Chapter 10: Strategies to Improve Motor Function

Developing strategies to improve motor function (motor control and motor learning) requires a thorough understanding of the neural processes involved in producing movement and learning and the pathologies that may affect the central nervous system (CNS). In addition, knowledge of recovery and neuroplasticity processes following CNS insult is essential. Treatment based on theories of motor control, motor learning, and recovery allows the therapist to organize thinking and approach clinical decision making in a coherent manner. Patients with disorders of the CNS frequently demonstrate impaired motor function with a wide variety of impairments, activity limitations, and restrictions in the ability to participate in normal roles. Careful examination of cognitive, sensoriperceptual, motor, and learning behaviors, along with the environmental contexts in which they occur, provides an appropriate base for planning (see Chapter 5, Examination of Motor Function: Motor Control and Motor Learning). Different intervention strategies and techniques have been developed by physical therapists to address disorders of motor function. An optimal plan of care (POC) must address the individual needs of the patient. This includes minimizing or eliminating impairments, reducing activity limitations and physical disabilities, and promoting full participation in life roles to the maximum extent possible. An effective POC also enhances overall quality of life.

Information Processing

Motor control has been defined as "an area of study dealing with the understanding of the neural, physical, and behavioral aspects of biological (e.g., human) movement."^{1, p. 497} Information processing of human motor behavior occurs in stages (Fig. 10.1). In the initial stage, stimulus identification, relevant stimuli about current body state, movement, and environment, are selected and identified. This includes somatosensory, visual, and vestibular inputs. Meaning is attached based on past sensorimotor experiences. Perceptual and cognitive processes including memory, attention, motivation, and emotional control all play an integral role in ensuring the ease and accuracy of information processing during this stage. Selection of relevant sensory input is sensitive to the clarity and intensity of the stimuli received. Thus, precise and stronger stimuli result in enhanced attentional mechanisms and information processing. Processing is also influenced by stimulus pattern complexity. Complicated and novel patterns of stimuli prolong stimulus identification. An intrinsic knowledge of movement (e.g., position of limb, length of limb, distance to goal, and so forth) is a critical characteristic of motor behavior.

In the response selection stage the plan for movement is developed. A motor plan is defined as an idea or plan for purposeful movement and is made up of component motor programs. A general rather than detailed response is selected; that is, a prototype of the final movement. Decision making during this stage is sensitive to the number of different movement alternatives possible and the overall compatibility between the stimulus and response. A natural or firmly linked association between stimulus and response enhances the ease of the decision making. For example, in a well-learned movement such as crossing at a streetlight, an individual easily responds to the green light by moving forward. If a crossing guard signals the individual to move forward even though the light is red, the individual is likely to be more hesitant in responding.

The final stage is termed response programming. Neural control centers translate and change the idea for movement into muscular actions defined by a motor program. A motor program is defined as "an abstract representation that, when initiated, results in the production of a coordinated movement sequence."^{1, p. 497} The structuring of motor programs includes attention to specific parameters such as synergistic component parts, force, direction, timing, duration, and extent of movement. Parametric specification is based on the constraints of the individual, the task, and the environment. Information processing during this stage is sensitive to the complexity of the desired movement and duration. Thus, complex and lengthier movement sequences increase the duration of processing during this stage. Programming can also be affected by response–response compatibility. This is the compatibility for dual movement tasks that either occur simultaneously (e.g., bouncing a ball while walking) or when choices are required (e.g., one paired movement response must occur before another). During response execution (movement output), muscles are selected against an appropriate background of postural control. Feedforward control is the sending of signals in advance of movement to ready a part of the system for incoming sensory feedback or for a future motor command.¹ It allows for anticipatory adjustments in postural activity. Feedback is response-produced sensory information received during or after the movement and is used to monitor movement output for corrective actions.¹ Although this simplified model gives the appearance that the information flow is linear, actual processing by the CNS is both serial and parallel. Thus, information flows in a specific pathway (serial order) and in multiple pathways (parallel order) in order to process information to more than one center. Many times processing occurs using both serial and parallel order depending on the complexity of the movement.

The association areas of the cortex decide that a movement is called for. The premotor area (PMA) and supplementary motor areas (SMA) (collectively known as Area 6) devise a plan for the movement. The primary motor cortex (Area 4) is located just anterior to the precentral sulcus and issues the motor commands to the descending motor neurons either directly or indirectly by way of nuclei and interneurons in the brainstem and spinal cord. A major source of subcortical input arises from the loop from the cortex through the basal ganglia (BG) and back to the cortex, primarily to the SMA via the ventral lateral nucleus (VL) of the dorsal thalamus. This loop functions in assisting in the selection and initiation of voluntary movements. A second motor loop arises from the cortex through the lateral cerebellum and back to the cortex via the VL. This loop also functions in the production of voluntary movement and is concerned with execution of planned, coordinated multijoint movements (i.e., direction, timing, and force). Neurons that give rise to descending pathways are termed upper motor neurons (UMNs). Lateral UMN pathways are involved in the control of voluntary movements through the corticospinal tract. UMN pathways are also involved in indirect control by way of neural subsystems in the brainstem. The reticulospinal tracts and to a lesser extent rubrospinal tracts are the primary alternate route for the mediation of voluntary movement. The tectospinal tract descends from the superior colliculus to the cervical levels and is important for reflex turning of the head. The vestibulospinal tracts are involved in control of postural adjustments and head movements. The ventral horn of the spinal cord gives rise to the peripheral nerve (lower motor neuron [LMN]). Activation of muscle fibers is from the motor unit.

