Interventions for Neuromuscular Reeducation
PTA 204L Neurological Dysfunctions Lab

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Contact howardc@lanecc.edu for permissions.

Fundamentals of Neuromuscular Re-Education

Goals of Physical Therapy

1. Use movement analysis and determine the patient's:
1. movement strategies, postural responses, and appropriate feedback
2. skills and abilities - prerequisites for movement
3. missing components of normal movement
2. Active patient-participation in movement
3. Movement transfers to activities of daily living (functional exercise)
4. Apply frequent practice in a variety of environments for maximum adaptability

Decision-Making Framework for Selecting Interventions

D.W. Fell introduced a clinical decision-making framework for selecting and progressing interventions in this population. All interventions typically applied in this population (e.g., gait and locomotion training, functional training, balance and coordination training, conditioning and reconditioning) can be selected and progressed based on clinical decisions that fall into one or more of these three categories:

• Progressing function through motor learning principles
• type of practice (components, variety)
• feedback (extrinsic to intrinsic)
• environment (closed to open, simple to complex)
• Progressing function through addressing characteristics of movement / task
• amplitude, velocity, amount (frequency, intensity, duration)
• endurance
• single to multi-joint motions
• Other parameters
• developmental sequence
• supportive and assistive devices
• level of assistance (physical, verbal cues, etc.)

In clinical practice, there are a variety of manual techniques used to facilitate functional recovery in patients with neuromuscular impairments. In laboratory practice, we will learn and practice the technical aspects of a few, selected rehabilitation techniques (e.g. manual contact, direction of force, cues, etc.).

During skill checks, you are graded on your ability to technically perform the selected techniques with some level of accuracy. In clinical practice (and practical examination), you will select appropriate interventions based on how you can best help the patient relearn movement patterns and restore postural control.

Interventions to Support Sensory Systems

PTAs can provide opportunities for patients with sensory dysfunction to attend, discriminate, and functionally adapt to sensory information so that movement improves during functional activities. In PTA 132L, 133L, and 104L, we introduced orthopedic interventions, such as closed chain activities, that facilitate improvements in kinesthesia and proprioception. Additional examples of interventions to support sensory systems while working to improve movement and motor control include:

• manually-facilitated stretching followed by functional activities
• superficial and deep pressure and tapping to increase attention to affected area(s)
• weight bearing activities (closed chain): prolonged stretch can reduce spasticity while practicing functional activities
• stereognosis activities (e.g., identifying and object placed in the hand with eyes closed)

PTAs instruct patients and family members in strategies to increase attention to sensory stimulation and integration. As patients recall and reuse strategies to attend to stimuli, the neuromuscular system is set up to become as successful as possible. Sensory neglect and visual field cuts impact safety and recovery of the involved side. As the patient progresses, cueing should decrease and the situations and environments should be made progressively more complex to optimize functional recovery. The following are examples of using multi-modal feedback to promote attention to areas of sensory impairment and neglect during functional tasks:

• tie a colored ribbon around wrist on involved side and cue patient to keep the ribbon in sight during an activity
• position in bed to facilitate visual attention to neglected side (e.g., sidelying with TV/radio on involved side, arms supported by pillows)
• use sound (voice, bells, snaps) on involved side to encourage localization and attention to the involved side
• practice upper extremity activities that require patient cross midline
• provide multiple methods of visual, tactile, and proproceptive stimuli to provoke functional use of the affected side.

Use of Supportive Devices to Improve ROM and Joint Mobility

• Position UE on lap tray or arm trough
• Tone reducing UE splints (resting splints, hand cones) to prevent hand contractures
• Wheelchair positioning with pommel cushion or anti-thrust cushion
• Prone positioning for hip flexor stretching
• Standing frame activities for WB stretch to calf and plantar foot

Neuromuscular Re-Education Treatment Approaches

Following CVA and TBI, patients experience varying degrees of deficits in central nervous system processes which are necessary for normal movement. The level of motor impairment and potential for functional recovery is evaluated by the physical therapist. A summary of examination processes are included in the Interactive Lecture: Neuromuscular Examination Elements.

