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1 Guiding Principles in Neurological Rehabilitation...

1 Guiding Principles in Neurological Rehabilitation Sheila Lennon, Clare Bassile OUTLINE Introduction, 3 Principle 6: Motor Control: A Systems Model, 11 Why is a Conceptual Framework Important?, 4 Principle 7: Functional Movement Re-Education, 11 Guiding Principles for Neurological Rehabilitation, 5 Principle 8: Skill Acquisition, 12 Principle 1: The ICF, 5 Task Practice Issues, 12 The Value of Participation, 6 Role of Feedback, 14 Principle 2: Team Work, 7 Amount of Practice, 14 Principle 3: Person-Centred Care, 7 The Optimal Theory of Motor Learning, 14 Principle 4: Prediction, 9 Principle 9: Self-Management (Self-Efficacy), 15 Principle 5: Neural Plasticity, 10 Principle 10: Health Promotion, 15 What Type of Training Drives Neural Plasticity and Conclusion, 16 Recovery of Function?, 10 rehabilitation team together with the patient and his or her INTRODUCTION family collaboratively agree on joint treatment goals before Neurological rehabilitation has been defined as a process devising a treatment plan. that assists individuals who experience disability to achieve Developing a treatment plan is not easy; therapy is a and maintain optimal function and health in interaction complex intervention composed of multiple components with their environment (World Health Organization which are combined to tailor the intervention to each [WHO] 2011, 2017). Rehabilitation is a complex process patient’s needs and preferences. A structured treatment that combines the knowledge, skills, education and advice plan is essential to provide appropriate interventions, needed to support patients and their families to cope with which should be based on the best available evidence. a different life after neurological injury and disease (Barnes Standardised measures with published reliability, validity 2003). It requires an active partnership between the and sensitivity should be used to establish a baseline of patient, their family and a whole range of health and social performance before rehabilitation and then at key strate- care professionals. This book provides an explanation of gic points to document change as a result of rehabilitation the theories, tools and techniques that underpin the physi- interventions (see Chapter 4 on measurement tools for fur- cal management of people with neurological conditions in ther information). The assessment, interventions and mea- rehabilitation practice. surement tools specific to each neurological condition are Health professionals use a clinical reasoning approach discussed in subsequent separate chapters. to plan physical management across any neurological con- Theory is important to inform the development of com- dition. Fig. 1.1 summarises the key steps in the clinical plex interventions to change health behaviours in patients reasoning process. Assessment is always the starting point with chronic, long-term conditions (French et al 2012, for clinical reasoning. This assessment process is used to Michie et al 2005, Michie et al 2009); however, understand- guide intervention by identifying clinical problems. The ing the theoretical beliefs and assumptions that influence 3 4 SECTION 1 Background Knowledge Assessment (collect information) Subjective review chart, liaise with the rehabilitation team, interview the patient and family Objective identify impairments, functional restrictions, and participation limitations Use standardised outcome measures Interpretation (hypothesis formation) Establish a problem list Agree goals with patient and family Develop a treatment plan Implement the plan Reeducation of movement and function Introduce self-management Consider maintenance, prevention & health promotion Evaluate, Reassessment, Review Measure outcome and progress towards goals Consider modification to the plan, transfer of care, or discharge Plan next review FIG. 1.1 Clinical Reasoning in Neurological Rehabilitation. (Garner & Lennon, 2018, with permission) practice is also important, because these beliefs determine explanation for the actions and decisions of the health- how interventions will be delivered (Lennon et al 2006). care team (Shephard 1991). It is critical to state explicitly Since the late 1980’s there has been an explosion of the theoretical assumptions underlying our interventions, knowledge in neurological rehabilitation providing sound because this enables hypotheses to be formulated and evidence upon which to base healthcare interventions, yet tested. Understanding the theoretical framework to which to date incorporating evidence into practice has remained therapists subscribe can also lead to the development of challenging. The beliefs and attitudes of both patients new treatment strategies (Carr & Shepherd 2006). The and health professionals may actually impose barriers to beliefs of health professionals influence how they deliver implementing evidence-based interventions in practice intervention, as well as the techniques they select in their (McCluskey & Middleton 2010). This chapter will explain intervention plans (Lennon 2003, Lennon et al 2006). why theory and evidence-based practice (EBP) are import- Physical management in neurological conditions needs ant, and discuss the key neurophysiological, kinesiological, to be based on beliefs that are substantiated by evidence, motor learning and behavioural principles that guide neu- bearing in mind that the theoretical explanation under- rological rehabilitation within a conceptual framework. lying intervention may have to change as the evidence evolves. Historically, specific treatment approaches such as WHY IS A CONCEPTUAL FRAMEWORK the Bobath concept have influenced the content, structure and aims of physical therapies based on therapist preference. IMPORTANT? Although such approaches remain popular today, to date Health professionals need to subscribe to a conceptual there is no evidence to suggest that adopting a treatment framework for intervention, because theory provides the approach such as the Bobath concept is more effective than  CHAPTER 1 Guiding Principles in Neurological Rehabilitation 5 other approaches (Kollen et al 2009). An updated Cochrane KEY POINTS review by Pollock et al (2014) has reiterated that physical rehabilitation should not be limited to named approaches, Understanding the beliefs that guide practice helps but rather should be composed of evidenced-based physical explain the content, structure and delivery of therapy. techniques, regardless of historical or philosophical origin. A conceptual framework is essential to enable clini- The evidence base underlying physical interventions is cians to determine their assessment and intervention expanding year upon year. The challenge for clinicians is to strategies. keep up to date with that evidence, to transfer/implement Components selected within rehabilitation sessions that evidence into practice, but also to be prepared to change should be evidence based rather than based on ther- their preferred practice, when the evidence clearly identifies apist preference for a specific treatment approach. that their preferred intervention is not effective or that a Evidence needs to be individualised through shared different intervention would be more appropriate. There