Transcript Current Issues in Neurorehabilitation

Exercise- a prescription for all
or not?
Susan Edwards
FCSP SRP
Historical perspective
•
•
•
•
•
•
no possibility of neuronal recovery
orthopaedic approach
clinical practice - change was possible
review of neurophysiological rationale
impaired reciprocal innervation
skill acquisition and training
• FUNCTION
UMN lesion
Abnormal muscular contraction
Dynamic
• spasms
• co-contraction
• clonus
• associated reactions
• flexor withdrawal
Static
Weakness
Immobilisation at
short muscle length
• spasticity
• spastic dystonia
Biomechanical changes
Hypertonia
+
Reduced ROM
• reduced compliance
• contracture
Abnormal postures
Impaired function
Sheean 2001
Nervous and musculo-skeletal system cannot be
separated
Balanced view of neural control of movement,
biomechanical requirements for the task and
limitations of CNS damage on both of these systems
Which therapy approach?
• Physiotherapy is of value in the treatment of stroke
but does it matter what type?
(Kwakkel et al 1999)
• Lack of relevant literature
• 88% of UK physiotherapists use Bobath (Davidson and
Waters 2000)
What is it?
Bobath (1990) suggested that excessive cocontraction of agonists and antagonists resulted
in stiffness and slow, difficult movement.
More likely to contribute to limb stiffness in children
with CP but in adults with stroke, the primary problem
seems to be in the inability to produce adequate force
in the agonist (Davies et al 1996)
Biomechanical Model
Over-emphasis on the neural control of movement has
led to a neglect of the importance of muscle strength,
force production and movement velocity
Muscle Stretch
6 hours for CP child
(Tardieu et al 1988)
half hour for neurologically intact mouse!
(Williams 1990)
biomechanical properties of muscle –
optimal force at mid range
(Rothwell 1994)
Task-specific training or practice approach
is showing enhanced evidence over
impairment-focussed approaches
(National Clinical Guidelines for Stroke 2002)
Repetition
Variety of movement patterns
How often can a therapist carry out movements?
Need for regular exercise / stretching programme
Task-specific training
• Programmes using CIMT focus attention towards the
weaker limb and use repeated and extensive practice
for up to 6 hours a day.
(Liepert et al 2000)
• Treadmill training with supported body weight
- incomplete spinal cord injury (Deitz 2003)
- stroke (Hesse 1995, 1999)
Muscle Strength and Aerobic Fitness
• Potential health benefits from regular exercise:
- improved fitness and muscle strength
- improved mood and sense of well-being
- weight control
- improved bone density
- improved co-ordination
Muscle Strength and Aerobic Fitness
“Individuals with physical impairments will need a
great deal of encouragement to engage in regular
intensive exercise. This encouragement may not
always be forthcoming from therapists who have
been led to believe that effortful activity is harmful to
their patients and must be avoided. However,
recent evidence shows that this is not the case and
that exercise should be an integral part of an overall
rehabilitation programme.”
(Haas and Jones 2004)
Muscle Strength and Aerobic Fitness
“There is a consensus that muscle weakness is a
feature in many neurological pathologies. The
notion that increased co-activation of antagonistic
muscles rather than muscular weakness is
responsible for motor control problems has not
been confirmed by scientific evidence.”
(Haas and Jones 2004)
American College of Sports Medicine
Guidelines
• Strengthening programme, 8-10 separate exercises
for major muscle groups
• 8-10 repetitions
• At least twice a week
• Concentric as well as eccentric exercise
• Normal breathing should be maintained during the
exercises
• Most patients will require supervision
• Exercises through as full a range as possible
Aerobic Training
• General health check
• Gradually build up time from 10 minutes to 30
minutes
• Patients have reduced exercise capacity
• Physiological burnout
• Walking has greatest potential for increasing overall
activity levels
Summary
Therapists need to encourage perseverance with
tasks which are meaningful and at a level sufficient
to induce changes in strength and fitness.
This should include on-going management / exercise
outside of the ‘neurogym’ with more active
collaboration with agencies providing leisure and
social pursuits.