Systems Theory

Contemporary theory of motor control has evolved over time, and reflects current understanding and interpretation of nervous system function. The reader is referred to the work of Schmidt and Lee¹ and Shumway-Cook and Woollacott² for excellent reviews of this topic. The term systems theory is used to describe the process by which various brain and spinal centers work cooperatively to accommodate the demands of intended movements. Both internal factors (joint stiffness, inertia, movement-dependent forces) and external factors (gravity) must be taken into consideration in the planning of movements. Systems theory assumes a shifting locus of neural control, referred to as a distributed model of control. Thus, large areas of the CNS may be engaged for complex motor tasks whereas relatively few centers are engaged for more discrete movements. This type of multilevel control allows for the control of a number of separate independent dimensions of movement, termed degrees of freedom.³ The executive level (cortex) can be freed from the responsibility of control of some movements or the demands of having to control many degrees of freedom at one time.⁴ For example, the use of central pattern generators (CPGs) in the spinal cord to initiate multijoint and intralimb coordination (coupling) for locomotion is well documented.^5,6 This is in contrast to an older theory of motor control, hierarchical theory, in which control was viewed as proceeding only in a descending, top-down direction from higher to lower centers, with the cortex always in control. Multiple descending systems are engaged for control movement and posture. These include corticospinal/corticobulbar, medial (e.g., medial vestibulospinal) and lateral (e.g., reticulospinal, lateral vestibulospinal) descending pathways. Thus, both voluntary (conscious) and involuntary (automatic) pathways regulate posture and movement.

Coordinative Structures

Motor programs allow for movements to occur in the absence of sensation (deafferentation) or in situations in which limitations in speed of processing feedback negate control. Motor programs also free the nervous system from conscious decisions about movement, reducing the problem of multiple degrees of freedom. Preprogrammed instructions to a set of effectors (motor program) run virtually without the influence of peripheral feedback or error detection processes, termed an open-loop system.⁷ For example, rapid and skilled movements during piano playing occur too rapidly to benefit from feedback and function in an open-loop control system. This is in contrast to a closed-loop control system, which employs feedback and a reference for correctness to compute error and initiate subsequent corrections.¹ Feedback and closed-loop processes play a critical role in the learning of new motor skills (response selection) and in the shaping and correction of ongoing movements (response execution). Feedback is also essential for the ongoing maintenance of body posture and balance.⁸

The complexity of human movement negates any simplistic model of movement control. An intermittent control hypothesis described by Schmidt and Lee¹ proposes a blending of both open-loop and closed-loop control processes, in which both operate in concert as part of the larger system. Motor programs provide the generalized code for motor events (schema) rather than having every specific motor act stored in the brain. Feedback is used to refine and perfect movements.⁸ Either may assume a dominant role, depending on the task at hand. Both may operate within a given movement but at different times and with different functions. Generalized motor programs include both invariant characteristics and parameters. Invariant characteristics are the unique features of the stored code: relative force, relative timing, and order of components. Parameters are the changeable features that ensure flexibility of motor programs and variations in movements from one performance to the next. These include overall force and overall duration of the movement. For example, speeding up or slowing down can change walking performance (changes in speed) while the basic order of stepping cycle and relative timing of the components (invariant characteristics) are maintained.

Muscle synergies are used to simplify control, to reduce or constrain the degrees of freedom, and to initiate coordinated patterns of movement. Synergies are functionally linked muscles that are constrained by the CNS to act cooperatively to produce an intended motor action. Control is flexible with the cerebellum acting to generate the appropriate sequence of precise force, timing, and direction. A synergy can act in isolation for discrete movements. More frequently, synergies are combined to produce an appropriate sequence of muscle actions required for a functional task (e.g., the sequence of actions required during a transfer). Synergies are learned through motor skill practice, are flexible, and can be adapted to changes in the task or environment. For example, basic movement strategies (synergies) are well defined for postural control and balance, and include ankle, hip, and stepping strategies.^9,10,11 The organization and utilization of these strategies varies from quiet to perturbed stance and positions of instability.

