Interventions for neurological conditions

Principles of motor learning/motor control

Motor learning and motor control are integrated concepts that encompass both the body’s intrinsic neuromuscular capabilities—relying on intact physiological systems—and external environmental factors that enhance an individual’s ability to execute movements accurately. The central nervous system relies on continuous input to learn and retain the ability to perform tasks.

Definitions

Motor program

Sequence of movements or motor actions stored in the brain that are activated when perform specific tasks or motor skills

Motor plan

Cognitive process involved in preparing and executing a movement

Feedback

Information given after task performance regarding the accuracy of performance of a task

Feedforward

Information given prior to task performance about how to prepare for an activity

Strategies for motor learning

Motor learning strategies are required when attempting to learn a new skill through a combination of mass practice and experience. Specific strategies for how to assist an individual with learning a new skill are as follows:

• Practice skill
  • Begin skill practice with guided imagery- kinesthetic learning (passive movement)
  • Initially blocked schedule practice progressing to variable schedule practice to finally progressing random schedule practice as practice repetitions increases and learning improves
• Provide effective feedback
  • Begin with extrinsic feedback
  • Progress to intrinsic feedback with augmented feedback
    • The types of augmented feedback are knowledge of results and knowledge of performance
  • Types of feedback schedules
    • Feedback given after completion of every task (early stage of learning)
    • Summed feedback- feedback given after a set number of attempts
    • Fading feedback- decreasing the amount of feedback given to none as appropriate
    • Bandwidth feedback- feedback only given if movement is outside of designated range
• Transfer specific skill to be generalized in various environments
  • Skill acquisition leads to the skill being applied in varied situations and environment successfully
  • This occurs after patient is deemed proficient in original skill

Definitions

Blocked practice

Practice of a single motor skill repetitively

Variable practice

Practice of a set number of motor skills in which individual is expected to make modifications to skill as appropriate; this occurs once there is mastery of multiple skills that are not being put together and practiced

Random practice

Practice of a group of motor skills in no predictable order

Intrinsic feedback

Internal sensory information used to correct self when performing motor skill

Extrinsic feedback

External sensory information used to correct performance of motor skill by an outside observer

Knowledge of results

Augment feedback about the outcome of movement (understanding the goal)

Knowledge of performance

Augmented feedback about the characteristics of the movement performed (understanding the process of attaining a goal)

Stages for motor learning

Stages by which motor skill acquisition follows.

• Cognitive-”What to do” stage
  • Learner develops understanding of tasks and how to perform
  • Movements are slow and inconsistent; there exists an increased amount of trial and error
    • Extrinsic feedback only
    • Blocked scheduling
    • Consistent feedback after each trial of movement
• Associative- “How to do” stage
  • Leaner practices and refines movement
  • Learner begins to understand errors of movement
    • 50% extrinsic feedback and 50% intrinsic feedback
    • Continue with blocked scheduling and progressing to variable as skill acquisition occurs
    • Feedback should progress from summed to faded or decreasing over time.
• Autonomous- “How to succeed” stage
  • Skills performed automatically and with minimal conscious error
  • Highly skilled and consistent performance
    • Intrinsic feedback only
    • Random practice schedule
    • If any feedback, bandwidth feedback given

Task specific training

The goal of task specific training is to promote recovery of motor function to baseline after injury due to central nervous system insult. The involved segments are the targeted practice.

Examples of task specific training

• Locomotor training
  • Motorized treadmill training with partial body weight support to promote early gait training
  • This activity is used to assist with meeting the needs of patient based on their current functional status with goal of returning back to baseline
• Constraint-induced movement therapy (CIMT)
  • Utilized post-stroke to constrain the unaffected upper extremity by use of protective hand mitt
    • The goal is to constrain the unaffected extremity and force the use of the affected limb to be utilized

Proprioceptive neuromuscular facilitation (PNF)

Proprioceptive neuromuscular facilitation is a technique utilized to promote increased movement within synergy patterns that have been developed. PNF utilizes various systems to improve movement strategies such as stretch resistance, overflow, manual contacts, approximation, and traction. Movements are spiral and diagonal. PNF techniques can be broken down into the following categories:

Rhythmic initiation

• A progression of movement from passive → active-assisted → active → resisted. This technique is used to improve the initiation and coordination of movement.
• Example:
  • Patient: A person with Parkinson’s disease.
  • Application: Therapist helps initiate movement for rolling from supine to sidelying, gradually allowing the patient to take over the movement and eventually providing resistance for strengthening.