decision making within the context of the clinician– are many examples of specific training strategies, such as patient relationship. strength training or task-specific practice, which are effective at improving movement and function (Verbeek et al 2014; French et al 2016; see http://www.cochrane.org for relevant GUIDING PRINCIPLES FOR NEUROLOGICAL systematic reviews). There are also many clinical guide- REHABILITATION lines that provide a comprehensive review of all the avail- able evidence to date for the management of people after Neurological rehabilitation requires that health profes- stroke (National Clinical Guidelines for Stroke 2016, Stroke sionals keep up to date with evidence across many practice Foundation 2017, Winstein & Stein 2016), with Parkinson’s fields. A conceptual framework is essential to enable clini- (Keus et al 2014) and with multiple sclerosis (MS; National cians to determine their assessment and intervention strat- Institute for Health and Care Excellence 2014, Haselkorn egies. This conceptual framework should be independent et al 2015). These guidelines, developed by a multidisci- of treatment approaches, integrating neurophysiological, plinary panel and subjected to peer review, provide a useful kinesiological, motor learning and behavioural perspec- starting point for busy clinicians, when available. tives to focus on both physical and psychological recovery. Components selected within therapy sessions should We propose 10 key principles for consideration in the con- be evidence based rather than based on therapist prefer- ceptual framework to guide clinicians working in neuro- ence for a specific treatment approach. However, it is also logical rehabilitation: the WHO International Classification important to realise that there are still many key areas of of Functioning, Disability and Health (ICF), team work, clinical practice with no evidence or conflicting evidence; patient-centred care, prediction, neural plasticity, a sys- therefore therapists will always need to rely on their clinical tems model of motor control, functional movement reed- reasoning skills to select treatment techniques appropriate ucation, skill acquisition, self-management (self-efficacy) to the needs, wishes and goals of patients and their carers. and health promotion (Fig. 1.2). This meets the requirements of EBP, which is defined as the integration of best evidence with clinical expertise and Principle 1: The ICF patient values (Sackett et al 1996). In 2001 the WHO developed the ICF (http://www.who.in- Since the turn of the 21st century, EBP has attempted t/classifications/icf) with the aim of shifting the focus from to replace tradition and anecdote with high-quality ran- disability and impairments to health (Fig. 1.3). The ICF has domised controlled trials to guide neurological reha- become accepted as a universal framework for describing bilitation; getting this research adopted in practice has neurological disability, composed of five categories: body proved problematic, possibly because the emphasis on functions and structures, activities, participation, envi- integrating clinical expertise with the needs and wishes of ronmental factors and personal factors. The ICF provides patients and their families has been devalued (Greenhalgh a systematic way of understanding the problems faced by et al 2014). Complex patients do not easily map to a sin- patients, illustrating the multiple levels at which neurolog- gle evidence-based guideline (Greenhalgh et al 2014). The ical rehabilitation may act. The activities dimension covers founders of EBP are demanding a return to real EBP, which the range of activities performed by an individual. The par- respects professional knowledge and applies appropriate ticipation dimension classifies the areas of life in which for research evidence to inform dialogue with our patients and each individual there are societal opportunities or barriers. families about what best to do and why at each point in the Impairment is defined as a deficit in body structure or patient’s illness in a more personalised way with sensitivity function. Following a stroke, an example of impairment to context and individual goals (Greenhalgh et al 2014). would be weakness, leading to a limitation in the activity 6 SECTION 1 Background Knowledge ICF Patient-centred Team work Prediction (participation) care (goal setting) Health promotion Neurorehabilitation Neural (prevention) conceptual plasticity framework Skill Functional Self-management Motor control acquisition movement (self-efficacy) (systems model) (motor learning) reeducation FIG. 1.2 A conceptual framework for neurological rehabilitation. Health condition Body functions Activities Participation and structures Environmental Personal factors factors FIG. 1.3 Interactions Between the Components of International Classification of Functioning, Disability and Health. (WHO 2001, p. 18) of walking and thus requiring the use of a wheelchair for goal setting, as well as selecting appropriate interventions mobility. Being in a wheelchair may restrict that individual and outcome tools. However, further research is required from resuming his or her job, a limitation in participating to determine the benefits of using the ICF within clinical in that individual’s previous role in society. Environmental practice. and personal factors are the contextual factors that enable the rehabilitation team to identify facilitators and barriers The Value of Participation for the neurorehabilitation process such as having a house Changes at the level of impairment and activity are only that is wheelchair accessible without stairs. really meaningful for the patient and the family carer if they Within the ICF framework, physical interventions may enable them to participate in their family and community directly target both impairment (a loss or abnormality of life by resuming albeit in a different way their desired life body structure) and activity (performance in functional roles. That is why health professionals need to measure activities) with the overall aim of improving quality of life the effects of their interventions at different levels of the and participation in desired life roles. Lexell and Brogardh ICF; they should use standardised measures that have been (2015) have reviewed how the ICF can be used to enhance shown to have meaningful clinically important differences the clinical reasoning process by facilitating assessment and (see Chapter 4 on measurement tools).  