Kristofferson G. Mendoza, PTRP Department of Physical Therapy

Name: Kristofferson G. Mendoza, PTRP Department of Physical Therapy
Uploaded: 2017-12-22T12:54:37+00:00
Duration: PTM29S10
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Description: Kristofferson G. Mendoza, PTRP Department of Physical Therapy

Techniques to Improve Mobility in Neurologic and Developmental Conditions
Kristofferson G. Mendoza, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila 14 December 2009 All Rights Reserved 2009

Learning Objectives At the end of the session, the learner should be able to: Identify the principles of the Bobath Approach, Brunnstrom’s Movement Therapy in Hemiplegia, PNF and/or Motor Learning used in functional training of patients with neurologic or developmental conditions Identify the activities used in functional training using the Bobath Approach, Brunnstrom’s Movement Therapy in Hemiplegia, PNF and/or Motor Learning used in functional training of patients with neurologic or developmental conditions

Learning Objectives At the end of the session, the learner should be able to: Identify the ways and the appropriate time to progress functional training using the Bobath Approach, Brunnstrom’s Movement Therapy in Hemiplegia, PNF and/or Motor Learning used in functional training of patients with neurologic or developmental conditions Apply the principles of the Bobath Approach, Brunnstrom’s Movement Therapy in Hemiplegia, PNF and/or Motor Learning in the functional training of simulated patient with neurologic or developmental conditions

Functional Mobility Bed Mobility Sitting Assumption Transfers
Standing Assumption Ambulation Other Mat activities

Bed Mobility Moving towards HOB, FOB, side of bed
Turning to side, prone supine Bridging

Bed Mobility Mat Activities Prone on elbows Prone on hands Quadruped

Bed Mobility Assumption of sitting Supine  sitting
Sidelying  sitting Sitting on the mat (cross-, side-, long-, ring-, kneel sitting)

Transfers Bed  wheelchair / chair Bed  gurney
Wheelchair / chair  chair Wheelchair / chair  floor Wheelchair  car / tub / pool

Standing Assumption Sitting  standing

Assumption of Other Upright Postures
Kneeling Half kneeling

Ambulation Level surfaces Uneven surfaces

Patterns of Transition (Mat)
Supine Long Sitting Sidelying Ring Sitting Cross Sitting Prone on elbows Prone Side Sitting Prone on hands Quadruped Kneeling Kneel Sitting Half kneeling Patterns of Transition (Mat) Standing

Neurodevelopmental Techniques

Review of Concepts Aim Help the patient gain control over the released patterns of spasticity by inhibition Inhibition done by special handling to facilitate the movement patterns of the higher integrated righting and equilibrium reactions

Review of Concepts more normal sensations of movement
more normal sensations of tonus Providing the patient with: Change in the motor output Teach unaided control of motor output

Review of Concepts Stage of Flaccidity Stage of Spasticity
Stage of Relative Recovery

NDT Functional Training
Stage of Flaccidity Fear of falling on affected side Loss of movement patterns No midline orientation There is lack of tonus and no spasticity  no associated reactions Cannot turn over towards sound side, cannot sit unsupported, cannot stand or walk All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Flaccidity Focus carrying weight on the affected side learn to balance on affected side in sitting and standing All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Flaccidity Turning over from supine to sidelying Preparing the patient for sitting up and standing Working for control of the leg Extension in preparation for weight bearing Preparing to walk without circumduction Control of abduction at the hip in supine Sitting up from supine and sidelying All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Flaccidity Clasping of hands awarenes of equality of both hands, some supination of the affected hand, spreading of the fingers at the MCP facilitates extension of the wrist and fingers and acts against flexor spasticity Shoulder well forward to prevent retraction of shoulder and the elbow extended (reflex inhibiting pattern) All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Spasticity Gradual development of spasticity Arm and leg take up a permanent and fairly typical posture More weight is borne on the unaffected side when standing and sitting Side flexion of the trunk with the affected side lower than the sound side Gait deviation All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Spasticity Focus progression of the activities done during the first stage more treatment done in sitting and standing All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Spasticity Treatment in sitting and standing up Treatment for standing up and standing Treatment for walking Stance phase Swing phase Treatment in prone-lying and kneeling All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Relative Recovery Lesser spasticity  does not interfere with movement Gait deviation or ambulation with a cane All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Stage of Relative Recovery Focus improve the patient’s gait All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

NDT for Children Widely use Strictly follow the developmental sequence
Used with other techniques All of these leads to negation of affected side and complete orientation to the sound side Fear of falling on affected side because lack of balance and arm support on affected side This should be negated and not reinforced

Brunnstrom’s Movement Therapy in Hemiplegia

Stages of Recovery Stage 1 Flaccidity; No movement can be initiated Stage 2 Spasticity begins to develop; Basic limb synergies or their components may appear as associated reactions Stage 3 Peak of spasticity; Patient gains control of the movement synergies; Semi-voluntary movement

