training

Functional Training environment

Environment is important during this type of training May start in a closed environment -Quiet, controlled, stable, predictable -Patient room, treatment room, clinic setting -What is the benefit of this type of environment? Progress to more real life, open environment -Community, walking on street, shopping at the store Want to avoid context-specific training where the individual is only successful with task in one type of environment

Tools for Improving Dynamic Postural Control

Exercise ball Resistance bands Weighted balls

Knee Ankle Foot Orthosis (KAFO)

Extends from the shoe to the thigh Provides support for those with more extensive paralysis or deformity Consist of a shoe, foundation, ankle control, knee control, and superstructure

Functional Training specifics

Extensive practice & appropriate feedback are essential Must understand the essential elements within a task and the environment Early training must focus on use of the involved extremity, practicing modified tasks that are beneficial, yet allow the patient to be successful Tasks are continually modified to increase difficulty and promote independence. Example: Sit to stand from higher to lower surface or using an AD and decreasing dependence

Gait/Locomotion Training: Precautions

FALL RISK High tone and patterned synergies ↓ activity level if tone ↑ ↑ support if tone ↑ Rigidity and akinesia Low tone Provide increased external stability Increased abnormal reflexes ↓ level of activity ↑support Severe balance dysfunction

Functional training cont'd

Functional training involves the concept of behavioral shaping Immediate and explicit feedback is provided to the patient meant to shape and improve performance Feedback is positive and directed towards what the patient has done successfully Tasks need to be within the patient's capabilities, but challenging The therapist then provides motivation to progress

Interventions to Improve Coordination and Agility

Generally benefit from use of light resistance to slow limb and trunk movements (cuff weights, bands, weighted walkers/canes, water resistance) PNF is appropriate -Must balance proprioceptive loading vs. fatigue Movements should be slow and controlled Augmented feedback such as biofeedback or rhythmic auditory stimulation (metronome) - modulate speed and improve focus Devices that promote reciprocal movement and timing are helpful (bike, treadmill with harness) Initially should practice in low stimuli environment Distributed practice tends to be more beneficial secondary to low endurance/high fatigue Need to consider ADs for safety and ↓ fall risk

Spiral AFO

Have a single upright that spirals from the foot plate around the leg terminating in a proximal band. Controls but does not eliminate motion in all planes Contraindicated in those wit fluctuating edema as it can't be adjusted readily Fit snugly for maximum control & minimal conspicuousness Made from polypropylene, nylon, acrylic, or carbon fiber

Gait/Locomotion Training:Precautions (cont.)

Impaired endurance -Monitor for fatigue -Monitor vital signs Impaired perceptual status -Increase guidance & orientation Impaired cognitive status -Modify commands & assistance as needed

Joint strategies postural control

Improving standing control, patient should practice fixed-support strategies Ankle strategy: patient practices small-range, slow-velocity shifts progressing to holding steady -May use a wobble board or foam roller Hip strategy: larger shifts in COM that approach the LOS and/or faster body sway motions •Hip flex/ext. responses are generated with A/P displacements •Lateral hip motions are generated during lateral hip displacements •Tandem standing, SLS, use of a foam roller Patient should also practice anticipatory postural adjustments Patient given information in advance: Example: Keep your sitting balance while catching a weighted ball Practice in a variety of environments and moving towards functional, daily activities

Aerobic Training: Indications & Contraindications

Indications Debilitation Decreased endurance Fatigue Contraindications Severe cardiac condition Metabolically fragile •End stage kidney failure •End stage COPD or emphysema

Functional Training: Indications and Precautions Dressing/Eating/Bathing/Toileting Training - ADLs

Indications Decreased independence in these areas Usually addressed incorporating regular routine into tx session Usually addressed by OT Precautions Impaired endurance •Monitor for fatigue and monitor VS Impaired perceptual status •Increase guidance & orientation Impaired cognitive status •Modify commands & assistance as needed Monitor safety, judgment & problem solving

Strength Training: Indications & Contraindications

Indications Decreased strength Contraindications Severely impaired cardiac status •Monitor for Valsalva Maneuver Unstable muscle and tendon structure

Balance & Coordination Training: Indications & Contraindications

Indications Impaired balance Impaired equilibrium coordination Impaired non-equilibrium coordination Contraindications WB restrictions

KAFO

Knee Joint - The Hinge Joint The simplest joint Provides medial-lateral stability Restricts hyperextension of the knee Does allow for knee flexion The Knee Joint - The "OFFSET JOINT" Is a hinge placed posterior to the midline of the leg Stabilizes the knee in extension during stance phase It does not interfere with knee flexion during swing phase or sitting Drop Ring Lock Most common When one stands with the knee in full extension, the ring drops preventing the uprights for further flexion / bending Serrated Lock Used for knee flexion contractures which have a drop ring lock for stability in the partially flexed knee The basic offset joint and drop ring locks are contraindicated in patients with knee flexion contractures There are also KAFOs with computer-controlled knee joints