Motor learning has been defined as "a set of internal processes associated with practice or experience leading to relatively permanent changes in the capability for motor skill."^{1, p. 497} Learning a motor skill is a complex process that requires spatial, temporal, and hierarchical organization of the CNS. Changes in the CNS are not directly observable but rather are inferred from changes in motor behavior. Improvements in performance result from an understanding of the task and practice and are a frequently used measure of learning. For example, with practice an individual is able to develop appropriate sequencing of movement components with improved timing and reduced effort and concentration. A performance curve can be used to plot the average performance of a subject or group of subjects across a number of practice trials. Performance, however, is not always an accurate reflection of learning. It is possible to practice enough to temporarily improve performance but not retain the learning. Conversely, factors such as fatigue, anxiety, poor motivation, or medications may cause performance to deteriorate while learning may still occur. Because performance can be affected by a number of factors, it should be viewed as a temporary change in motor behavior observed during practice. Retention provides a better measure of learning. Retention, as measured by a retention test, refers to the ability of the learner to demonstrate the skill over time and after a period of no practice (retention interval).¹ Performance after a retention interval may decrease slightly, but should return to original performance levels within relatively few practice trials. This is referred to as a warm-up decrement in performance. For example, riding a bike is a well-learned skill that is generally retained even though an individual may not have ridden for years. The ability to adapt and refine a learned skill to changing task and environmental demands is termed adaptability.² This is another important measure of motor learning. Individuals who learn to transfer from wheelchair to platform mat can apply that learning to other types of transfers (e.g., wheelchair to car, wheelchair to tub). The time and effort required to organize and learn these new types of transfers is reduced. Finally, resistance to contextual change can be used to measure learning. This is the adaptability required to perform a motor task in altered environmental situations. Thus, an individual who has learned a skill (e.g., walking with a cane on indoor level surfaces) should be able to apply that learning to new and variable situations (e.g., walking outdoors, walking in a busy mall). Motor learning is the direct result of practice and is highly dependent on sensory information and feedback processes. The relative importance of the different types of sensory information varies according to task and to the phase of learning. Individual differences exist in motor ability, a relatively stable characteristic or trait that is largely unmodifiable by practice. Abilities underlie and support the development of skills.¹

Theories of Motor Learning

Adams'⁷ theory of motor learning was based on closed-loop control (closed-loop theory). He postulated that sensory feedback from ongoing movement is compared with stored memory of the intended movement (perceptual trace) to provide the CNS with a reference of correctness and error detection. Memory traces are then used to produce an appropriate action and to evaluate outcomes. The stronger the perceptual trace developed through practice, the greater the capability of the learner to use closed-loop processes for learning movements. This theory helps to explain learning that occurs during slow, linear-positioning responses. It does not, however, adequately explain learning under conditions of rapid movements (open-loop control processes) or learning that occurs in the absence of sensory feedback (deafferentation studies).

Schema theory, proposed by Schmidt,⁸ is an essential concept in motor learning theory. Schema is defined as "a rule, concept, or relationship formed on the basis of experience."^{1, p. 499} It can be viewed as a generalized motor program (GMP).

Schema allows storage into short-term memory of such things as initial conditions (body position, weight of objects, and so forth), relationships between movement elements, movement outcomes, and sensory consequences of movement. This information is then abstracted into motor memory (procedural memory), defined as "the memory for movement or motor information."^{1, p. 497} According to schema theory, it consists of two schema, recall and recognition schema. Recall schema are used to select and define the relationship among past parameters, past initial conditions, and past movement outcomes produced by these combinations. Recognition schema are used to evaluate movement responses and are based on information of the relationships among past initial conditions, past movement outcomes, and the sensory consequences produced by these combinations.¹ Clinically, schema theory supports the concept that "we learn skills by learning rules about the functioning of our bodies—forming relationships between how our muscles are activated, what they actually do, and how these actions feel."^{1, p. 448} Practicing a variety of movement tasks and outcomes would improve learning through the development of expanded rules or schema. It also enhances our understanding of how novel and open skills performed in a variable and changing environment are learned.

Stages of Motor Learning

The process of motor learning has been described by Fitts and Posner¹² as occurring in relatively distinct stages, termed cognitive, associated, and autonomous. These stages provide a useful framework for describing the learning process and for organizing training strategies during rehabilitation. Table 10.1 provides a summary.

Cognitive Stage

During the initial cognitive stage of motor learning, the major task at hand is to develop an overall understanding of the skill, termed the cognitive map. This decision making phase of "what to do" requires a high level of cognitive processing as the learner performs successive approximations of the task, discarding strategies that are not successful and retaining those that are. The resulting trial-and-error practice initially yields uneven performance with frequent errors. Processing of sensory cues and perceptual–motor organization eventually leads to the selection of a motor strategy that proves reasonably successful. Because the learner progresses from an initially disorganized and often clumsy pattern to more organized movements, improvements in performance can be readily observed during this acquisition phase. The learner relies heavily on vision to guide early learning and movement. A stable environment free from distractors optimizes learning during this initial stage.