Stage 4 Spasticity declines; Some movement outside the limb synergies are mastered Stage 5 More difficult movement combinations are mastered; Synergies lose their dominance Stage 6 Spasticity disappears; Individual joint movements are possible Stage 7

Brunnstrom’s Functional Training
Bed Exercises Proper bed posture LE: knees and hip slightly flexed UE: abduction of humerus from scapula avoided Passive  active-assisted movements including head, neck and trunk Moving around the bed while protecting the affected arm: Turning to sidelying, sitting up

Exercises in Sitting Sitting used as soon as feasible Opportunity to improve trunk control Communication is easier Trunk movements may facilitate UE Orientation of the UE to erect position for functional carryover

Exercises in Sitting Balance in sitting Trunk inclination exercises Trunk rotation Head neck and UE movements

Preparation for walking: Modification of motor responses of the lower limb Bilateral contraction of hip flexor muscles Unilateral contraction of hip flexor muscles Activating ankle dorsiflexors Alternate responses of antagonistic muscles Knee flexors and extensors

sitting semi-standing half-prone standing

Standing and Walking: Knee stability in standing Standing knee bends Lateral weight shift Marking time, knees slightly flexed Preparation for swing through in walking Trunk rotation with arm swing Automatic gait Assisted walking Obstacle clearance Stairs

Brunnstrom for Children
Brunnstrom specifically for treatment of patients with hemiplegia.

Proprioceptive Neuromuscular Facilitation

What is Proprioceptive Neuromuscular Facilitation?
Review of Concepts What is Proprioceptive Neuromuscular Facilitation? Having to do with any of the sensory receptors that give information concerning movement and position of the body Involving the nerves and muscles Making easier

Review of Concepts PNF procedures are used to:
Increase the patient’s ability to move or remain stable Guide the motion by proper grips and appropriate resistance Help the patient achieve coordinated movement through timing Increase the patient’s stamina and avoid fatigue

Review of Concepts “…effectiveness [of PNF] does not depend on having the conscious cooperation of the patient.” (Adler, Becker and Buck, 1993)

Irradiation and Reinforcement Body position and Body mechanics
Review of Concepts Basic Procedures Resistance To aid muscle contraction and motor control, to increase strength Irradiation and Reinforcement Use of the spread of the response to stimulation Manual contact To increase strength and guide motion with grip and pressure Body position and Body mechanics Guidance and control of motion by the alignment of the therapist’s body, arm and hands Verbal (commands) Use of words and appropriate vocal volume to direct the patient The command is divided into three parts: Preparation: readies the patient for action Action: tells the patient to start the action Correction: tells the patient how to correct and modify the action

Traction and Approximation
Review of Concepts Basic Procedures Traction is used to: Facilitate motion, especially pulling and antigravity motions Aid in elongation of muscle tissue when using the stretch reflex Vision Use of vision to guide motion and to increase force Traction and Approximation The elongation or compression of the limbs and trunk to facilitate motion and stability Stretch Use of muscle elongation and the stretch reflex to facilitate contraction and decrease muscle fatigue Timing To promote normal timing and increase muscle contraction through “timing for emphasis” Patterns Synergistic mass movements, components of functional normal motion Timing for Emphasis involves the changing of the normal sequencing of motions to emphasize a particular muscle or a desired activity Approximation is used to: Promote stabilization Facilitate weight-bearing and the contraction of antigravity muscles

PNF Principles in Functional Training
Use of developmental sequence Hasten motor learning thru “sensory cues” Repetition used to increase strength and endurance Resistance are graded according to the abilities of the patient

Proximal to distal development head, neck and trunk are trained first Strictly follows developmental sequence one phase is the foundation for the next Progress is enhanced by performance of an activity within a sequence rather than by inadequate performance of a variety of activities

Activities range from single movements to complex combinations Activities are broken down into parts and the parts practiced

When the goal is to move Movement is permitted Stronger patterns are resisted strongly Weaker components are reinforced by a stronger segment When the goal is to maintain balance Movement is not allowed A stronger segment is used to augment a weaker segment

Mat Activities Gait Training

Mat Activities Gait Training Both movement and stability Patient learns to: move into the position stabilize in that position combine functional motion with stability of position Approximation promotes stability and balance while traction and stretch increase ability to move Use a firm, large, pliant, smooth mat

Mat Activities Gait Training Emphasis on the trunk Use of resistance to increase patient’s ability to balance and move Resisted gait are exaggerations of normal motions Adequate ROM of hip, knee and ankle needed Strength of muscles of ankle, knee, hip and trunk needed

Mat Activities Gait Training Rolling Prone on elbows Side sitting Long sitting Short sitting Crawling Kneeling Half-kneeling Hand-and-Feet position to standing Bridging

Mat Activities Gait Training Standing up and sitting down Standing One leg standing Weight shifting Repeated stepping Walking Walking forwards Walking sidewards Walking backwards Walking up and down

PNF in Children does not depend on having the conscious cooperation of the patient Progress treatment using activities that suit the developmental level of the individual

Motor Relearning Program

Task-Oriented Approach
Environment Individual

Task-Oriented Approach
Intervention Impairment Level Strategy Level Functional Level

Does not progress from one section to the other Each session should have materials from each section

Muscle control not muscle strength Spasticity is unnecessary muscular activity which has become habitual Eliciting appropriate muscle activity and eliminate of unnecessary muscular activity Physically and mentally practice MUSCLE CONTROL is essential and NOT MUSCLE STRENGTH. It is the appropriate number of motor units recruited which is important and not the maximum number of motor units recruited. Spasticity is defined as unnecessary muscular activity which has become habitual so that treatment is geared towards eliciting appropriate muscle activity and elimination of unnecessary muscular activity.