Trunk Hip Knee Ankle Foot Orthosis (THKAFO)

Lumbosacral orthosis attached to KAFOs Provides more stability than HKAFO Covers part of the thorax as well as the lower limbs Is heavy & cumbersome Not used often

Sensory Stimulation Techniques cont'd

Maintained pressure Slow, repetitive stroking Light touch Neural warmth Prolonged cooling Slow vestibular stimulation Rapid vestibular stimulation Covered in greater detail during lab

Orthotic, Protective or Supportive Devices

May be necessary to promote safety, independence and stability with functional activities Examples include: AFO or HKAFO, wheelchair trough, sling, platform for a walker

Neuromuscular Facilitation Precautions

Monitor for hypersensitivity to tactile stimulation High tone •Decrease activity level if tone increases •Increase support if tone increases Low tone •Provide increased external stability Increased abnormal reflexes •Decrease level of activity •Increase support

Range of Motion: Precautions

Monitor for pain reactions to motion Bone fragility (consider age & forces used in motion) Joint instability with motion

AFO - Ankle Control

Most AFOs are prescribed to control ankle motion by limiting DF or PF or by assisting motion Effective in controlling toe drag Dorsiflexion weakness can be assisted by a spring that lifts the foot during swing phase Adults with hemiplegia demonstrated better gait with use of the AFO Improved cadence, stride, speed, ankle dorsiflexion

Strength Training: Additional Considerations

Movements should be slow and controlled Progression should be monitored and occur in small increments Reduce intensity with sudden onset of fatigue and exhaustion or prolonged/severely DOMS Maintain regular breathing patterns Consider medications the patient is taking and ex. Ask: Is exercise contraindicated? Relate strength training to functional tasks

Enhancing Muscle Strength: Definitions

Muscle Performance "The capacity of a muscle or group of muscles to generate forces." Muscle Strength "Muscle force exerted by a muscle or group of muscles to overcome a resistance under a specific set of circumstances." Muscle Power "The work produced per unit of time or the product of strength and speed."

Relaxation training benefits

Muscle relaxation Lower blood pressure Reduced ischemic pain Enhanced awareness of emotional state & memory Increased energy level -Increased sense of control Training should include quiet, deep breathing and attention on a single focus May also use imagery Environment should be relaxing and quiet

Augmented Interventions

NDT Neuromuscular Facilitation Sensory Stimulation Techniques Biofeedback NMES

Interventions to Improve Gait and Locomotion

Often a patient's #1 goal Often a significant factor in determining a patient's discharge placement PT must evaluate and establish a realistic POC Must consider functional demands of the patient's home (carpet vs. hardwood, stairs), community, work environments Is an assistive device appropriate to ↑ safety and independence? Handling techniques, verbal cues, visual feedback Body weight supported treadmill training (BWST) is becoming more and more popular with the neuro population. Will discuss in greater detail in SCI lecture.

Muscle Strengthening Principles

Overload principle Must load a muscle to gain strength Specificity principle Type of training will have specific carryover Train isometric and ability to produce isometric contraction improves but not isotonic contraction Cross training Produces broad demands of the neuromuscular system for diversity of potential motor behaviors Reversibility If you don't use it, you lose it

Correcting Posture

PT interventions should focus on: Improving MS impairments (strength, ROM) Demo of correct posture Verbal cues Tactile cues (manual and external objects) Visual feedback (mirrors) Application to functional situations Body mechanics

Strengthening Training: Precautions

Partially denervated muscles Proceed slowly with sub-maximal strengthening Do not over fatigue High tone Decrease activity level if tone increases Increase support if tone increases Low tone Provide increased external stability Increased abnormal reflexes Decrease level of activity Increase support Avoid resistive ex's that are likely to ↑ abnormal reflexes

Intervention to Improve Postural Control and Balance

Patient needs to practice steady state, anticipatory and reactive balance control using activities that focus on both static and dynamic postural control. Important for the therapist to understand the distress felt by a patient when placed in situations where the patient is in jeopardy of falling. How can you, as the therapist, ensure safety for a patient when performing balance activities?