Associative Stage

During the middle or associative stage of motor learning, refinement of the motor pattern is achieved through continued practice. Spatial and temporal aspects become organized as the movement develops into a coordinated pattern. As performance improves, there is greater consistency and fewer errors and extraneous movements. The learner is now concentrating on "how to do" the movement rather than on what to do. Proprioceptive cues become increasingly important, whereas dependence on visual cues decreases. The learning process takes varying lengths of time depending on a number of factors. The nature of the task, prior experience and motivation of the learner, available feedback, and organization of practice can all influence acquisition of learning.

Autonomous Stage

The final or autonomous stage of learning is characterized by motor performance that after considerable practice is largely automatic. There is only a minimal level of attention, with motor programs so refined they can almost "run themselves." The spatial and temporal components of movement are becoming highly organized, and the learner is capable of coordinated motor patterns. The learner is now free to concentrate on other aspects, such as "how to succeed" at a personal goal or competitive sport. Movements are largely error-free with little interference from environmental distractions. Thus the learner can perform equally well in a stable, predictable environment (termed closed skills) or in a changing, unpredictable environment (termed open skills).

Patients with neurological lesions may demonstrate impairments in voluntary movements (impaired motor planning or programming) or in the corrective actions (feedback adjustments) needed to initially relearn and coordinate movements. Movements can be uncoordinated with evidence of difficulty initiating or scaling the velocity of movements and controlling force, timing, or direction. Functionally linked synergies may be disorganized or fail to emerge and may show evidence of scaling issues. Reciprocal actions of agonists-antagonists, which normally are fine-tuned, become asynchronous. Disrupted synergistic patterns lead to impairments in body function. Instead of movements that are well matched to the intended movement and the environment, movements become highly stereotyped and limited. Abnormal obligatory or stereotypical synergies may emerge as is seen in the patient recovering from stroke, making it difficult to perform everyday functional tasks. Postural control and balance, a largely automatic function, becomes impaired with evidence of impaired activation of motor strategies, increased conscious control, and difficulty in maintaining balance. Overall, the efficiency and flexibility of motor patterns is significantly reduced.

Additional constraints are imposed by impairments in the musculoskeletal system (e.g., weakness, contracture, postural deformity). Impairments in muscle strength are common in patients with neurological dysfunction. Patients may exhibit complete loss (paralysis or plegia) or partial loss of muscle strength (paresis). Impairments can be localized to one side (hemiplegia), both lower extremities (paraplegia), or all four extremities (tetraplegia). Voluntary movements may become limited or absent with significant loss of the ability to perform common abilities. Fatigue, which can be directly due to a health condition (e.g., MS) or due to secondary factors such as prolonged immobility, often accompanies weakened muscles. Abnormal tone (spasticity or flaccidity) may also limit movement and alter posture. Spasticity and coactivation of agonist-antagonist muscles typically result in fixed, abnormal resting postures, and movements that are characteristically stiff and limited. Hyperactive stretch reflexes and inadequate recruitment of motor neurons present increased challenges for activating and controlling movements. Movements that might be possible at slow speeds become disordered or impossible at faster speeds. Overall, the number, range, and speed of movements are greatly reduced.

Constraints also emerge with impairments in sensory reception or perception, resulting in errors in stimulus identification or response selection. Motor learning is delayed, disorganized, or absent. Response programming may be impaired in the absence of accurate feedback to monitor and correct movement and posture. The central representation of the movement, termed reference of correctness, becomes inaccurate as a result of failed or inaccurate feedback. Impairments in cognitive processes (attention, planning, problem solving, emotional stability) may significantly affect learning and motor control. The patient with profound cognitive deficits (e.g., the patient with traumatic brain injury [TBI]) is unable to understand the idea of the movement. This inability to form a cognitive map creates severe limitations during the initial stage of learning and is particularly evident with complex or novel movements. Cognitive interference is also readily evident during complex movements such as dual tasking and performing in novel or open environments. Patients with cognitive deficits may also demonstrate a complete lack of awareness of their deficits. Impairments in the cardiovascular system (e.g., limited endurance) can significantly affect movement behavior and the ability to practice. The patient who exhibits profound deficits in motor control and learning can become poorly motivated. Every attempt at movement becomes a frustrating challenge, and activities previously done with ease become labored or impossible. The challenges of learning new motor behaviors can seem insurmountable. In addition to the individual system limitations and impairments discussed above, patients with CNS dysfunction may demonstrate failure of the whole system to function as an integrated whole. The design of a successful intervention needs to be based on careful examination of component parts, as well as the integrated whole.