CHAPTER 1 Guiding Principles in Neurological Rehabilitation 7 The concept of person-centred care is fundamental to not just to share information, but rather to collaborate as ensuring that patient and family preferences and priorities a team in goal setting, care planning and decision making. are central to the clinical reasoning process of team mem- The evidence on which the model of team working works bers. Although it is important to identify the main clinical best is unclear (Clarke & Forster 2015). The Stroke Unit problems that can be modified by our intervention, assess- Trialists’ Collaboration (2013) has identified that patients ment should also identify strengths, interests and desires who receive organised stroke unit care provided in hospital that are specific to the achievement of a patient’s goals. by nurses, doctors and therapists who specialise in look- Goal setting also needs to be adapted to different stages ing after stroke patients and work as a coordinated team in the rehabilitation process (see Chapter 5 on goal set- are more likely to survive their stroke, return home and ting). For example, more consideration needs to be given become independent in looking after themselves. Thus it to community-based training in context to enable people would appear that team working is an essential factor in with neurological disability to gain confidence and skills improving patient outcomes. in their own environments. Innovative strategies such as Developing an appropriate plan of care revolves around wearable and assistive technologies may also help to trans- collaborative goal setting within the team. Team goal set- late gains in rehabilitation departments to the home and ting is recognised as a core component of neurorehabili- community environment (Kimberley et al 2017). The tation. Setting goals aims to motivate the team and the influence of assistive technology in neurorehabilitation is patient, coordinate activities, and ensure that all import- discussed in Chapter 18. ant goals are identified (Wade 2009) (see Chapter 5 for a An optimal treatment plan will use a range of outcome review of goal setting). Team goals need to be based on the tools that will evaluate whether improvements in impair- patient’s wishes, expectations, priorities and values; one ments and function (activity) translate into improved way of facilitating appropriate goal planning is to use the participation such as quality of life and improved health SMART acronym, which recommends that goals should status. It is not sufficient to choose measures that mainly be specific, measurable, achievable/ambitious, relevant and measure impairment or function (see Chapter 4 and timed (Playford et al 2009; see Bovend’Eerdt et al 2009 for the pathology-specific chapters for selected outcome some practical guidance on how to set SMART goals). measures). Clarke and Forster (2015) offer the following recom- The wider context of society also plays a major role. mendations for improving team working in stroke survi- The government and society have a responsibility to vors during the rehabilitation phase: develop policies, systems and services to ensure inclusion Have written protocols and pathways which help and access to health services, education, work and leisure remove organisational and professional barriers. opportunities for people with neurological disability in Have specialist training and knowledge. the global health agenda (Tomlinson et al 2009). A WHO Agree on a consistent approach for clinical problems. (2017) report entitled ‘Rehabilitation 2030: A Call for Share treatment sessions. Action’ has called for global action by all key stakeholders Understand the thinking and beliefs of different to upscale rehabilitation services worldwide. Clinicians are disciplines. mostly concerned about the impact of their interventions Have an information provision strategy with consis- at an individual level, but they also need to consider how tent messages and access to further information when they can influence and improve practice at the policy and required. service delivery. These recommendations may also benefit people with other long-term neurological conditions (e.g. MS, Parkinson’s). Principle 2: Team Work After the initial rehabilitation phase, patients will continue Neurological rehabilitation requires an active partner- to need long-term follow-up, with collaboration between ship between the patient, the family and a whole range of different disciplines remaining important; supported healthcare and social care professionals; thus team work is self-management may be a more appropriate mode of care a critical element of care. The current evidence base distin- at this later review stage of care. guishes teams who are multidisciplinary versus interdisci- plinary in their way of working. Teams have been defined Principle 3: Person-Centred Care as multidisciplinary where there is sharing of information Person-centred care can be defined as a philosophy of care on assessments and interventions, whereas team members that encourages and supports patients and their carers to have been defined as interdisciplinary where there is a high develop the knowledge, skills and confidence they need to level of communication, mutual goal planning and evalu- effectively manage and make decisions about health (Health ation. It should be emphasised that it is really important Foundation 2014). Person-centred care can be viewed as a 8 SECTION 1 Background Knowledge partnership from the perspective of the patient, the family THE PICKER PRINCIPLES OF PATIENT- and the healthcare professional. Whalley Hammell (2009) CENTRED CARE (http://www.picker.org) has identified the characteristics of person-centred practice (see Characteristics of Person-Centred Practice box). 1. Fast access to reliable healthcare evidence 2. Effective treatment by trusted professionals 3. Continuity of care and smooth transitions CHARACTERISTICS OF PERSON-CENTRED 4. Involvement of and support for family and carers PRACTICE (Whalley Hammell 2009, with 5. Clear and comprehensive information, and support permission) for self-care 6. Involvement and shared decision making with Respect for clients’ values, priorities and perspec- respect for patient preferences tives 7. Emotional support, empathy and respect Respect for clients’ autonomy and rights to choose 8. Attention to both physical and environmental needs and enact choices Growing evidence links patient experience to health Seeks to realign and equalise power between thera- outcomes, adherence to recommended clinical prac- pist and client tice, as well as safety (Doyle et al 2013). Parish et al Provides client-orientated information to enable (2015) offer the following suggestions for getting per- informed choices son-centred care into practice: Enables clients to identify their priorities, needs and ensure that services are well coordinated; goals support and empower people to take charge of their Facilitates client participation in the rehabilitation pro- health; cess adopt a coproduction approach to health care; and Strives for collaboration and partnership in achieving produce a cultural change within policy and practice. clients’ goals Individualises service delivery Assesses the achievement of outcomes that matter Emphasis on involving family members, and their pref- to the client erences and needs, in the rehabilitation planning process Focuses on ensuring that service provision is useful is important, especially when the family carers may be the and relevant only ones providing ongoing support for patients after they leave the health service (Tang Yan et al 2014). Caring for people with neurological conditions can be very challeng- Person-centred care is not just about working in part- ing; the healthcare team needs to also focus on the health nership and sharing decision making with individual and well-being of the carer to reduce caregiver burden and patients and their families within the rehabilitation pro- burnout (Krishnan et al 2017). Key strategies to help relieve cess, it also means using that patient and carer experi- caregiver stress