Interventions for pt's w/ neurologic conditions

• Studies for locomotor recovery following neurologic injury

  • The amount and intensity of task-specific practice are key determinants of gains in walking function
  • Walking ability, balance, and reducing fall risks is improved by allowing and imposing movement errors and increasing task difficulty and variability
• The Academy of Neurologic Physical Therapy has a national campaign called Moving Forward to improve practice for physical therapists in neurologic physical therapy
• The position of the Academy of Neurologic Physical Therapy is to accentuate the use of the best available evidence and research in the treatment of adults with acute-onset movement disorders following neurologic injury
• The best available evidence does not support the use of traditional rehabilitation strategies including NDT and PNF
• The best available evidence supports the use of training parameters that provide the greatest chance of exploiting the effects of neuroplasticity and functional gains which include specificity, amount, intensity, and saliency of task practice
• Contemporary neurorehabilitation approaches


  1. Intensity Matters campaign

  2. Task-oriented approaches to intervention

  3. Constraint-induced therapy

  4. Locomotor training

  5. Functional task-oriented strength training

  6. Guidelines for intervention progression
• Intensity Matters


  The impact of cardiovascular intensity on functional outcomes in patients with neurologic disorders
• The Clinical Practice Guideline on improving locomotor function after chronic stroke, incomplete spinal cord injury and brain injury found that intensity or workload as estimated by heart rate or perceived exertion, is an active ingredient causing changes in walking function defined as walking speed and distance
• Active ingredients


  • Specificity
  • Intensity
  • Repetition
• Specificity


  The nature of practice
• Intensity


  The workload of practice
• Repetition


  The amount of practice
• Physical therapists should use moderate to high intensity walking training interventions to improve walking speed and distance
• Intensity


  Determined via the patient's target heart rate with the recommended target heart rate range from 70 to 85% of heart rate maximum or 60 to 80% heart rate reserve to improve locomotor function following chronic stroke, incomplete spinal cord injury, and brain injury
• Task-oriented approaches


  • Utilize functional activities as a primary component of the intervention session
  • Require the patient to actively participate in defining task goals, problem-solve as needed to manipulate the environment or task for goal completion and perform these activities in the most typical environment or surroundings where they function on a daily basis
• Task-oriented training


  Involves challenging and meaningful practice that targets the involved body segments provided in a supportive environment structured to promote successful task performance, enhance concentration, and reduce distractors
• Motor learning strategies incorporated in task-oriented training

  • Practice
  • Feedback
  • Behavioral shaping techniques that use reinforcement and reward to promote skill development
• Interventions can range from repetition of component parts of functional tasks to completion of obstacle courses requiring problem-solving skills
• The level of practice is intense involving daily practice for extended periods of time with the number of repetitions reaching the physical limits of the patient
• Activities are continually modified to increase the level of difficulty and adaptation and transference of skills
• The physical therapist's role


  A coach, structuring the practice and providing appropriate feedback while encouraging the patient
• Patients who are not able to participate in intense task-specific training include those who lack initial voluntary control or have limited cognitive function
• Goals of task-oriented training

  • Resolve, reduce, or prevent impairments in body structure and function
  • Develop effective and efficient task-specific strategies for accomplishing functional task goals
  • Adapt functional goal-oriented strategies to changing task and environmental conditions in order to maximize participation and minimize disablement
• Task-oriented training strategies


  • Promote recovery of function
  • Induce adaptive plasticity and decrease maladaptive plasticity that occurs with learned nonuse
  • Enhance patient motivation, autonomy, and self-efficacy and facilitate an active commitment to recovery
  • Minimize hands on therapy and maximize the physical therapist's role as a training coach to maintain focus on active learning
  • Encourage problem-solving by having the patient evaluate performance, identify challenges, generate potential solutions, and relate success to overall goals
  • Select activities based on the patient's history, health status, age, interests, experience, abilities, strengths, recovery level, learning style, impairments, activity limitations, and participation restrictions
  • Target active movements that engage the more involved extremities, restrict the use of the less-involved extremities, and limit compensatory strategies
  • Intersperse more difficult activities with easier ones
  • Manage fatigue and excessive effort by determining rest and practice times and establishing intensity and minimal number of repetitions
  • Model ideal performance to establish a reference of correctness
  • Control instructions, extrinsic feedback and assisted or guided movement
  • Gradually modify the activity to increase the challenge and make it progressively more difficult as patient performance improves
  • Emphasize the positive aspects of the patient's performance, acknowledging small improvements
• Constraint-induced movement therapy


  A task-oriented intervention using massed practice that addresses learned nonuse of an involved upper extremity after a central nervous system lesion
• Constraint-induced movement therapy


  • Involves restraining the unaffected upper extremity using a mitt, glove, hand splint, or arm sling for a specified period of time each day while performing task-specific activities with the involved upper extremity
  • Training is intense, averaging 3 hours of supervised intervention a day for a period of 2 or 3 consecutive weeks
  • Motor training is based on shaping principles which is a highly standardized and systematic approach to progress the difficulty level of motor tasks attempted
  • Includes a transfer package of techniques to facilitate transfer of therapeutic gains from the supervised intervention sessions to everyday life situations
  • Feedback is immediate, specific, quantitative, and emphasizes only positive aspects of the patient's performance
• Main objective of constraint-induced movement therapy

  For the patient to use the more-affected upper extremity repeatedly in a concentrated, massed-practice fashion to overcome learned nonuse and induce adaptive cortical plasticity
• The clinical changes observed with constraint-induced movement therapy are correlated with structural changes in the cortical motor areas, the hippocampus, and white matter
• Locomotor training

  1. Reduce underlying impairments of body structure and function that constrain gait

  2. Modify gait pattern to effectively and efficiently meet progression and stability requirements

  3. Develop ability to adapt gait to changing task and environmental demands
• Task-specific locomotor training using treadmill with/without partial body weight support

  1. Facilitate automatic locomotion using intensive task-oriented practice

  2. Provide rhythmic input to reestablish or reinforce coordinated reciprocal lower extremity locomotor patterns

  3. Intense practice of 30-60 minute sessions, 5 days per week for 6-12 weeks

  4. Load limbs to tolerance

  5. Maintain active upright posture and balance

  6. Provide manual assistance as needed to guide locomotor rhythm, limb placement, weight shifts, and symmetry

  7. Progress to no manual assistance or body weight support to overground and community ambulation
• Strategies that provide large amounts of task-specific walking practice at higher cardiovascular intensities or with increased engagement, saliency can improve walking speed and timed distance
• Nonspecific and reduced intensity interventions result in inconsistent or negligible gains in locomotor function
• Complex walking activities


  1. Improve anticipatory and reactive components of postural control during ambulation

  2. Improve ability to walk under altered sensory contexts or while performing other tasks
• Functional task-oriented strength training


  • Addresses multiple system impairments and promotes transfer to functional skills
  • Facilitates activity-dependent neuroplasticity, potentially enhancing neurologic recovery
• Intervention progression

  Manipulate variables related to motor learning and practice, characteristics of movement/task, and other parameters to challenge the patient's movement system further