Motor development is the evolution of changes in motor behavior occurring as a result of growth, maturation, and experience.¹ Foundational skills are learned in infancy and childhood with the emergence of specific markers of developmental maturation.^13,14,15 These skills are often referred to as developmental motor skills although they are best viewed as functional motor skills because they remain a permanent part of movement experience throughout life. Examples include movements such as rolling over and getting up out of bed. Motor skills can be categorized according to specific attributes or characteristics into four main groups:

• Transitional mobility refers to skills that allow movement from one posture to another (e.g., supine-to-sit, sit-to-stand).

• Static postural control, or stability, refers to the ability to maintain a posture with orientation of the center of mass (COM) over the base of support (BOS) and the body held steady (e.g., holding in sitting, kneeling, or standing).

• Dynamic postural control (controlled mobility) is the ability to maintain postural stability while parts of the body are in motion. Examples include weight shifting or maintaining a posture with the addition of progressively more challenging movements (e.g., sitting with upper trunk rotation and upper extremity [UE] reaching or standing with lower extremity [LE] stepping).

• Skill is the highest level of motor behavior and includes highly coordinated movement patterns such as grasp and manipulation and locomotion.

See Table 10.2 for a description of these categories of motor skills with examples of activities/postures and impairments.

Changes in motor skills are evident throughout the life span. During infancy (birth to 1 year) and childhood (1 to 10 years), changes are rapid and linked to cognitive/perceptual development and experience. During adolescence (11 to 19 years), motor skills become more complex and responsive to increasing cognitive/perceptual development and complex task and environmental demands. In adults, motor skills continue to be refined and are influenced by a number of factors, including age-related changes, overall health and nutrition, activity levels, and emerging pathology.^16,17,18,19 In middle adulthood (40 to 59 years), changes associated with aging are moderate in most systems. In older adults (60 years and older), changes are more apparent though there is marked heterogeneity in the aging process. Spirduso et al¹⁹ have identified a continuum of physical function among older adults varying from the high ranges of the physically elite and physically fit to a middle range of physically independent to the lower ranges of physically frail, physically dependent and disabled. In the older adult, all stages of information processing are affected.²⁰ Sensory losses (decline in receptor sensitivity, recognition, and sensory encoding) affect stimulus identification. Response selection and programming are also affected by CNS changes with slowing of reaction time, especially for increasingly complex tasks. An age-related slowing of movement time is well documented.²¹

Changes in motor units with a decrease in the overall number and increase in the size of motor units result in impaired coordination, especially for fine motor skills. There is a decreased ability to generate force and an increased tendency to coactivate agonist-antagonist muscles. This coactivation is most likely the result of attempts to modulate movement variability and maintain accuracy.²² Older adults are also more sensitive to complexity of movement.²³ The principle of speed–accuracy tradeoff typically applies as adults age, that is, the accuracy of a movement is decreased as its speed is increased. To accommodate for this change, older adults typically move slower, especially when accuracy is required.¹ Overall movements become less efficient and more variable with age.

Secondary lifestyle factors (nutrition, body weight, exercise) have a significant impact on assisting individuals in maintaining health and in delaying the age of dependency. Decreasing levels of cardiovascular fitness, strength, and endurance and obesity commonly associated with a sedentary lifestyle adversely affect the performance of motor skills. In addition, older adults often experience multiple disease pathologies that affect their ability to move and learn. For example, an older adult may alter the method used to roll over and sit up secondary to an increase in body weight, a decrease in overall strength and fitness, and an emerging pathology such as Parkinson's disease (PD).

Recovery of motor performance is defined as the reacquisition of motor patterns that were present before CNS injury. In complete recovery, performance of the reacquired skills is identical in every way to preinjury performance. It is far more likely that the individual with CNS insult will demonstrate recovery using preinjury skills that are modified in some way. Recovery can be further categorized into two main types:

1. Spontaneous recovery: the neuronal changes that result from the repair processes occurring within the CNS immediately after the insult, resulting in function being restored in neural tissue initially lost.

2. Function-induced recovery: the restoration of the ability to perform a movement in the same or similar manner as it was performed before the injury; occurring in response to changes in activity and the environment (e.g., increased use of involved body segments in behaviorally relevant tasks).