Rhythmic rotation

• Slow, passive rotational movements around a longitudinal axis are applied to reduce hypertonia (increased muscle tone) and promote relaxation.
• Example:
  • Patient: An individual with spasticity in the trunk.
  • Application: Therapist slowly rotates the patient’s trunk to assist in relaxing the muscles before initiating trunk flexion activities.

Rhythmic stabilization

• This involves isometric contractions of antagonist muscle groups simultaneously to improve joint stability and postural control.
• Example:
  • Patient: A patient sitting unsupported.
  • Application: Therapist applies multidirectional resistance to the patient’s shoulders, challenging them to maintain their posture and improve trunk stability.

Approximation

• Gentle compression of joint surfaces, typically in weight-bearing positions, to stimulate mechanoreceptors and enhance postural stability and muscle activation around the joint.
• Example:
  • Patient: A person in a quadruped position or standing.
  • Application: Therapist gently compresses the patient’s shoulder joints during weight-bearing to promote co-contraction and stabilize the joint.

Slow reversals

• Alternating concentric contractions of agonist and antagonist muscles without relaxation to improve coordination and ensure smooth transitions between movements.
• Example:
  • Patient: A patient with knee weakness.
  • Application: Therapist resists knee flexion, then extension in a seated position, alternating back and forth to improve functional control and coordination.

Hold-relax

• An isometric contraction of a muscle group followed by relaxation and passive stretching. This technique is particularly useful for improving range of motion when pain or tightness is present.
• Example:
  • Patient: A person with hamstring tightness.
  • Application: The patient performs an isometric contraction of the hamstrings against resistance, followed by passive stretching to improve flexibility.

Contract-relax

• An isotonic contraction of the muscle through its available range followed by relaxation and passive movement into an increased range of motion to improve flexibility.
• Example:
  • Patient: A person with limited hip range of motion.
  • Application: The patient resists the therapist’s push into hip extension and then relaxes, allowing the therapist to stretch the hamstrings and improve flexibility.

Repeated contractions

• This involves repeated quick stretches followed by resisted contractions to enhance the initiation and strength of weak muscles.
• Example:
  • Patient: A person with weakness in shoulder flexion.
  • Application: The therapist provides a quick stretch to the anterior deltoid, followed by resistance to strengthen the muscle and improve range of motion.

PNF patterns are associated with the way in which the joints are moved to perform specific patterns outside of synergy. PNF patterns exist for both the upper and lower extremities. The patterns are as follows for upper extremity:

D1 flexion

Shoulder: flexion, adduction, external rotation

Forearm: supination

Wrist: radial deviation, flexion

Finger: flexion

D2 flexion

Shoulder: flexion, abduction, external rotation

Forearm: supination

Wrist: radial deviation, flexion

Finger: extension

D1 extension

Shoulder: extension, adduction, internal rotation

Forearm: pronation

Wrist: ulnar deviation, extension

Finger: flexion

D2 extension

Shoulder: extension, abduction, internal rotation

Forearm: pronation

Wrist: ulnar deviation, extension

Finger: extension

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The patterns are as follows for lower extremity:

D1 flexion

Hip: flexion addiction, and external rotation

Ankle: dorsiflexion and inversion

Toe: extension

D2 flexion

Hip: flexion, abduction, and internal rotation

Ankle: dorsiflexion and eversion

Toe: extension

D1 extension

Hip: extension, adduction, and external rotation

Ankle: plantar flexion, inversion

Toe: flexion

D2 extension

Hip: extension, abduction, internal rotation

Ankle: plantarflexion, eversion

Toe: flexion

Neurodevelopmental treatment (NDT)

Neurodevelopmental training (NDT) is a hands-on approach focusing on appropriate posture through tactile and sensory input by therapists to facilitate improvement patterns. NDT can be used to treat individuals with neurological disorders such as cerebral palsy, stroke, or brain injury to improve movement strategies. Individuals will utilize NDT uses the following principles for treatment approach.