Enhancing Flexibility: Patient with Spasticity

Patient with UE spasticity following CVA Therapist grabs patient's hand by the thumb, moves the elbow into extension with hand open Palm is then placed down onto the mat at patient's side, weight bearing position Weight shifting forward and backward inhibits the spastic muscles and maintains range

Improving Reactive Balance Control

Patients with motor function and balance deficits are often unable to respond effectively to external perturbations. Therapists can provide perturbations Small to large manual pushes/pulls •Small activates ankle/hip strategies •Large activates stepping strategy Applied at various body parts (shoulders vs. hips) Vary the direction, type, speed Use an elastic band around the hip

AFO - Tone Reducing Orthoses

Plastic AFOs for spasticity (CP, CVA) Footplate & broad upright are designed to modify reflex hypertonicity by applying constant pressure to the plantar flexors and invertors Good for moderate spasticity with varus instability without a fixed deformity

Enhancing Flexibility: Serial Casting (prec/contraind)

Precautions should be taken for patients who are highly agitated or have cognitive/communication impairments Contraindicated for patients with: Heterotopic Ossification- abnormal formation of bone in the soft tissue Compromised skin integrity Impaired circulation and marked edema Uncontrolled HTN Autonomic Storming-increase in sympathetic nervous system activity Unstable ICP-intracranial pressure Pathological inflammatory conditions (gout, arthritis) Individuals at risk for nerve impingement

Functional Training cont'd

Primary focus of functional training is achieving control in various postures and functional activity Example - a patient with poor trunk control and sitting balance deficits is asked to lie prone on elbows -What benefit does the patient receive from being in this posture? -What activities might you perform in this position? -How would you progress this patient from prone on elbows?

Managing Muscle Tone: Hypertonia

Prolonged Stretch Increases muscle spindle threshold decreasing muscle tone Inhibitory pressure Gentle but deep tendon pressure inhibit tone Manual maintained touch/pressure contact As in relaxation massage slow stroking Causes sensory accommodation and inhibits tone Neutral warmth Retention of body heat Generalized inhibition of tone Slow vestibular stimulation Low-intensity, slow and rhythmic vestibular stimulation •Slow rocking, slow movement on a ball, in hammock, in rocking chair Generalized relaxation; inhibition or dampening of tone and motor output; decreased arousal

Considerations with ROM Exercise

ROM exercises are performed through the full available range Limb must be well supported Movements should be slow Maintain movement within patient tolerance Excess force and pain are CONTRAINDICATED

Neuromuscular Facilitation Techniques

Resistance Quick stretch Tapping/repeated quick stretch Prolonged stretch Joint approximation Joint traction Covered in greater detail during lab

Functional Training safety

Safety must always be the focus during this type of training The therapist provides safety awareness training to the patient -Defining limits of stability -Identifying fall risks -Instruction in assistive and adaptive devices may improve safety May involve family and caregivers in safety training if applicable

KAFO stability planes

Sagittal plane stability A kneecap or anterior band or strap completes the 3 point pressure system required for stability Frontal Plane Stability Is achieved with plastic calf shells shaped to apply corrective force To reduce genu valgum -the medial portion of the shell extends proximally & applies a laterally directed force at the knee. To reduce genu varum - force is medially directed The semi-rigid shell is more effective than a valgum correction strap & is easy to don It applies force over a broad area without impinging on the popliteal fossa

Hip Knee Ankle Foot Orthosis (HKAFO)

Same as KAFO with a pelvic band that surrounds the lower trunk & addition of hip joints Usual hip joint is a metal hinge that connects the lateral upright of the KAFO to a pelvic band Prevents abduction, adduction and rotation

Functional Training: Indications and Precautions Standing

Standing - (I), with (A) or using tilt table/standing frame Indications Impaired standing ability Impaired standing tolerance Intolerance for upright posture Precautions --Weight bearing status •Incorporate accommodations/modifications into set-up of equipment --Orthostatic hypotension •Monitor vital signs •Progress slowly

Enhancing Flexibility: Passive Stretching

Static Stretching Muscle is slowly elongated to tolerance End stretch held 20-30" and repeated 4-5 times Low load stretching is less dangerous Frequency varies, but at least daily is recommended Should be combined with active exercise Family/caregivers should be educated on HEP Ballistic Stretching To prepare for plyometric exercise (advanced rehab) High-load, short duration, intermittent stretch Generally contraindicated for elderly, chronically ill, neuromuscular impaired patients Not well controlled, often associated with microtrauma and injury Low Load Prolonged Stretch15-30 minutes Mechanical pulleys, weights, specialized orthotics, tilt table, serial casting (discussed later)

Enhancing Flexibility

Stretch & position for patient with spasticity (UMN) Typically see limbs held in fixed, abnormal postures with anti-gravity muscles primarily affected Therapist should use constant, firm manual contacts, avoiding direct pressure over spastic muscles Spastic muscle is moved into the lengthened range using slow, repeated rotations of the limb Prolonged stretch should be used