Compensation is defined as the appearance of new motor patterns resulting from the adaptation of remaining motor elements or substitution of alternative motor strategies and body segments. Thus the old movement is performed in a new manner. For example, the patient recovering from severe stroke learns to dress independently using the less affected UE; the patient with a complete T1-level spinal cord injury (SCI) learns to roll using UEs and momentum.²⁴

Spontaneous Recovery

Immediately after a brain insult, a cascade of events occurs, producing transient depression of brain activity. Changes at a cellular level occur in the immediate area of damaged brain tissue. Disruption of the blood– brain barrier results in edema, with an accumulation of intracellular fluid and leakage of blood cells, proteins, and other toxic substances that disrupt nerve function. Release of neurotransmitters, glutamate, and calcium activates enzymes associated with neuron death and neuronal degeneration. Free radical damage from toxic particles of oxygen and iron also is associated with cell death. Denervation supersensitivity, defined as postsynaptic neuronal hypersensitivity, results in decreased synaptic efficiency. Changes also occur in areas remote from the injured brain. Blood flow changes suggestive of depressed neural activity have been found to exist on both sides of the brain and in both cortical and subcortical structures, areas that are remote from the injured site.^25,26,27

Injury-related cortical reorganization is evidenced by a reduction in motor cortex excitability of the involved areas, a decrease in the cortical representation area of paretic muscles, and impairment of motor function. Initial spontaneous recovery that occurs over a relatively short time frame (typically within 3 to 4 weeks) is evidence of return to function of undamaged parts of the brain with the resolution of temporary blocking factors (i.e., shock, edema, decreased blood flow, decreased glucose utilization). This process has been termed diaschisis. For example, the patient with cerebral edema following stroke is likely to demonstrate early worsening of clinical signs as edema develops followed by spontaneous improvement within a few weeks as the edema and other factors resolve.²⁵

Brain injury was for a long time thought to be permanent with little potential for brain repair. This is now viewed as incorrect and can represent a dangerous self-fulfilling prophecy when applied to the individual who suffers from such injuries. Neuroplasticity refers to "the ability of the brain to change and repair itself."^{25, p. 134} Mechanisms of neuroplasticity include neuroanatomical, neurochemical, and neuroreceptive changes. Anatomical changes include nerve growth (neural regeneration) and activation of brain areas previously not active. Trophic molecules (nerve growth factors) have been shown to play a key role in growth and repair processes. Nerve cells also change their interactions with each other, with physiological changes occurring at the level of the synapses. Regenerative synaptogenesis refers to sprouting of the injured axons to innervate (reclaim) previously innervated synapses. Reactive synaptogenesis (collateral sprouting) refers to the reclaiming of synaptic sites of the injured axon by dendritic fibers from neighboring axons. Neurotransmitter release and receptor sensitivity are improved (synaptic plasticity). Changes in synaptic strength, known as long-term potentiation (LTP), firm up neuronal connections and serve as a basis for all memory and learning.^{26,27,28,29,30}

It is important to remember that the brain is organized with parallel and distributed circuits that provide multiple inputs to many areas with overlapping functions. Different and underutilized areas of the brain (e.g., cortical supplementary and association areas) can take over the functions of damaged tissue, a process known as cortical remapping. Another possibility is that the CNS has backup or fail-safe systems (parallel cortical maps) that become operational when the primary system breaks down. The unmasking of new, redundant neuron pathways permits cortical map reorganization and maintenance of function. Whole different areas of the brain are also capable of becoming reprogrammed, a process termed substitution. An example of substitution is the increased sensitivity of the hands as a sensory information system for the person who becomes blind. In this example, the changes in sensory strategy lead to structural reorganization within the brain. Newer techniques in brain mapping have led to better understanding of these processes. These include (1) positron emission tomography (PET) scanning used to measure regional cerebral blood flow (rCBF), (2) focal transcranial magnetic stimulation (TMS) used to measure responses in motor cortical regions to focal magnetic field stimulation, and (3) functional magnetic resonance imaging (fMRI) used to measure small changes in blood flow during brain activation.^28,29,30,31 In summary, recovery is a complex and dynamic process, involving multiple cellular, network, and biochemical processes. It is important to remember that these neuroplastic changes may be adaptive, resulting in improved function, or maladaptive, resulting in nonfunctional motor behaviors.

Function-Induced Recovery

Function-induced recovery (use-dependent cortical reorganization) refers to the ability of the nervous system to modify itself in response to changes in activity and the environment. Repetitive learning behaviors have been shown to prevent degradation and atrophy, enable growth of neurons, strengthen synaptic connections (LTP), alter cortical field representations, and expand topographical areas of motor activity; receptive fields are altered, processing time is improved, and evoked responses demonstrate increased strength and consistency with improved synchronicity. Improvements in functional outcomes are correlated with observed changes in neural adaptation. These can include improved fine and gross motor coordination, sensory discrimination, postural control and balance, procedural memory, adaptability, and so forth.^32,33,34,35 In rehabilitation, constraint-induced movement therapy and locomotor training using partial body weight support (BWS) and a treadmill are examples of targeted interventions to promote function-induced recovery. Changes occur at the level of body function (i.e., the patient moves the limb in a more normal pattern) and at the activity level (the patient reaches or walks with a more normal movement pattern). They differ from conventional or standard care in terms of the high levels of intensity and frequency that are required to improve neural plasticity and function.

