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Thread: Basic rehabilitation methods for motor deficits in STROKE

  1. #1
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    Default Basic rehabilitation methods for motor deficits in STROKE

    Major theories of rehabilitation training

    Traditional Therapy:

    Traditional therapeutic exercise program consists of positioning, ROM exercises, strengthening, mobilization, compensatory techniques, endurance training (e.g., aerobics).
    Traditional approaches for improving motor control and coordination: emphasize need of repetition of specific movements for learning, the importance of sensation to the control of movement, and the need to develop basic movements and postures. (Kirsteins, Black, Schaffer, and Harvey, 1999)

    Proprioceptive (or peripheral) Neuromuscular Facilitation (PNF) (Knott and Voss, 1968)
    • Uses spiral and diagonal components of movement rather than the traditional movements in cardinal planes of motion with the goal of facilitating movement patterns that will have more functional relevance than the traditional technique of strengthening individual group muscles
    • Theory of spiral and diagonal movement patterns arose from observation that the body will use muscle groups synergistically related (e.g., extensors vs. flexors) when performing a maximal physical activity
    • Stimulation of nerve/muscle/sensory receptors to evoke responses through manual stimuli to increase ease of movement-promotion function
    • It uses resistance during the spiral and diagonal movement patterns with the goal of facilitating “irradiation” of impulses to other parts of the body associated with the primary movement (through increased membrane potentials of surrounding alpha motoneurons, rendering them more excitable to additional stimuli and thus affecting the weaker components of a given part)
    • Mass-movement patterns keep Beevor’s axiom: Brain knows nothing of individual muscle action but only movement

    Bobath approach / neurodevelopmental technique (NDT) (Bobath, 1978)
    • The goal of NDT is to normalize tone, to inhibit primitive patterns of movement, and to facilitate automatic, voluntary reactions and subsequent normal movement patterns.
    • Based on the concept that pathologic movement patterns (limb synergies and primitive reflexes) must not be used for training because continuous use of the pathologic pathways may make it too readily available to use at expense of the normal pathways
    • Probably the most commonly used approach
    • Suppress abnormal muscle patterns before normal patterns introduced
    • Mass synergies avoided, although they may strengthen weak, unresponsive muscles, because these reinforce abnormally increased tonic reflexes, spasticity
    • Abnormal patterns modified at proximal key points of control (e.g., shoulder and pelvic girdle)
    • Opposite to Brunnstrom approach (which encourages the use of abnormal movements); see the following

    Brunstrom approach/Movement therapy (Brunnstrom, 1970)
    • Uses primitive synergistic patterns in training in attempting to improve motor control through central facilitation
    • Based on concept that damaged CNS regressed to phylogenetically older patterns of movements (limb synergies and primitive reflexes); thus, synergies, primitive reflexes, and other abnormal movements are considered normal processes of recovery before normal patterns of movements are attained
    • Patients are taught to use and voluntarily control the motor patterns available to them at a particular point during their recovery process (e.g., limb synergies)
    • Enhances specific synergies through use of cutaneous/proprioceptive stimuli, central facilitation using Twitchell’s recovery
    • Opposite to Bobath (which inhibits abnormal patterns of movement)

    Sensorimotor approach/Rood approach (Noll, Bender, and Nelson, 1996)
    • Modification of muscle tone and voluntary motor activity using cutaneous sensorimotor stimulation
    • Facilitatory or inhibitory inputs through the use of sensorimotor stimuli, including, quick stretch, icing, fast brushing, slow stroking, tendon tapping, vibration, and joint compression to promote contraction of proximal muscles

    Motor relearning program/Carr and Shepard approach (Carr et al., 1985)
    • Based on cognitive motor relearning theory and influenced by Bobath’s approach
    • Goal is for the patient to relearn how to move functionally and how to problem solve during attempts at new tasks
    • Instead of emphasizing repetitive performance of a specific movement for improving skill, it teaches general strategies for solving motor problems.
    • Emphasizes functional training of specific tasks, such as standing and walking, and carryover of those tasks

    Behavioral approaches (Noll, Bender, and Nelson, 1996) include:
    • Kinesthetic or positional biofeedback and forced-use exercises
    • Electromyographic biofeedback EMGBF: makes patient aware of muscle activity or lack of it by using external representation (e.g., auditory or visual cues) of internal activity as a way to assist in the modification of voluntary control
    – In addition to trying to modify autonomic function, EMGBF also attempts to modify pain and motor disturbances by using volitional control and auditory, visual, and sensory clues
    – Electrodes placed over agonists/antagonists for facilitation/inhibition
    – Accurate sensory information reaches brain through systems unaffected by brain → via visual and auditory for proprioception

    These are only the basics...

  2. #2
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    Default Ashworth Scale

    Ashworth Scale

    The Ashworth Scale is a measurement of the increase in muscle tone which happens after a neurological event of some type.
    All our muscles carry tension - if they didn't, we would be floppy and unable to move. We always have a 'background tone', all the time. Some muscle groups have a higher 'background tone' than others, particularly the muscles that usually work to keep us upright - our antigravity muscles. These would include our calf muscles, the muscles at the front of the thigh, the buttock muscles, the biceps in the arm and others.
    If an event of some type happens in the brain to cause the normal dampening of this tone to be lessened, then we get an increase in our background tone, and it's particularly pronounced in the muscle groups I've mentioned. This is called hypertonicity or spasticity.
    In order to quantify how severely the tone is raised, various scales or assessments are used. The Ashworth Scale is about the most widely used. It's a five point scale, very simple to grade, and easy to understand.

    1. No increase in muscle tone.

    2. Slight increase in tone giving a “catch” when affected part is moved in flexion or extension.

    3. More marked increase in tone but affected part is easily flexed.

    4. Considerable increase in tone; passive movement difficult.

    5. Affected part is rigid in flexion or extension.

    The modified Ashworth scale:

    0. No increase in muscle tone

    1. Slight increase in tone with a catch and release or minimal resistance at end of range

    2. As 2 but with minimal resistance through range following catch

    3. More marked increase tone through ROM

    4. Considerable increase in tone, passive movement difficult.

    5. Affected part rigid

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