Enhancing Flexibility: Facilitated Stretching

Techniques used to relax (inhibit) and elongate (stretch) muscles using neuromuscular techniques PNF - facilitated stretching techniques Contract-Relax (CR) and Hold-Relax (HR) Limb moved to end range, patient performs maximal isometric contraction of shortened muscle (held 5-8"), then relaxation In HR, therapist passively moves limb into new range In CR, patient moves limb to new range against resistance Research supported technique Not effective with very weak, paralyzed or chronic contracture

Neurodevelopmental Training (NDT) cont'd

Termed Therapeutic Handling/Key Points of Control Used to influence the quality of the motor response Is carefully matched to the patient's abilities to use sensory information & adapt movements Includes: Neuromuscular Facilitation Neuromuscular Inhibition Or a combination

Sensory Stimulation Techniques

These techniques are used to: 1.Improve attention and arousal 2.Enhance sensory selection and discrimination Guidelines: Use appropriate intensities (consider excess stimulation and response, adaptation) Consistency and function are important Interventions include sensory reeducation, tactile kinesthetic guiding, repetitive sensory practice and desensitization

Managing Muscle Tone: Hypotonia

Timing emphasis- max resistance facilitates strong contraction Overflow - Irradiation -Using stronger synergist to facilitate weaker synergists Manual Contacts -Sensory stimulation specific to synergy patterns Positioning -Positioning the joint at the optimal length-tension Verbal patient directed commands -Preparatory, action, corrective Visual cueing -Patient visual awareness of the movement Quick stretch -Stimulation of stretch contract response Approximation -Joint compression to facilitate extensor stabilizing muscle contraction

Why would a patient be unable to maintain postural control while moving segments of the body?

Tonal imbalance ROM restrictions Impaired voluntary control and hypermobility-ataxia Impaired reciprocal actions of the antagonist-cerebellar dysfunction Impaired proximal stabilization

Neurodevelopmental Training (NDT, Bobath) cont'd...

Treatment does not reinforce abnormal patterns of movement Reflex inhibiting movement patterns are used to inhibit abnormal patterns reactions and facilitate automatic and voluntary movement Postural sets are utilized in order to reduce spasticity and initiate more normal movement patterns The PTA utilizes keys points of control to guide movement

Neurodevelopmental Training (NDT)

Treatment focuses on: Ongoing analysis of sensory-motor function Planned interventions to improve impairments, function limitations & disabilities Specific task goals & functional skills Modification of task &/or environment to enhance function Active participation of patient Motor learning principles •Reinforcement •Repetition •Facilitation of error awareness (trial & error learning) •Conducive environment •Minimization of other factors that may impede or inhibit success

Aerobic Training

Types: ergometry, recumbent stepper, aquatics, bike, treadmill, walking Moderate intensities are generally appropriate for the rehab patient (40-70% max O2 consumption) Average: 3-5 days per week, 20-30 minute sessions -Alternative: multiple, 10 minute sessions

Enhancing Flexibility: ROM for the Patient with Hypotonia

Typical of a patient with LMN syndrome During PROM, therapist needs to be cognizant of end range instability and risk of hyperextension injury May consider supportive devices during functional training

Relaxation Training

Typically patient's with motor dysfunction experience a great deal of stress SNS responses are often heightened Relaxation response is associated with PNS response

Plastic AFOs

Usually have a single upright or shell Both the solid ankle & the hinged solid ankle AFOs have a posterior shell extending from the medial to the lateral midline of the leg Provides excellent medial-lateral control Provides a broad surface to minimize pressure

Metal & Leather AFO

Usually have medial & lateral uprights to maximize structural stability Aluminum uprights are lighter in weight than steel Even lighter are carbon graphite & titanium that are as strong as steel but are more expensive Most orthoses have a posterior calf band made of plastic or leather upholstered metal with an anterior buckle or Velcro pressure closure strap The farther the band from the ankle, the more control of leverage The band most not interfere with the peroneal nerve

Muscular Endurance and Fatigue

What is the difference between muscular strength and muscular endurance? Fatigue: the inability to contract muscle repeatedly over time -Thus, exercise can not be sustained, and exercise tolerance is reduced Fatiguing a muscle can be dangerous to some neuro patients (MS, GBS, PPS, etc.) Important to closely monitor and progress patients slowly to avoid overexertion, exhaustion and injury. The real danger is the risk of acute exercise overdose producing exhaustion and injury

Intervention to Improve Postural Control and Balance

What is the difference between static and dynamic postural control? Accurate initial analysis of a patient's posture is an important foundation for treatment of postural control issues as well as balance impairments.

Improving Static Postural Control

Why would a patient be unable to maintain a steady position? Weakness Tonal imbalance Impaired voluntary control and hypermobility Sensory hypersensitivity Increased anxiety or arousal Therapist should use weight bearing positions (anti gravity) to develop stability -Example: modified plantigrade in standing Consider: Safety Patient level of control Functional tasks Should allow for patient success but provide challenge