There is an accumulating body of research on constraint-induced movement therapy (CIMT) in patients following stroke that has demonstrated significant improvements in UE function.^{36,37,38,39,40,41,42,43,44,45} One important study is the EXCITE Randomized Clinical Trial, a large multisite trial. It consisted of a 2-week CIMT intervention program with training of the more affected UE up to 6 hr/day and use of the mitt on the less affected hand for up to 90% of waking hours. Participants were also encouraged to practice two to three tasks daily at home. Measurements were taken before and after intervention and at 4-, 8- and 12-months' follow-up. Patients in the intervention group showed greater improvement than the control group in all measures of hand function (the Wolf Motor Function Test Performance Time, the Motor Activity Log Amount of Use and Quality of Movement, self-perceived hand difficulty—Stroke Impact Scale).^36,37 Treatment-induced cortical reorganization has also been demonstrated with CIMT.^44,45 Box 10.1 Evidence Summary presents a summary of evidence from selected research in this area. Factors critical to the successful outcomes achieved in these studies include the following:

• A concentrated and repetitive task-specific practice using the more involved UE was utilized (Fig. 10.2). Training was intense, averaging 6 hr/day in CIMT studies. Page et al⁴¹ demonstrated improved function with less intensive, longer duration modified CI therapy (mCIMT). All subjects started with some voluntary movement (wrist and finger extension) in their affected limb.

• Movement was constrained in the less affected UE through the use of a mitt worn up to 90% of waking hours.

• Behavioral techniques were used to enhance adherence and increased use of the affected UE in everyday life. Patients signed a behavioral contract indicating how often and with which activities patients will use their affected limb. Daily administration of the Motor Activity Log (MAL) also increased awareness of using the affected limb, assisting in overcoming

learned nonuse. Shaping techniques (operant conditioning) and functional training were used to develop challenging intervention tasks. Tasks were selected and tailored to address the specific motor deficits of the patient and shaped to allow for improving movement control and appropriate rest intervals. Feedback, coaching, modeling, and encouragement were provided to set goals, provide motivation, and overcome learned nonuse. Patients were rewarded for improvement and correct movement patterns. Incorrect or poor performance was ignored in an attempt to break the cycle of learned nonuse.

Task-specific locomotor training using partial BWS, a treadmill, and manually assisted trunk and limb movements has also been shown to be effective in promoting function-induced recovery.^{46,47,48,49,50} As in CIMT, practice is intense and task-specific. The limbs are loaded to tolerance and active postural control maximized. The treadmill allows control and progression of gait speed and provides rhythmic timing of the stepping movements. Training is progressed by decreasing the amount of loading (BWS) and manual assistance and moving toward overground and community ambulation. See discussion in Chapter 11, Locomotor Training, and Chapter 20, Traumatic Spinal Cord Injury, and the Evidence Summary Boxes in Chapter 15, Stroke, and Chapter 20.

Evidence from animal studies suggests beneficial effects from an enriched environment in promoting brain plasticity and development. Rats raised in enriched environments with opportunities for physical activity and social interaction with other rats demonstrated increased cortical depth, brain weight, dendritic branching, size of synaptic contact areas, and enzyme activity when compared to rats raised in impoverished environments. They also performed significantly better on motor tasks. When brain lesions were induced in rats, exposure to enriched environments and activity before surgical insult had a protective effect with greater sparing of function and improved recovery. Lesioned rats exposed post-surgery to enriched environments also demonstrated improved recovery and performance when compared to those in impoverished surroundings. Finally, socialization influenced outcomes. Rats housed in social groups in enriched environments demonstrated superior recovery over isolated rats.^{51,52,53,54,55}

In humans, an unfamiliar and unpredictable hospital or rehabilitation environment may contribute to depression, disorientation, and decline of function. This same environment may be overly structured and protective to the point that it contributes to learned helplessness and disuse. Carr and Shepherd⁵⁶ argue that poor recovery after stroke may be partially explained by the impoverished and non-challenging environments that many individuals recovering from stroke are exposed to. Although there are few environmental studies with humans, there is evidence that patients recovering from stroke who were treated on an acute stroke unit demonstrated better recovery and functional outcomes than patients who received a comparable amount of physical therapy while on a general medical unit.⁵⁷ This difference could also be due to the better coordination of care and expertise in specialized rehabilitation units. As Carr and Shepherd⁵⁸ point out, an important consideration is the amount of "down time" patients typically experience while in rehabilitation. As much as 30% to 40% of the day can be spent in passive pursuits while time in therapy is limited.⁵⁹ During non-therapy time, there is often little attention to self-directed practice, thereby further limiting the potential for optimal recovery of function.^60,61 In summary, a rehabilitation POC that focuses on promoting function-induced recovery will emphasize active, task-oriented practice based on the patient's unique needs, an enriched environment, and effective utilization of practice time both in-therapy and out-of-therapy. Principles of promoting function-induced recovery are summarized in Table 10.3.