Typicall Vs. Atypical Motor Control

 Example of Synergies Post-Stroke

Techniques to Reduce Spasticity

• prolonged pressure on long flexor tendons of hand low, oscillating movements, incorporating trunk/limb rotation

• weight bearing positions: quadruped, kneeling, plantigrade standing

• sustained stretching in upright postures

• active contraction of antagonists to spastic muscles

• electrical stimulation to antagonists

• ice wraps/packs

• splinting (positioning, pressurized)

• biofeedback

Neuro Developmental Treatment (NDT) Techniques

History

• Developed by Berta Bobath, PT and Karel Bobath, MD for functional recover
• Main patient populations include: adult CVA/hemiplegia, and Cerebral Palsy

Theoretical Framework

NDT as a neuromuscular and functional reeducation technique now includes neuroplasticity as a basis how the brain can change and reorganize itself and its processes based on practice and experience

• facilitation of normal postural alignment and movement patterns
• demand should be placed on the involved side during developmental and functional activities
• sensory feedback (manual contact, visual integration, somatosensory reinforcement) is essential to recovering function
• treatment includes looking at the whole person and specific functional needs; recovery vs. compensation

Essentials for Treatment Effectiveness

• therapists must be able to observe and distinguish normal from abnormal alignment and movement patterns
• therapists must be able to make the functional retraining activities meaningful to the patient; task specific
• therapists must be able to select the optimal practice method, feedback, and environment for maximum function and independence
• therapists must have stable footwear, good flexibility in lumbar spine and lower extremities for optimal body mechanics during mat activities.

Key elements to Applying NDT

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Alignment Check points - PTs and PTAs use manual contact to establish, align and assist the patient with these key elements

• Base of support - wide, narrow, staggered, asymmetrical
• Body segment alignment - synergies, compensatory head and trunk position
• Muscle activation - pattern and timing of movement during functional activities
• Weight shift - in all planes

Functional Check points - PTs and PTAs will modify manual cues and feedback to the demands of the task and the ability of the patient. Examples of functional check points include:

1. Gravity
2. Levers
3. Time
4. Distance
5. Speed
6. Environment

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Example of NDT Techniques

PNF Approaches

Proprioceptive Neuromuscular Facilitation (PNF) is a stretching technique used to increase range of motion, flexibility, and improve muscle performance (Hindle, Whitcomb, Briggs & Hong, 2012).

Initially developed by Kabat, Knott, and Voss, PNF is applied to treat impairments associated with neuromuscular conditions and musculoskeletal conditions. There are multiple theoretical mechanisms proposed for the effects of PNF, largely based on antagonist inhibition with maximum voluntary contraction.

Manual contact enhances the muscular response and faciltates recruitment. This can occur through indirect (distal) and direct facilitation. Manual contact can also influence the direction of force produced; therefore manual contact should be in placed to inform the direction of motion.

Resistance is applied based on the desired action from the patient. For example, if the patient needs to stabilize in a position, the resistance is applied in a slow velocity and in a direction that requires the patient to and "match" the resistance. This is referred to maintained isotonic contraction. Unlike an isometric contraction where there is no movement ("hold"), isotonic contractions is a recruitment pattern where the muscles are trying to prevent external forces from producing movement ("don't let me move you").

Note the manual contact and the appropriopriate resistance demonstrated in the video clip and how hand placement, speed, and verbal cuing influences the motor response.

Skill Check Techniques

Manual Contact

On a neuromuscular level, motor responses are heavily influenced by pressure receptors. Therefore, appropriate pressure is a necessary component for influencing the direction of motion and facilitating a maximal response. Manual contact should impart a feeling of security and should not be painful. Proper body positioning and mechanics are preliminaries for appropriate application of pressure.

NDT and PNF are specific for an open hand approach to facilitating movement: there is no grasping the patient to facilitate optimal alignment or movement.

With NDT, contact is very light initially and allows for a graded increase in pressure depending on the stimulus needs of the patient.

Appropriate Resistance

Appropriate resistance is that amount of manual resistance which facilitates a maximal response while still allowing a smooth and coordinated contraction. Maximal resistance facilitates irradiation and overflow from stronger components to those that are weaker. Emphasis should be placed on avoiding the valsalva maneuver.