• Developmental stages
  • Each individual with neurological deficits has varied functional deficits.
    The aim of the develop[mental stage is to assess what is their current functional status and then aid in getting to the next stage.
    • Example Stroke patient can sit independently, , next stage would be to work on standing prior to gait
• Sensory integration
  • Providing individuals with neurological deficits require sensory input to assist with understanding their environment and how to respond to it
• Postural control
  • Emphasizing the need for appropriate postural alignment and stability to aid in improving movement patterns
• Hands on approach
  • Therapists provides tactile feedback to given individual knowledge of correct movement patterns

Frenkel exercises

Frenkel Exercises are a series of coordinated movement exercises to treat patients with ataxia, particularly sensory (proprioceptive) ataxia resulting from conditions like multiple sclerosis or posterior column lesions of the spinal cord.

Description:

• Frenkel exercises are slow, repetitive, and precise movements performed in supine, sitting, and standing positions.
• They emphasize visual control to compensate for loss of proprioception.
• Movements are performed actively, and the patient is instructed to watch their limbs while moving.
• Exercises are progressed from simple to complex, and from unilateral to bilateral movements.
• Rhythm, speed, and range are gradually increased as control improves.
• Can be done with or without verbal cues and metronome guidance to aid timing.

Role in neurological rehabilitation:

• Improves coordination in patients with sensory ataxia, where proprioceptive feedback is diminished.
• Promotes motor control and timing through visual compensation and repetition.
• Enhances concentration and motor planning through attention to precise limb movement.

Example exercises:

1. Supine: Heel slides along a straight line to the knee or shin of the opposite leg.
2. Sitting: Touch heel to a series of marked points on the floor in a set sequence.
3. Standing: Step to and from targets marked on the floor without losing balance.

Treatment strategies for individuals with pusher syndrome

Pusher syndrome is a condition occurring post stroke or brain injury in which the individual pushes their body to the paretic side- leading to a tilted position (patient has difficulty achieving full vertical position). The non-paretic side (which is the pushing extremity) is positioned in abduction and extension to propel the individual towards the paretic side. Individuals with pusher syndrome will resist (push against) passive correction to aid in midline orientation.

Pusher syndrome can be caused by lesions to the right or left side of thalamus. It can be associated with neglect and aphasia. Pusher syndrome typically does not last greater than 6 months but in the short term impairs functional mobility and movement.

Treatment strategies can include the following;

• Do not push/pull to correct posture
• Utilize visual cues in the environment to assist with achieving upright position such as door frames or windows
  • This gives the individual with pusher syndrome a cue as to what is vertical
• Stand/sit with non-paretic side against wall to provide support for vertical alignment
• Increase weightbearing to paretic side through manual pressure techniques
• Place tape on floor to assist with giving visualization of vertical
• Distract non-paretic side to avoid pushing by this extremity