and burden are (Krishnan et al 2017): edu- ence to plan, deliver and evaluate health care to improve cation, effective communication, maintaining physical care; this is often referred to in the literature as co- and psychological well-being and building a local support production (Batalden et al 2015). Thus active involve- system. Getting involved with voluntary organisations and ment should be encouraged at all levels and at all stages peer and caregiver support groups can also reduce feelings of the rehabilitation process including research and of isolation and provide additional support. service development and design. The Picker Institute, Heath professionals are encouraged to listen to the per- which focuses on using patient experience to improve spectives of both patients and carers. The personal expe- health and social care, has identified eight principles rience of Fuller (2016), who cared for her husband for 21 of person-centred care (see The Picker Principles of years after a devastating stroke at age 50 years, sends some Patient-Centred Care box). strong messages on understanding the carer experience to Having a team approach is a key step to promoting per- help the patient live as full a life as possible (Table 1.1): son-centred care, where the team discusses and explains treatment options; patients and their carers then use this ‘From day one of Clive’s stroke, my family stepped out of information to make decisions about their goals and choose a life we once knew and took for granted, and stepped treatment solutions. The process of goal setting provides a into an alien world; a world which we knew we would mechanism for patient-centred care by enabling autonomy have to embrace to move forward with our lives. Our and appropriate pacing of information and responsibility lives, especially mine, revolved around Clive’s therapy (Playford et al 2009). sessions, as I was very aware how important therapy  CHAPTER 1 Guiding Principles in Neurological Rehabilitation 9 TABLE 1.1 Key Messages from a Carer on the Rehabilitation Process (adapted from Fuller 2016 with permission) Overwhelming disbelief, shock and grief  ive patients time to absorb that they have suffered a G life-threatening illness. Fear of the unknown, depression Evoke negative thoughts – is the effort worthwhile? Take into consideration the extent of the stroke, the L  anguage barriers may impede the process of understanding hidden disabilities: aphasia/dysphasia and dyspraxia a directive thereby sending an erroneous message to the patient and resulting in misinterpretation by the therapist. (e.g. the client has plateaued) Chronic fatigue Inhibits clients to work at their full capacity Medication and side effects may play a negative role Affects comprehension Changes regarding rehabilitation centres: closures/ C  lient having to travel longer distances to access therapy reallocation causing disorientation – intensifies fatigue and/or anxiety Limited parking or car parks situated some distance D  ifficult for carers and clients who require the use of from venue. wheelchairs – increases anxiety Do not discourage, give the client the chance to prove They all want to improve – they want to be the best they can be his/herself: Give encouragement, even if the session is a S  ome will do better than others – there may be an underlying nonevent issue Listen to the client and/or carer They may have experienced/witnessed some significant gain Introduce achievable hobbies All work and no play is not a good balance Never, ever rule out HOPE F  or some, hope is the only ‘positive’ they can aim towards to create a change in their life was in an endeavour to regain any sort of movement; and maintaining the right type of hope may be the first sign always at the back of my mind was the golden rule: “if that the patient is taking control towards managing his or you don’t use it you lose it”. The only way I could her own recovery and rehabilitation by identifying his or give Clive the support he needed, was to step into his her own goals and developing his or her own strategies to shoes; try to feel what he was feeling and continual- pursue these goals (Soundy et al 2010). This can in fact be ly ask myself: ‘What would I want if the tables were viewed as self-management, another guiding principle of turned and it was I who had experienced the stroke?’ rehabilitation that will be discussed later in this chapter. Research highlights the importance of the patient’s Fuller, personal communication, with permission and the carer’s voice, and representing their expectations in clinical decisions (Trede 2012). Dialogue between the One of Fuller’s key messages is ‘to never rule out hope, patients and their carers can be dominated by professional as hope is the only “positive” they can aim toward to cre- authority; thus another important aspect of person-centred ate a change in their life.’ The exploration of hope as a key care is training healthcare professionals to be more person concept in rehabilitation is relatively new. Hope supports centred. An updated Cochrane Review by Dwamena et al adjustment, perseverance and positive outcomes; it can (2012) has confirmed that training healthcare professionals reflect expectations, goals and optimism, as well as act as a to promote person-centred care in clinical consultations is motivator and source of strength (Bright et al 2011). There successful in improving person-centred skills, with some can be a tendency among health professionals to empha- evidence that person-centred care has beneficial effects on sise the importance of being ‘realistic’ in the early stages of patient satisfaction, health behaviour and health status in recovery or being worried about giving false hope to patients general medical conditions. Person-centred care is a cor- and their families. However, hope is not just about physical nerstone of the rehabilitation process. improvement; it can represent the possibility of returning to activities that are important and meaningful to a patient’s Principle 4: Prediction past self (Soundy et al 2014). The meaning of hope in neu- Therapists are being asked to make predictions about rological rehabilitation requires further exploration. Getting patient recovery every day, regardless of practice setting. In 10 SECTION 1 Background Knowledge KEY POINTS: PERSON CENTRED CARE confirmed that plasticity (defined as enduring changes in structure and function) does occur after damage to Patient and carer involvement are valued by service the nervous system also as a result of experience and users and improve clinical outcomes. therapy. The brain responds to injury by adaptation Active involvement of the patient and carer should aimed at restoring function. Thus cortical maps can be be encouraged at all levels and at all stages of the modified by a variety of inputs such as sensory inputs, rehabilitation process including research and service experience, learning and therapy, as well as in response development. to injury (Nudo et al 2013). Rehabilitation is likely to Health professionals need skills and training in be most effective when principles of neuroplasticity person-centred care. are considered (see Principles of Neuroplasticity for Clinicians box). the acute care hospital setting in the USA, the team must make a discharge recommendation soon after initial assess- PRINCIPLES OF NEUROPLASTICITY ment of the patient after acute stroke. What forms the basis FOR CLINICIANS (from Hordacre & of that recommendation? Embedded along with the home McCambridge, 2018 with permission) situation, previous and current level of functioning is the therapist’s prediction bias about recovery for the patient Neuroplasticity is use dependent and specific. (Bland et al 2015, Magdon-Ismail et al 2016, Mees et al Repetition and greater intensity induce neural 2016, Stein et al 2015). Will recovery be fast and attainable changes. in the home or outpatient department setting, or will it be Neuroplasticity is time sensitive; early intervention slow and possibly not full so that a subacute setting is more may be better. appropriate, or will recovery be fast enough to be attained in Neuroplasticity is influenced by salience, motivation, a 2- to 3-week stay on an acute inpatient rehabilitation unit? feedback and attention. We are also asked by our patients: ‘Will I walk again?’ ‘Will I Neuroplasticity is strongly influenced by features of be able to use my hand again, move my arm, run again?’ The the environment. list goes on. Having knowledge of the prediction literature Enhanced sensory, cognitive, motor and social stimu- allows the therapist to be realistic with the patient and carer. lation facilitate increased neuroplasticity and learning Much research has been performed to identify predictors of (Nithianantharajah & Hannan 2006). recovery for arm and walking function for a variety of neu- Adjunct therapies prime the motor system to facil- rological diagnoses (see relevant chapters for predictors spe- itate greater neuroplastic response (Ackerley et al cific to conditions). For example, as early as 72 hours after 2014, Byblow et al 2012). stroke slight shoulder abduction and minimal digit exten- Neuroplasticity is influenced by patient characteris- sion predicts good arm recovery (Nijland et al 2010). tics such as age, genetics and stress levels. Ambulation recovery after stroke has also been linked to early Pharmacology influences neuroplasticity. static sitting attainment (Verheyden et al 2006). Predictors for ambulation recovery after Spinal Cord Inju­ry using American Spinal Cord Injury Association Impair­ment What Type of Training Drives Neural Plasticity and Scale levels have been documented (Dobkin et al 2007). Recovery of Function? Prediction is never 100% accurate, and there will always Task-specific training facilitates functional and neural be those patients who defy the odds. However, having this plasticity (Dimyan & Cohen 2011, Dobkin et al 2004, knowledge allows us to express optimism to those patients Hubbard et al 2009). When patients practice tasks, their who exhibit the positive predictors. It also encourages us focus is on achieving success of the task. It is the therapist’s to intervene to promote the exhibition of these motor expertise that structures the task in such a way as to get the responses, and thereby enhance recovery. Thus EBP requires movements they wish to encourage and to have the task be therapists to know and utilise the prediction literature to challenging yet achievable to enhance self-efficacy, but also influence their assessments and interventions. Prediction of varied enough to encourage generalisation. The practice outcomes will lead to clearer patient expectations and better of actual tasks enhances positive transfer of training prin- selection of interventions (Kimberley et al 2017). ciples both on a musculoskeletal level and by repetitively activating pathways that are engaged in the activity being Principle 5: Neural Plasticity practiced (Blennerhassett & Dite 2004, Dayan & Cohen Although there is always a degree of spontaneous recov- 2011, Dean & Shepherd 1997, Dean et al 2000, Dobkin et al ery after brain damage, advances in neuroimaging have 2004).  CHAPTER 1 Guiding Principles in Neurological Rehabilitation 11 Aerobic exercise enhances neural plasticity, by the individual, the task and the environment. Although it increasing blood flow to the brain, facilitating the release is important to understand the role of major circuits and of neurotrophic factors and improving brain health pathways of the central nervous system, and the effects of (brain volume). A variety of individuals with neurolog- lesions on these structures and circuits, it is important to ical diseases have been shown to lack aerobic condition- understand that there are many subsystems and multiple ing either as a result of their impairments interfering connections within the nervous system that work in hierar- in physical activity or adoption of a sedentary lifestyle chy and in parallel to generate movement (Shumway Cook (Brazzelli et al 2012, Dean et al 2000). This puts them at and Woollacott, 2017, pp. 7–18). This means in clinical risk for further comorbidities, including hypertension, practice, it is essential to work on functional tasks, rather diabetes mellitus and stroke. Thus aerobic conditioning than mainly focusing on movement patterns to improve should be part of every patient’s programme for multi- quality of movement. ple reasons. The actions of a person with damage to the nervous sys- Actively engaging patients in problem solving when tem are the result of an individual’s best effort at that time relearning motor tasks also influences neural plasticity. to organise a movement to achieve a successful task (A.M. Enhancement and diminution of neural activation within Gentile, personal communication). It is a consequence of the brain is dependent on the stage of skill acquisition the impairments caused by the damage, the compensa- (Dayan & Cohen 2011). The early stage of learning has tory strategies that enable function to be achieved in the shown enhanced excitation of multiple regions of the presence of impairments, the effects of the environment brain, including cerebellum, visual and prefrontal corti- the person has been experiencing since the lesion and the ces, where the learner is identifying the relevant features person’s confidence in his or her ability to achieve success of the task to pay attention to and attempting to organise (Shumway-Cook & Woollacott 2017, pp. 7–18). An exam- a movement pattern that is successful at accomplishing the ple of a compensatory strategy related to a seated reaching goal. During the later stage of skill acquisition, there is a task in a patient after a stroke might be reaching to an ante- diminution of activity in the aforementioned areas and an rior target using scapular elevation with shoulder abduc- enhancement in the motor cortices, where the learner is tion and trunk lateral flexion. modifying the successful movements to become efficient The key points to remember when designing therapy and less effortful. programmes are that therapists can reduce impairments Although evidence to date in humans is limited, animal and compensatory movement strategies by promoting studies suggest that there may be a critical time period for functional recovery and return to participation. This can rehabilitation poststroke, with early intervention deter- occur through structuring the environment or the task in mining greater functional gains (McDonnell et al 2015). a way that enables the patient to elicit or practice both