PT 834: Neurorehabilitation Principles

• Principles of Neurological Rehabilitation and Progression is covered in PT 834 Adult Neuromuscular Diagnosis and Management Spring 2025

Four Major Principles

• Neurological rehabilitation involves a continuous cycle of deductive and inductive reasoning
• The goal of neurological rehabilitation is functional competence
• Functional competence is promoted by basing rehabilitation strategies on embedded models of motor behavior and neurological rehabilitation
• Neurological rehabilitation involves motor learning and self-efficacy according to Fell (2018)

Principle 1: Cycle of Reasoning

• A sound theoretical foundation and models of practice underlie effective neurological rehabilitation
• Physical Therapists test hypotheses in the clinic to confirm, revise, or reject the validity of theories and models
• Objectivity and a systematic approach of analysis are important when testing hypotheses in the clinic
• Motor behavior reflects a self-organized interaction of multiple body structures and functions
• It is important to look for clusters of impairments and rate-limiting variables

Principle 1: Cycle of Reasoning Diagram

• Movement science, medical science, and rehabilitation science all lead to Model of Practice
• Model of Practice has two outputs, clinical science & inductive reasoning
• Deducive reasoning theories are tested in the clinic with hypothesis testing
• Inductive reasoning uses clinical observations to support or revise theories, which informs clinical investigations

Concepts of Motor Behavior Table

• Past approaches of Neurorehab have the following qualities
• Muscle Reeducation was championed by Jacobson, DeLorme, Goldthwait, Kendall, and Kenny
• Muscle Reeducation had verbal cues to motivate conscious contraction and relaxation activities and progressive resistance exercises
• Muscle Reeducation includes strengthening exercises and highlights muscle physiology
• Neurofacilitation was championed by Rood, Knott and Voss, Bobath, Brunnstrom, Johnstone
• Neurofacilitation leveraged sensory stimuli and manual facilitation
• Neurofacilitation focuses on inhibiting techniques to alter motor tone and promote “normal” movement patterns and hierarchical models of motor control
• Motor Learning was championed by Schmidt, Weinstein, Gentile, Carr and Shepherd, Lee, Magill
• Motor learning focuses on patient-driven approach to motor planning, error-detection, and problem-solving while using cognitive psychology
• Motor learning leverages task and environmental structure as it relates to compensatory movements

Principle 2: Functional Competence

• Functional competence is the goal of Neurorehab
• Refers To the ability of individuals to perform daily activities with only minimal physical and cognitive expenditure

Functional Competence Requires

• Individuals to be motivated and confident in their abilities
• Performing daily activities in a variety of environments and conditions

Functional competence involves

• Patients efficiently performing and modifying Movement Strategies to carry out a task Movement Patterns
• Actual kinematics employed to perform a task as intended (body segment amplitudes of movement, Velocity, Acceleration)

No Two Task Same

• Functional competence necessitates that patients learn to generate "general forms" for their actions
• That can be adapted to specific task contexts and environments.
• "General forms" can be referred to as Movement Topologies/synergies (Bernstein, 1967), Attractor States (Thelan, 1991), Schemas/motor programs (Schmidt, 1975), Coordination Modes (Newell, 1991) used by Majsak (2018)

Principle 3: Functional Competence

• By manipulating tasks and environments skillfully, PTs can simultaneously influence the actions, movements and cellular processes of patients
• PTs can promote competence by basing rehab strategies on embedded models of motor behavior and Neurorehab: apples not oranges
• Functional competence involves patients working within their own intrinsic biomechanical, neuromuscular or psychological constraints to meet extrinsic constraints
• Biomechanical aspects consist of range of motion; flexibility of the body
• Neuromuscular aspects such as strength, sensory processing, coordination, balance, motor tone
• Psychological aspects such as alertness, cognition, motivation, problem-solving, memory
• Body morphology, range of motion, flexibility are aspects of body that are biomechanical
• Strength, sensory processing, coordination, balance, and motor tone are neuromuscular
• Alertness, cognition, motivation, problem-solving, and memory are Psychological

Constraint factors

• Spatial Constraints of the location of objects being used and the size of the task space
• Temporal Constraints include available time as determined By motion or restricted task time, not performer choice

Functional Movement

• Patients best appreciate movement strategy when they are "embedded" in everyday functional tasking.
• Embedded examples include: the ability to pick up a dinner tray with both hands

Principle 4: Motor Learning

• It promotes the optimization engagement of patients to create functional competence.
• It promotes capacity by using aerobic exercises, and achieving high levels of motivation and self-efficacy to perform daily tasks
• Motor learning also involves self and environment perception
• Optimizes patient engagement for motor control
• What is being learned is the main point
• Manipulation of the tasks, schedule, timing, and type of information provided for patients to optimize the engagement of learning

General Perspectives of learning

• Motor Learning (Schmidt, 1988) is a set of processes associated with practice or experience leading to capacity for responding
• Learning not only includes the initial Acquisition of a behavior, but also Retention and the ability to Transfer that behavior to a comparable task
• Optimize patient engagement in the processes of learning is the key to optimizing motor control (Majsak, 2018)

Task Environment

• Perception of self and other environmental qualities relates to motor learning
• Intrinsic components deal with having a patient learn the nature of their self-organizing system and their intrinsic constraints
• Intrinsic constraints are limits needed to carry out tasks

Internal types of learning resources

• Patients have explicit, implicit, motor skills and cognition: all utilized to manage error while planning, analyzing, and problem-solving
• Both types of learning occur across all stages of learning, but explicit learning is often the primary type used in early learning with a shift to implicit learning after extended practice
• The ability coordinate spatial constraints is vital for having functional competence

Extrinsic tasks

• The difficulty patients actually experience, referred to as “Functional” difficulty, as rated in relation to their skills, in terms of their daily tasks (Guadagnoli and Lee, 2004).

Motor performance in the tasks of patients should engage as a whole (Table 14-3)

• Process of Performing self-perception has questions for hemiplegic patients who crushed a cup
• Motor planning is engaged when a patient stands with ataxia or rolls over in bed with hemiplegia

Motor planning requires refining effective movement when performing patterns to address mistakes and behavior

• Skilled PTs can share their planning observations and ask what a patient is planning and why
• Patients perform information and behavior to create new coordination for cyclical processes
• Repetition, and intensity all contribute to the practice of information
• Creating New Coordination is a cycle with cyclical components

Practice

• In order to be functionally competent patients need to practice to perform variations of the tasks they are learning

Ways to Practice

• Blocked practice allows all trials to be performed before beginning task variations
• Trials are intermingled if their performance is random
• Serial happens in a fixed order

Learning should engage through implicit practice

• Intensity plays a factor, but has an overtraining possibility
• Performance typically does not carry out high levels of practice (Lang, 2007)
• Overtraining can be a possibility (Sullivan, 2007)
• Stroke patients have capacity and a direct relationship of recovery (Byl, 2008; Lohse, 2014; Lang, 2015)
• Patients report five factors that influence learning: level of fatigue, task level, long training, enjoyment and level of muscle soreness (Merlo, 2013)

Specific practice

• Should be promotes based on multiple frames of references through biomechanics actions with gravity forces or movement of information
• How movement is coordinated is vital for learning to coordinate, and tasks which relate to the the actions of patients and environments

Treatment Progression With Framework (Fell 2004)

• The goal of practice is to create functional movement and optimize functional outcomes

Parameters of progression

• Includes variability, attention, practicing compounds and components, feedback and environmental movement
• Also includes amplitude and level of work to be done and also whether region applies
• Includes progression such as developmental to supportive assistance or equipment