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NEUROPHYSIOLOGICAL APPROACHES IN NEURO
REHABILITATION:
knowledge of understanding the physiology that helps CNS function.
adaptation and reorganization of CNS function.
lead to noninvolved part of the brain functionally compensating for the affected area of the brain.
-education Approach (1920s) -70s) Sensorimotor Approach (Rood, 1940s) Movement Therapy Approach (Brunnstrom, 1950s) Approach (Bobath, 1960-70s) Approach (Knot and Voss, 1960-70s)
Jenn Ayers1920 -1989) -Oriented Approach (1990s)
- Combination of strongest components of synergies (mixed synergies)
These synergies appear during early spastic period of recovery.
AIM: development of synergy pattern in spastic muscle and once it developed then break the synergy.
1. Flexor synergy of upper limb Retraction and/or elevation of the shoulder girdle External rotation of the shoulder Abduction of the shoulder to 90 degrees Flexion of the elbow to an acute angle Full range supination of the forearm
The dominant component of flexor synergy is elbow flexion .The movement pattern is typically initiated by
either elbow flexion or shoulder girdle elevation.
2. Extensor synergy of upper limb Fixation of shoulder girdle in a protracted position Internal rotation of the shoulder Adduction of the arm in front of the body Extension of elbow, complete range Full range pronation of the forearm Shoulder adduction and internal rotation dominate the movements within extensor synergy. 3. Flexor synergy of lower limb Flexion of the hip Abduction and external rotation of the hip Flexion of the knee to about 90 degrees
Dorsiflexion and inversion of the ankle Dorsiflexion of toes Flexor synergy is typically the weaker of the two lower extremity synergies and is dominated by hip flexion.
4. Extensor synergy of lower limb Extension of the hip Adduction and internal rotation of the hip Extension of the knee Plantar flexion and inversion of the ankle Plantar flexion of the toes Extensor synergy typically dominates in the lower extremity with considerable hip adduction, knee extension and ankle plantar flexion appearing. The strongest component is knee extension.
ATTITUDINAL AND POSTURAL
REFLEX:
1. Tonic reflexes (STNR, ATNR, tonic labyrinthine "supine & prone", tonic lumbar reflex, tonic thumb reflex, +ve supporting reaction, -ve local static reaction, tonic thumb reflex and flexor withdrawal reflex). Influence of reflexes: Varying degrees of influence of the postural reflexes may be noted, and are often associated with spasticity and synergy involvement. Symmetric Tonic Neck Reflex (STNR): Flexion of the neck results in flexion of the arms and extension of the legs; extension of the neck results in extension of the arms and flexion of the legs. Asymmetric Tonic Neck Reflex (ATNR): Head rotation to the left causes extension of left arm and leg and flexion of right arm and leg; head rotation to the right causes extension of right arm and leg and flexion of left arm and leg.
flexion of the involved lower extremity. RECOVERY STAGES OF BRUNNSTORMS :
STAGE 1: Immediately following acute episode, flaccidity of the involved limbs is present, and no movement, on either a reflex or a voluntary basis can be initiated.
STAGE 2: As recovery begins. The basic limb synergies or some of their components may appear as associated reactions, or minimal voluntary movement responses may be present. Spasticity begins to develop and may be particularly evident in muscle groups that dominate synergy movement (e.g.: elbow flexors. knee extensors) STAGE 3: The patient gains voluntary control of movement synergies, although full range of all synergy components does not necessarily develop.
Spasticity, which may become severe in some cases, reaches its peak. This stage in recovery process may be thought of as semi voluntary in that the patient is able to initiate movement in the involved limbs on a volitional basis but is unable to control the form of resulting movement, which will be the basic limb synergies STAGE 4: Some movement combinations that do not follow the paths of the basic limb synergies are mastered, first with difficulty, then with increasing ease. Spasticity begins to decline, but the influence of spasticity on no synergistic movements is still readily observable. STAGE 5: If recovery continues, more difficult movement combinations are mastered as the basic limb synergies lose their dominance
over motor acts. Spasticity continues to decline.
STAGE 6: Individual joint movements become possible, and coordination approaches normalcy. As spasticity disappears, the patient may be capable of a full spectrum of movement patterns.
STAGE 7: As the last recovery stage, normal motor function is restored
PRINICIPLES OF TREATMENT:
- Treatment progress developmentally
- When no motion exists , movement Facilitated using reflexes, associated reactions, proprioceptive facilitation and /or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement.