the Thus it is also important to consider when best to deliver desired movement and the tasks required to achieve his or rehabilitation to maximise any critical time windows her goals. As previously stated, changes to the task instruc- to promote neural plasticity and to optimise functional tion and increasing a person’s confidence can also enhance recovery. goal attainment. Principle 6: Motor Control: A Systems Model Principle 7: Functional Movement Reeducation Motor control is an area of science that explores how the Normative data for everyday activities help therapists nervous system interacts with other body parts and the to understand motor performance and the impact environment to produce purposeful, coordinated actions of impairments on these everyday activities (Carr & (Muratori et al 2013); thus it is critical for therapists Shepherd 2006; see Chapter 3 for an overview of how involved in neurorehabilitation to understand how differ- therapists observe and analyse movement). Therapists ent systems within the nervous system interact to produce place an emphasis on training control of muscles and pro- movement and perform tasks. For example, when a patient moting learning of relevant actions and tasks. Therapists is learning to dress himself, he must use the movement he aim to optimise movement and function; however, with can reproduce in terms of his available range, strength, the majority of neurological conditions, recovery of nor- pain level, and so on, as well as his cognitive ability to plan mal movement and function is not achievable for many the task alongside external factors in the environment, for patients; this depends to some extent on whether the example bed surface, clothing type and location and envi- patient has a progressive, deteriorating condition or a ronmental distractors, to perform the functional task. stable condition (Edwards 2002, p. 256). There are many different models of motor control. A One of the key roles of the therapist working in neu- dynamic systems model considers that solutions to patient rology is to help the patient experience and relearn opti- problems change according to the interaction between mal movement and function in everyday life within the 12 SECTION 1 Background Knowledge the pathology and the prognosis for recovery in collabora- tion with patients and caregivers to establish desired goals will help determine which of these aims should be empha- sised in physical interventions. Therapists use an array of techniques in their tool kit Restore Adapt to reeducate movement. It is always preferable to prioritise the practice of functional activities selected in collabora- tion with the patient; however, if the patient has impair- ments that make it difficult to practice these tasks directly, Movement therapists may also need to address impairments or prac- and function tice specific movements either before or during a modified version of functional task practice. For example, a patient may not have any signs of motor activity in the lower limb to practice the task of walking. In this case, the patient may Prevent Maintain require either hands-on assistance from therapists or sup- port from assistive technologies, e.g. a partial body weight system to practice the task of walking. Principle 8: Skill Acquisition Evidence from motor learning and skill acquisition can FIG. 1.4 Aims of Neurological Rehabilitation: Re- provide some guiding principles about how to structure covery, Adaptation, Maintenance and Prevention practice within therapy sessions to improve these aspects of (RAMP). skilled performance (Muratori et al 2013, Marley et al 2000; Winstein et al 2014). Motor skill learning can be divided constraints imposed by the disease process and presenting into three phases: an early cognitive phase, an intermediate impairments. Therapists are not only interested in which associative phase and an autonomous phase (Fitts & Posner functional activities patients can or cannot perform, but also 1967, cited in Schmidt & Lee 2005 Ch. 13: The Learning in how the patient moves (the quality of movement) to exe- Process pp. 357–383). When subjects are in the initial stage cute these activities. The aims of neurological physiotherapy of learning, individuals should be encouraged to actively can be summed up using the acronym RAMP − recovery, explore the environment through trial and error. In the adaptation, maintenance and prevention (Fig. 1.4). later stage of skill acquisition, the focus switches from ‘what Therapists ideally aim to restore movement and func- to do’ to ‘how to do’ the movement better (Schmidt & Lee tion in people with neurological pathology, but this may 2005, Ch. 13: The Learning Process pp. 357-383). Some tips not always be possible. Adaptation (compensation) refers for structuring therapy sessions are outlined in Table 1.2. to the use of alternative movement strategies to complete a task, in other words performing an old movement in a Task Practice Issues new way (Levin et al 2009). Therapists focus on promot- Task-specific or task-oriented practice is an approach to ing compensatory strategies that are necessary for func- rehabilitation that focuses on performance of functional tion and discouraging those that may be detrimental to tasks that are meaningful to the individual. For this type of the patient, e.g. promoting musculoskeletal damage such practice to be successful, a therapist must be able to accu- as knee hyperextension (Levin et al 2009). Interventions rately assess their patient and identify their limitations and aimed at recovery of function need to be emphasised over deficits. The therapist then alters the task (e.g. simplifying) compensation if the patient has the potential to change. or the environment to allow for repetitive successful practice Maintenance of function is just as important as recovery while achieving the task and reducing the impairment(s). and should be viewed as a positive achievement; several The task difficulty is progressed as the patient’s success reviews have now confirmed that functional ability can be increases. Different techniques may work better with differ- maintained despite deteriorating impairments in progres- ent patients; sometimes it will be necessary to practise the sive neurological disease (Keus et al 2014). Therapy also components of movement that comprise an activity, such aims to prevent the development of complications such as as pelvic tilting, before placement in the functional activity. contracture, swelling and disuse atrophy. There are differ- Sometimes it will work best to break tasks down and repeat- ent stages in patient management, where these aims may edly practice the different temporal sequences before get- have differential priorities. Understanding the nature of ting the patient to practice the whole sequence of activity in  CHAPTER 1 Guiding Principles in Neurological Rehabilitation 13 TABLE 1.2 Key Motor Learning Variables for Neurological Rehabilitation Issues to Consider (adapted mainly from Muratori et al 2013, Winstein et al 2014,Wulf & Key Variables Lewthwaite 2016) Practice  mount (intensity or dose) (Kwakkel 2006, Lang et al 2015, Hornby et al 2015) A Frequency (number of repetitions) Duration (number of minutes per session) Variety (alter regulatory features) (Gentile 2000), e.g. transfers