Outcome measures

• Berg balance scale
  • Purpose: predict risk for fall and prescription of assistive device
  • Setting: inpatient rehab, outpatient
  • Special considerations:
    • assesses individual in static and dynamic positions in both sitting and standing
    • score of 45 or less indicates an increased fall risk
• Functional gait assessment (FGA)
  • Purpose: evaluate balance and postural stability during gait
  • Setting: inpatient rehab, outpatient
  • Special considerations:
    • Deviation of the dynamic gait index (DGI) to allow for improved reliability and decrease the ceiling effect (can be used in a diversity of populations)
    • Score of 22 or less indicates increased risk for fall
    • Can be used to show change in disease process with a change of 4 or greater indicating significant change in disease process
• Dynamic gait index (DGI)
  • Purpose: measures an individual’s ability to respond to changing demands beyond steady-state walking- specifically for individuals with balance and vestibular deficits
  • Setting: inpatient rehab, outpatient
  • Special considerations:
    • Tests incorporates head turns, stepping over objects, avoiding obstacles as testing components- may be good for high level patents with balance deficits
    • Score of 19 or less is predictive of falls
• Tinetti (POMA)
  • Purpose: measures balance and gait to determine an individual’s risk for falling
  • Setting: inpatient rehabilitation, outpatient
  • Special considerations:
    • Tests static balance in chair and standing, gait, perception of balance during activities, and fear of falling
    • Score of 19-23 indicates moderate fall risk, 18 or less indicates high fall risk
• Functional reach
  • Purpose: measure an individual’s balance and stability as related to risk for falling
  • Setting: acute care, inpatient rehabilitation, outpatient
  • Special considerations:
    • Reaching 10 inches or greater indicates low fall risk
    • Used for individuals who demonstrate difficulty with stepping strategies and reaching outside base of support
• Fugl meyer
  • Purpose: evaluate and quantify motor function recovery in areas of severity of motor impairments, balance, and sensory status post stroke
  • Setting: inpatient rehabilitation
  • Special considerations:
    • Max score is 226 points
    • Goal is to demonstrate progress with intensive therapy
      • There is no normal score - the goal is to increase the independence level as therapy interventions are performed
      • Typically taken at initial evaluation and discharge
• Activities- specific balance confidence scale (ABC scale)
  • Purpose: measure self-reported confidence level in performing without losing balance or feeling unsteady
  • Setting: outpatient
  • Special considerations:
    • This is a self-report survey
    • Confidence levels is rated by percentages
      • Score for 80% or higher is high-functioning
      • 50-80% is moderate functioning
      • 50% is low functioning
• 5 time sit to stand
  • Purpose: assesses lower limb muscle strength, balance, and functional mobility
  • Setting: acute care, inpatient rehabilitation
  • Special considerations:
    • Norms are established by age
      • 11.4 seconds for 60-69 ages
      • 12.6 seconds for 70-79 ages
      • 14.8 seconds for 80-89 age
• Timed up and go (TUG)
  • Purpose: assess mobility, balanced, and walking while estimating fall risk
  • Setting: inpatient rehabilitation, outpatient
  • Special considerations:
    • Score of 10 seconds or less is considered normal
• Functional independence measure (FIM)
  • Purpose: evaluates an individual’s level of disability and amount of assistance needed to perform mobility and ADLs
  • Setting: inpatient rehabilitation
  • Special considerations:
    • Consists of 18 items that aid in development of goals for patients and give objectivity to level of function
    • There is no normal score - the goal is to increase the independence level as therapy interventions are performed

Common neuromuscular medications

• Levodopa
  • Mechanism of Action: Replaces dopamine in basal ganglia- use for Parkinson’s disease
  • System Interactions:
    • Neurological: confusion, hallucinations, delusions, psychosis, agitation
• Baclofen
  • Mechanism of Action: Decrease spasticity
  • System Interactions:
    • Musculoskeletal: Muscle stiffness, abnormal posturing, bone/joint stiffness, pain, muscle weakness
• Donepezil
  • Mechanism of Action: use in treatment of Alzheimer’s disease to slow the progression of memory loss and confusion
  • System Interactions:
    • Musculoskeletal: Muscle cramps, weakness, tremors
    • Gastrointestinal: Nausea, vomiting, diarrhea, weight loss
    • Neuro: Headache, seizures, dizziness
• tPA (tissue plasminogen activator)
  • Mechanism of Action: Dissolves blood clots, specifically for treatment for ischemic stroke
  • System Interactions:
    • Gastrointestinal: Nausea, vomiting
    • Neuro: Headache, dizziness, blurred vision
    • Pulmonary: Cough
• Keppra
  • Mechanism of Action: Used to treat seizures
  • System Interactions:
    • Cardiac: Chest pain
    • Gastrointestinal: Bloating, constipation
    • Integumentary: Acne
    • Neuro: Mood swings, dizziness, headache