- Resistance ( proprioceptive stimulus) Promotes a spread of impulses to produce a patterned response while
tactile stimulation facilitates only the muscle related to the stimulated area.
- When voluntary effort produces Or Contribute to a response, patient is asked to hold the contraction (ISOMETRIC). If successful, an eccentric(CONTRACTED LENGTHENING) is performed and finally a concentric (shortening) contraction is done.
- Facilitation is reduced or dropped out As quickly as the patient shows evidence of volitional control.
- Correct movement once elicited Is Repeated. ASSESSMENT: Sensory evaluation: Joint sense: With the patient seated and is blindfolded; the affected upper limb is supported by the examiner and moved to different positions asking the patient to perform identical position with the unaffected extremity. Touch sensation: The palmer aspect of the finger tips are touched with a rubber end of a pencil and the patient
voluntary extension of digits; individual finger movements present, less accurate than on opposite side.
MOTOR TESTS: TRUNK AND LOWER LIMB
STAGE 1: Flaccidity
STAGE 2: minimal voluntary movements of the lower limb.
STAGE 3 : Hip-knee-ankle flexion in sitting and standing
STAGE 4: sitting, knee flexion beyond 90 degrees with foot sliding backward on the floor; voluntary dorsiflexion of the ankle without lifting foot of the floor
STAGE 5: Standing isolated non weight bearing knee flexion, hip extended or nearly extended; standing, isolated dorsiflexion of the ankle, knee extended, heel forward in a position of a short step
STAGE 6: Standing, hip abduction beyond range
obtained from elevation of the pelvis; sitting, reciprocal in inner and outer hamstring muscles, resulting in inward and outward rotation of the leg at the knee, combined with inversion and eversion of the ankle MOTOR TESTS: SHOULDER AND ELBOW The patient is seated, preferably in a chair without armrests. Before the test begins it must be ascertained whether or not the patient can sit erect without side support .If not, use a wheelchair, or allow the patient to remain in bed. Beginning with stage 3, testing routinely done with the patient seated. RECOVERY STAGE 1 (INITIAL STAGE) A Patient is classified in stage 1 when no voluntary movement of the affected limb can be initiated. In this stage the limbs feel heavy when moved passively, and little or no muscular resistance to
movement can be detected. One of the limbs – usually the upper – may be more severely affected than the other.
RECOVERY STAGE 2
The basic limb synergies or some of their components now make their appearance either as weak associated reactions or on voluntary attempts to move .Components of the flexor synergy of the upper limb usually appear before components of the extensor synergy .spasticity is developing but may not be very marked. RECOVERY STAGE 3 The basic limb synergies or some of their components are performed voluntarily and are sufficiently developed to show definite joint movement .Spasticity has increased, during this stage it may become marked .Patient frequently remain at this stage for long periods of time, and those who are severely involved may never progress beyond it .When practical,
the active joint ranges may be recorded as 0, ¼, ½, ¾ or full range. The flexor synergy is first investigated. Shoulder girdle elevation and retraction do not appear automatically and in such cases the movements are tested separately.A suggestion such as, ‘‘Reach up as if you were to scratch behind your ear ’’is frequently helpful – it gives direction to the effort. The extensor synergy is attempted entirely, as the patient is asked to reach in a forward – downward direction to touch the palm of the examiners hand, held between the patients knee. In stage 3, it is commonly observed, namely, a combination of the strongest component of extensor synergy with the strongest component of the flexor synergy. This combination enables the patient to reach across the body towards the opposite shoulder. RECOVERY STAGE 4 When the patient progresses
which may not be called SPASTICITY.
TREATMENT:
- Bed posture
- Bed exercises (PROM, AAROM, AROM, balance sitting)
- Hand training
- Trunk rotation Trunk balance in sitting The patient is asked to assume sitting position, lifting the affected upper extremity by the unaffected one and do actively trunk movements in all directions.
- Standing and walking
- assisted walking
- Independent walking
- Obstacle walking
- Stair climbing
- Early mobility pattern protective in nature.
- Phasic and reciprocal type of movement.
- Contraction of agonist and relaxation of antagonist.
- CO-CONTRACTION:
- Tonic (static) pattern.