from different height chairs and different surface types Practice schedule (e.g. blocked practice, e.g. five reps at each seat height) versus random prac- tice (e.g. different seat heights each time) (Gilmore & Spaulding 2001, Murtori et al 2013) Choosing the practice schedule depends on a number of patient-centred issues such as expe- rience, age, memory and task. However, there are insufficient data on which sequence works best for which patient (Muratori et al 2013, Boyd 2001,Wulf & Lewthwaite 2016) Specificity of F unctional task practice must be both task and context specific; therefore whenever possible, training practice the task (Kwakkel et al 2004, Verbeek et al 2014) Consider critical requirements for each task (Carr & Shepherd 2003), as well as the impairments being targeted (Muratori et al 2013, Winstein et al 2014) Transfer of training Impairment-focused training such as strength, range, symmetry and postural sway may improve (generalisability) the parameters being trained, but these changes do not generalise to the activity or participation level (Kwakkel et al 2004, Muratori et al 2013, Verbeek et al 2014) Consider two types of transfer of training (Winstein 1991): (a) part task training: break the task down into simple steps, then put the steps back together again by practising the whole task; and (b) adaptive training: simplify the task by controlling a particularly difficult part, e.g. using a body weight support system that gradually adds the body weight into gait Task-related practice: some transferability will occur to a task which incorporates the compo- nents of transferring the centre of mass from the trunk to the lower extremities (e.g. practice of reaching greater than arm’s length in sitting transfers to the sit to stand transitional activity) (Dean & Shepherd 1997, Dean, Richards, Malouin 2000). Feedback F requency (How often? All or some of the time?) Do not give feedback on every trial (Muratori et al 2013, Winstein 1994) Timing (when to deliver the information: before, during or after?) Delivery mode (visual, verbal, manual) Consider using extrinsic feedback or feedback with an external focus (Wulf 2013); e.g. for a sit to stand task the focus should be on ‘pushing into the floor’, rather than ‘push your feet into the floor’, or ‘stand tall’ rather than ‘straighten your spine/back’ Modelling D emonstrate what you want the patient to do Consider delivery mode, e.g. live versus videotaped versus written instruction (Reo & Mercer, 2004, Laguna 2000, Williams & Hodges 2004, pp. 145–174) Mental Practice D efined as the act of repeating imagined movements several times with the intention of improv- ing motor performance (Jackson et al 2001); an adjunct to physical practice, it is not better than physical practice (Braun et al 2006, Nilsen et al 2010; Malouin & Richards 2010) Consider when to use it, e.g. when patient needs additional personnel to set up environment for independent practice, during rest periods or when patient is not safe to practice independently Reference point for imaging – ‘seeing’ themselves or ‘feeling’ themselves (Nilsen et al 2010) 14 SECTION 1 Background Knowledge a functional task, such as getting the legs off the bed before The Optimal Theory of Motor Learning elevating the trunk in a supine to sit task, or scooting for- Wulf and Lewthwaite (2016), through their ‘Optimal ward in the chair before attempting to stand up. On other Theory of Motor Learning,’ provide a template by which occasions, it will work best to practice the functional task in enhanced learning may be achieved. The theory proposes its entirety, emphasising the critical impairment/movement that optimising the intrinsic motivation of the learner and component that influences the task. providing verbal cues to enhance the attentional focus of the learner enhances learning on multiple levels of analysis. Role of Feedback First, enhance the learner’s expectation. Second, enhance Feedback can be delivered in many modes (visual, verbal, the learner’s autonomy. Third, provide an external focus manual) at various times (before, during or after) and in of attention for the learner. varying quantities from continuous to intermittent fash- To enhance the learner’s expectation and increase his ion (absolute, relative, bandwidth) (Muratori et al 2013, or her confidence level, the therapist must find ways which Shumway Cook & Woollacott 2017, pp. 33–37). Certain reinforce the learner’s ability to achieve success. By pro- types of feedback may be beneficial at different points in viding positive feedback, confidence levels are increased, skill acquisition. For example, manual guidance should thereby creating the learner’s expectation that he or she mainly be used at the early cognitive stage of motor learn- will achieve success (self-efficacy). Both achieving success ing, especially when safety is a concern, to give the patient and the patient’s perception on this success are associ- the idea of the movement or to control a degree of freedom. ated with dopamine release in the brain (Schultz 2013). However, during the later associative and autonomous Dopaminergic systems are involved in motor, cognitive stages of skill acquisition, it is preferable for the learner to and motivational functioning (Nieoullon & Coquerel actively problem-solve without relying on the therapist for 2003). Ways to enact this in the clinic are: feedback (Schmidt & Lee 2005, Chapter 13: The Learning 1. Provide feedback after good trials, e.g. ‘That was a good Process pp. 357–383. Sidaway et al 2008). one’, ‘Do that again.’ 2. Reduce perceived task difficulty: Define success liberally Amount of Practice so the criterion for a successful performance is not too Prescribing the most appropriate dose of practice for indi- difficult. vidual patients is a challenge because minimal data are 3. Alleviate the learner’s concerns. available and a large number of factors are unknown (Lang 4. When using self-modelling, show their best perform­ et al 2015, French 2016). Studies investigating neuroplastic ance. adaptations poststroke typically require animals to com- The learning literature supports enhancing learner plete hundreds of repetitions of a task daily or twice daily autonomy. Allowing the patient to have choices, even if (Birkenmeier et al 2010, Byblow et al 2016). these choices are incidental, has a positive effect on learn- Amount has been quantified as the number of repetitions ing. Using autonomy-supported language (e.g. ‘I’ve placed or the number of minutes of active therapy. Current research you in the parallel bars for this balance activity, if you wish suggests that the amount of practice is critical largely based to use the rail to stabilise yourself after a loss of balance on the constraint-induced movement therapy (CIMT) you may’ (even though the therapist knows that if a loss literature. The general consensus is that more is better. of balance occurs, the patient will most likely reach for the However, some recent studies have indicated that timing rail). ‘Here is your cane, you may place it wherever you may interact with dose (Bernhardt et al 2015), for exam- wish while we work on this activity’) and linking the envi- ple more therapy may not be better in the first few hours ronmental effect with the learner’s intention to produce it