Start as soon as the patient is medically stable Patients confined to the bed? No addition of conflicting techniques MRP should start as soon as the patient is medically stable If the patient is confined to the bed, start with what the patient can manage (practice of missing components that can be done in supine) Addition of conflicting techniques will interfere with the program

Analysis of Function Practice of Missing Components Practice of Activity Transference

Equipment A low bed of convenient height to practice standing up and sitting down Several small steps to enable different-sized patients to sit with feet supported Calico splints

Supine to Sit Rolling to Side Sitting up Over Side

Supine to Sit Essential Components Rolling onto Side rotation and flexion of the neck hip and knee flexion flexion of shoulder and protraction of scapula trunk rotation

Supine to Sit Essential Components Sitting up Over Side lateral flexion of neck lateral flexion of trunk (with abduction of lower arm) leg lowered over side

Supine to Sit Difficulties Rolling onto Side flexion of hip and knee flexion of shoulder and protraction of scapula

Supine to Sit Difficulties Sitting up Over Side rotates neck and flexes forward pulling with intact hand hooks intact leg under affected leg so that patient shifts weight backwards

Supine to Sit Missing Components to Practice Stimulate protraction of the scapula for rolling over Stimulate hip and knee flexion Stimulate lateral flexion of the neck

Sitting  Standing Standing does not require the patient to have good sitting balance, but good sitting alignment. Components Standing Up foot placement trunk forward by flexion at hips with extended neck and trunk extension of hips for final standing

Sitting  Standing Components Sitting Down trunk forward by flexion of hips with extended neck flexion of knees

Sitting  Standing Difficulties weight is on intact side inability to shift weight forward patient tries to shift weight forward by flexing trunk and head or wriggling forward to edge

Sitting  Standing Missing Components to Practice Stimulate trunk inclination forward at hips

Walking Components Stance Phase extension of the hip throughout lateral horizontal shift of the pelvis and trunk flexion of the knee

Walking Components Swing Phase flexion of the knee lateral pelvic tilt downwards at toe-off flexion of the hip rotation of the pelvis forward on side of swinging leg extension of the knee and dorsiflexion of the ankle prior to heel strike

Walking Difficulties Stance Phase (affected leg) lack of extension of hip lack of controlled knee flexion excessive lateral horizontal shift of pelvis excessive downwards pelvic tilt on the intact side, with excessive lateral pelvic shift to the affected side

Walking Difficulties Swing Phase (affected leg) lack of knee flexion at toe-off lack of hip flexion lack of knee extension plus ankle dorsiflexion on heelstrike

Walking Missing Components to Practice Stance Phase stimulate hip extension maintain extension of the knee train lateral horizontal pelvic shift

Walking Missing Components to Practice Swing Phase train flexion of the knee at the start of swing phase stimulate knee extension and foot dorsiflexion at heel strike

MRP in Children Applicable if the patient can understand simple instruction

NDT vs. MRP Mercado, RA & Loresca, AM (2002). First Moves Seminar. Section of Physical Therapy, Department of Rehabilitation Medicine, University of the Philippines – Philippine General Hospital.

Sources Adler SS et al (1993). PNF in practice: An illustrated guide. Germany, Springer-Verlag Berlin. Bobath B (1990). Adult hemiplegia: Evaluation and treatment (3rd ed). Oxford, Heinemann Medical Books. Carr JH and Shepherd RB (2003). Stroke rehabilitation: Guidelines for exericse and training to optimize motor skill. London, Butterworth-Heinemann. Sawner KA & LaVigne JM (1992). Brunnstrom’s movement therapy in hemiplegia (2nd ed). Philadelphia, J.B. Lippincott Company

Sources Shumway-Cook A and Woollacott MH (2001). Motor control: Theory and practical applications (2nd ed). Philadelphia, Lippincott Williams and Wilkins. Umphred DA (2007). Neurological rehabilitation (5th ed). Philadelphia, Mosby, Inc. Voss DE et al (1985). Proprioceptive neuromuscular facilitation: Patterns and techniques (3rd ed). Philadelphia, Harper and Row First Moves Seminar Handout (2002). Section of Physical Therapy, Department of Rehabilitation Medicine, University of the Philippines – Philippine General Hospital. Advanced Physical Therapy Clinical Training Program Module (2007). Section of Physical Therapy, Department of Rehabilitation Medicine, University of the Philippines Manila.

Kristofferson G. Mendoza, PTRP Department of Physical Therapy

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