- Simultaneous agonist and antagonist contraction
- HEAVY WORK:
- Controlled mobility pattern
- Stock Meyer ‘‘mobility superimposed on stability ’’
- Proximal muscles contract and move while the distal segment is fixed. E.g.: creeping
- SKILL
- Highest level of motor control
- Combined pattern
- Proximal segments are stabilized, distal segments move freely E.g.: typing LEVELS OF MOTOR CONTROL:
- WITHDRAWAL : Heavy workof trunk, neck, proximal regions of extremities: motion
occurs towards T10: reciprocal innervation pattern
- ROLL OVER : Flexion of upper and lower extremities on the same side.
- PIVOT PRONE : Bilateral holding of proximal extensors in shortened range; reciprocal innervation pattern.
- CO-CONTRACTION OF NECK : Co-contraction of neck extensors and flexors; thoracic extension
- PRONE ON ELBOWS : Scapular co-contraction; glenohumeral joint co-contraction; pushing backward
- ALL FOURS :Weight shifting backward – forward, side to side, creeping, alternate arms and leg
- STANDING : Static, shifting weight
- WALKING : Stance, push off, pick up, heel strike ONTOGENIC MOTOR PATTERNS:
- SUPINE WITHDRAWAL
- Total flexion response towards vertebral level T
- requires reciprocal innervation with heavy work of proximal segments Recommendations:
- Patients with no reciprocal flexion
- Patients dominated by extensor tone
- ROLL OVER TOWARDS SIDE LYING:
- Mobility pattern for extremities and lateral trunk muscles Recommendations:
- Patients dominated by tonic reflex patterns in supine
- stimulates semicircular canals which activates neck and extra ocular muscles
- PIVOT PRONE:
Combined pattern
Demands full range of extension of neck, shoulder, shoulder, trunk and lower extremities.
Position difficult to assume and maintain
Important role in preparation for stability of extensor muscles in upright position.
associated with labyrinthine righting reaction of the head
Integration: STNR & TLR reflexes
- NECK CONTRACTION:
- Real stability pattern
- activates both flexors and deep tonic extensors
- elicits the tonic labyrinthine righting reaction when the face is perpendicular to the floor. RECOMMENDATIONS:
- Patients need neck stability and extra ocular control.
- PRONE ON ELBOWS:
- Stretches the upper trunk musculature
- influence stability scapular and gleno humeral regions
- gives better visbility of the environment
- allows weight shifting from side to side RECOMMENDATIONS:
- Patient needs to inhibit STNR
- QUADRUPED POSITION:
- Lower trunk and lower extremities are in co-contraction
- can do weight shifts in forward/backward. Side to side and diagonal directions.
- standing (weight shift , unilateral weight bearing ) LEVEL 4: SKILL SKELETAL VITAL 9.prone on elbows ( head is doing skilled movement and one arm is free for skilled use; belly crawling )
- quadruped ( one arm free for skilled use; creeping , trunk rotation and reciprocal movement , crossed diagonal)
- standing and walking
- phonation
- speech
The steps are numbered sequentially, but they blend together, i.e. one step is not completely mastered before the next begins at the most basic level.
FACILITATORY TECHNIQUES:
- Extroceptive ▫ Tactile – Light moving touch Fast brushing Icing ▫ Vestibular
- Proprioceptive & Vibration Tactile Stimulation:
- Exteroceptive
- Protective withdrawal response
- Phasic contractions & Reciprocal inhibition
- Increased alertness through Ascending Reticular Activating Sequence Light moving touch:
- Touch promote normal growth, Sensory motor integration
- Mechanism ▫ Stimulate A- delta fibers – Low threshold hair end organs & Free nerve endings ▫ Phasic and reciprocal muscle activity
▫ Activate superficial muscles
Fast Brushing:
- Stimulate C fibers
- Battery operated brush 3s:30s
- Same dermatome & Myotome
- Phasic contractions
- Increased awareness ARAS Icing:
- Quick icing – 3 swipes with Blotting, rest of 30s at least
- Pressing Ice cubes
- Improve tone, enhances phasic contractions
- Increased awareness Vestibular:
- Fast stimulation produces facilitator effect, Slow produces inhibition
- Rocking, Tilting of head
- Improve extensor tone of Neck, Trunk, LL
- Improve balance, Righting reactions gaze and bilateral integration Proprioceptive:
- Heavy joint compression
- Stretch
- Resistance
- Tapping
- Vibration
- Osteopressure
- Proprioceptors react slowly than exteroceptors, Produces a sustained effect
- Produces sustained postural patterns Heavy Joint compression:
- Weight applied through longitudinal axis
- Can be applied manually or using weights
- Ontogenic sequence
- Produces co-contraction
- Stability
- Prone on elbows, Neck stability etc