Resistance during PNF is dependent on the desired outcome of the intervention. For example resistance applied to build stability will differ in speed and force than resistance applied to produce a stretch

Body Mechanics and Safety

Gross motor skills are task-specific: physical therapy providers need to be able to work in and at the bedside, on hi-low mats, in parallel bars (sitting/standing) and in functional environments (bathroom, kitchen, car). Principles of good body mechanics (center of gravity, base of support, flexibility) must be observed during skill check and clinical activities.

Safety for you and your patient is the key to a successful treatment and career. Follow your clinical site's policy on use of a gait belt. In some cases, you will not be covered under Workmen's Compensation if you are injured during patient care and DID NOT follow safety policies and procedures, including correct use of a gait belt. When in doubt, put on the belt!

Verbal Cueing

Cueing should be simple, concise, audible. Depending on the condition and patient status, the patient should be given ample time to respond volitionally to the motor command. PNF cueing emphasizes the desired response (e.g. "hold" vs. "don't let me move you")

PNF Rhythmic Stabilization

Alternate isometric resistance to various manual contact points to enhance balance. Direction of pressure and hand positions are altered smoothly, increasing and decreasing resistance slowly, so that the patient continues to maintain a stabilizing contraction

Sample Videos NDT Techniques

Sample Videos PNF Techniques

Clinical Decision-Making Practice

How could this therapist use Fell's framework and manual facilitation interventions to progress this patient's

1. Attention to the L side during functional sitting task?
2. Functional use of the L side (limbs and trunk)?
3. Postural alignment in static sitting?

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Positioning and Shoulder Pain Management

A significant percentage of patients develop some form of shoulder pain following stroke.

Downward scapular rotation and rotator cuff weakness due to loss of motor control on the affected side leads to subluxation of the glenohumeral joint. Pain can result from prolonged stretch, shoulder impingement from malalignment, adhesive capsulitis from loss of active or regular range of motion.

Over time, repeated microtrauma can result in severe pain throughout the limb: Complex Regional Pain Syndrome.

Signs and symptoms of CRPS include: red and swollen hand, cool hand/limb or change in temperature, shiny skin and increased sweating, thenar and hypothenar atrophy

Interventions to minimize shoulder pain

Support a flaccid arm at all times: pillows in bed, wheelchair lap tray, UE sling/hemi sling

Maintain glenohumeral external rotation

Maintain scapular mobility on the thorax

manual scapular ROM

PNF techniques in multiple directions with scapular facilitation

Avoid

passive or active shoulder movements beyond 90 degrees unless the scapula is gliding toward upward rotation and sufficient external rotation is available.

pulleys: they may cause impingement

Educate family members and nursing staff in use of positioning and protective strategies; proper transfer techniques to prevent pulling or lifting on affected limb

Positioning

References

Fell DW. (2004) "Progressing therapeutic intervention in patients with neuromuscular disorders: a framework to assist clinical decision making. J Neurol Phys Ther. 2004;28(1):34-46

Fisher, BE, Sullivan, KJ. "Activity-Dependent Factors Affecting Post Stroke Functional Outcomes" Topics in Stroke Rehabilitation. 2001;8(3):31-44.

Institute of Physical Art. (2018). PNF [Video file]. Retrieved from https://www.youtube.com/playlist?list=PLN-IyZZvkkxTFISSJbqvuCN1lpgFENPks

Nudo, RJ. "Role of Cortical Plasticity in Motor Recovery After Stroke" Neurology Report, Neurology Section, APTA. 1998;22(2).

Runyan, C. (2008) NDT/Bobath Certificate Course in Treatment and Management of Adults with Hemiplegia: NDTA Inc. Approved Course. Recovering Function.

Shaab, Kathryn R. "Neurodevelopmental Treatment of Adults with Hemiplegia". Sheltering Arms. May 2008. Web 9 Sept 2010.

Velickovic, TD, Perat, MV. "Basic Principles of the Neurodevelopmental Treatment" Medicina. 2005;42(41):112 - 120.

Voss, DE, Ionat, MK, Myers, BJ. Proprioceptive Neuromuscular Facilitation. Philadelphia. 1985. Print