and days after stroke and could lead to slower recovery. The has been shown to enhance learning (Sanli et al 2013). VECTORS study (Dromerick et al 2009) demonstrated that Most of Wulf’s (2013) research on attentional focus an increased dose of CIMT during acute inpatient rehabil- during learning of motor skills has supported an external itation was detrimental when compared with a lesser dos- focus of attention to achieve the desired movement result age or conventional therapy. Lang et al (2016) showed that rather than an internal focus on body movements regard- gains in upper-limb function did not improve as a function less of the phase of learning that the learner is in. Cues of dose for task-specific therapy in patients, beginning 6 should be as external from the person as possible (e.g. for months or more poststroke. Current best practice suggests a golf swing, focus on club tip swing, not the arms/body; that a minimum of 300–400 repetitions of upper extremity for a sit to stand task the focus should be on ‘pushing into actions or tasks is required per session to demonstrate gains the floor’, rather than ‘push your feet into the floor’, ‘stand (Birkenmeier et al 2010, Dean et al 1997) and a minimum tall’ rather than ‘straighten your spine/back’). The move- of 20 minutes walking practice duration over 12 sessions to ment patterns which emerge from using an external focus improve gait in stroke survivors (Peurala et al 2014). have been shown to be smoother, more coordinated and  CHAPTER 1 Guiding Principles in Neurological Rehabilitation 15 TABLE 1.3 Key Components of self-management skills. Tailoring self-management sup- port requires an appreciation of factors that act as barri- Self-Management (Based on Chapter 17 by ers to or enablers of behaviour change. Two systematic Jones & Kulnik With Permission) reviews have found that self-management programmes Problem solving Deciding on the problem improve quality of life and self-efficacy for stroke survi- by the patient B reaking it down into small steps vors in the community, but further research is required to Thinking of various solutions identify key features of effective programmes (Fryer et al Selecting a course of action 2016, Lennon et al 2013). Trying out the action or strategy Evaluating success Principle 10: Health Promotion Choosing an alternative action if Promoting health is of critical importance to the field of necessary neurological rehabilitation. The WHO (2017) has empha- Target or goal T ranslating thoughts into actions sised that accessible and affordable rehabilitation plays a setting Providing mastery experiences fundamental role in ensuring healthy lives and promot- ing well-being for all ages (sustainable development goal). Resource A ccessing local self-help group Promoting health can be considered on three levels: pri- utilisation Seeking expert advice mary, secondary and tertiary prevention. Primary preven- Using friends or family for support tion seeks to prevent the onset of disease through healthy Collaboration W orking together with a healthcare living. It is achieved by health education and lifestyle and professional behavioural changes. Secondary prevention aims to stop Sharing expertise or slow disease progression, and prevent complications through early diagnosis and adequate treatment. Tertiary prevention is focused on reducing impairments and activ- success achieved earlier when compared with those using ity restrictions. All members of the rehabilitation team an internal focus. Wording of instructions for an external have a role to play in enabling people to return towards focus requires a change from what is most often used by meaningful roles in the wider community with a focus on therapists and may present a difficult challenge. health and wellness, rather than a focus mainly on ill health and disability (Cott et al 2007, Dean 2009). Ultimately this Principle 9: Self-Management (Self-Efficacy) means that rehabilitation involves changing behaviour. A recent report by National Health Service England (2016) Neurological rehabilitation has to date focused on ter- defines self-management as ‘any form of formal education tiary prevention, delivering short bursts of physical ther- or training for people with long-term conditions that focuses apies to restore function after acute events or declines in on helping people to develop the knowledge, skills and con- function resulting in a loss of the initial gains, resumption fidence to manage their own health and care effectively.’ In of a sedentary lifestyle and worsening levels of disability Chapter 17, Jones and Kulnik have outlined the key com- over time (Ellis & Motyl 2013). The goals of physical inter- ponents involved in effective self-management (Table 1.3). ventions must extend beyond impairments and function Self-efficacy is a cornerstone of self-management; it is to include health promotion with an emphasis on physical defined as people’s beliefs about their capabilities to influence activity and exercise. There is growing evidence that reha- key events that affect their lives (Bandura 1997). People with bilitation can prevent secondary complications if we inter- a strong sense of efficacy set themselves challenging goals and vene early to delay onset of motor symptoms in progressive maintain strong commitment to them; they continue to sus- disease (Kimberley et al 2017). tain their efforts in the face of failure or setbacks (Bandura Physical therapists should encourage fitness through 1997). A review specific to physiotherapy by Barron et al participation in enjoyable activities that follow American (2007) has shown that self-efficacy can be related to better College of Sports Medicine guidelines (see Chapter 20 health, higher achievement, more social integration and on physical activity for further guidance). Diseases like higher motivation to act. Growing evidence provides support hypertension and diabetes mellitus may be prevented for the importance of self-efficacy as a correlate of adherence (1° prevention) or if present may be controlled (2° pre- to therapy (Rhodes & Fiala 2009); however, evidence is still vention) through regular exercise, thus preventing other emerging regarding the most effective ways of supporting and diseases (stroke or heart attack). For instance, in the enabling individuals with neurological problems to manage event of a stroke, the medical team will use 2° prevention ways of living with their chronic disability (Jones 2006). measures to stop or slow the progression of the stroke Health professionals need to consider how they (e.g. give tissue plasminogen activator for ischemic can promote self-efficacy and enhance their patients’ stroke if in time window, remove blood for intracerebral 16 SECTION 1 Background Knowledge hemorrhage), as well as prevent a recurrence (e.g. lower 5. When do therapists make predictions about functional blood pressure, correct cardiac arrhythmias). Physical recovery for their patients? How is the prediction liter- therapists are well equipped to promote health and par- ature useful for clinicians? ticipation across all levels of prevention through identi- 6. What are the three types of prevention for health promo- fying, modifying and encouraging appropriate enjoyable tion? 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