Neurorehabilitation interventions have evolved over time for the management of patients with disorders of motor function. Many treatment ideas emerged from empirical knowledge and clinical practice. Theory was applied to explain the success of these interventions and to organize them into a coherent treatment philosophy. Our understanding of motor function and its theoretical base has changed over the years. Emphasis on evidence-based practice has resulted in increased validation of therapeutic interventions through research.

The therapist's role is to accurately determine the patient's strengths and limitations and to develop a collaborative POC that includes goals and outcomes that match the patient's unique needs. See Box 10.2 for examples of general goals and outcomes for patients with disorders of motor function. The therapist must also determine an appropriate level of intensity, frequency, and duration of treatment. An important framework for practice is based on current understanding that movement arises from the interaction of three basic elements: the task, the individual, and the environment (Fig. 10.3).² All three components must be considered in developing a successful POC.

Box 10.3 presents a framework of current neurorehabilitation interventions. The interventions are organized from top to bottom starting with restorative interventions that are designed to promote and restore optimal functional capacity. These include functional training, defined as activity-based, task-oriented intervention that uses normal patterns to accomplish the task and motor learning strategies. The next level includes impairment-specific and augmented interventions. Augmented interventions include hands-on assistance (guided or assisted movements) and neuromotor development training and are designed to "jumpstart" functional recovery for involved individuals with limited motor function and independent movements. Finally, some individuals will require compensatory interventions in the presence of severe impairment, poor prognosis, and multiple co-morbidities. These interventions are designed to promote optimal function using altered movement patterns and strategies using all body segments. A focus on preventive intervention is also important. Some activities designed to minimize impairments and disabilities also fall into this category. For example, the patient with stroke who presents with a flaccid and weak shoulder is given a protective sling to wear during transfer training to reduce the likelihood of shoulder pain and subluxation. Interventions may be used concurrently or in some cases sequentially. For example, the patient with weak hip and knee extensors and limited range of motion (ROM) in hip extension will not be successful in accomplishing sit-to-stand transitions until LE strength is increased and ROM is improved. The following section of the chapter presents an overview of motor learning strategies and therapeutic interventions.

Motor Learning Strategies

Motor learning involves a significant amount of practice and feedback, with a high level of information processing related to control, error detection, and correction. Motor learning can be facilitated through the use of effective training strategies, summarized by stages in Table 10.1.

Strategy Development

The overall goal during the early cognitive stage of learning is to facilitate task understanding and organize early practice. The learner's knowledge of the skill and any existing problems must be ascertained. The therapist should highlight the purpose of the skill in a functionally relevant context. The task should seem important, desirable, and realistic to learn. The therapist should demonstrate the task (modeling) exactly as it should be done (i.e., coordinated action with smooth timing and ideal performance speed). This helps the learner develop an internal cognitive map or reference of correctness. Attention should be directed to the desired outcome and critical task elements. The therapist should point out similarities to other learned tasks so that schema that are part of other motor programs can be retrieved from memory. Features of the environment critical to performance should also be highlighted.

Highly skilled individuals who have been successfully discharged from rehabilitation can be expert models. Their success in returning to the "real world" will also have a positive effect in motivating patients new to rehabilitation. For example, it is very difficult for a therapist with full use of muscles to accurately demonstrate appropriate transfer skills to an individual with C6 complete tetraplegia. A successful former patient with a similar level injury can accurately demonstrate how the skill should be performed. Modeling has been shown to be effective in producing learning even with unskilled patient models. In this situation, the learner/patient benefits from the cognitive processing and problem solving used while watching the unskilled model attempt to correct errors and arrive at the desired movement.⁶¹ Demonstrations can be live or videotaped. Developing a video library of demonstrations of skilled former patients is a useful strategy to ensure availability of effective models.

Guided movement involves physically assisting the learner through the task to be learned. It can have considerable positive effects during the early period of skill acquisition.^62,63,64 The therapist's hands can effectively substitute for missing elements, hold a part of the body stable while constraining unwanted movements, reduce errors, and guide the patient toward correct performance. It also allows the learner to preview the tactile and kinesthetic inputs inherent in the task, that is, to learn the sensations of movement. The supportive use of hands also allays fears and instills confidence while ensuring safety. Verbal guidance, "talking someone through the task," is also a form of guidance that can be used to improve performance. As discussed previously, improved performance does not represent true learning or retention of a skill. Without active trial and error, discovery learning, the changes in performance may be only temporary. The key to success in using guided movements is to limit guidance and intersperse practice with active movements as soon and as much as possible. Overuse of guided movements is likely to result in overdependence on the therapist for assistance, thus becoming a "crutch." The patient who tells you that he or she can only perform the skill if "my therapist" helps or the way "my therapist does it" is demonstrating an overreliance on guided movement. Guidance is most effective for slow postural responses (positioning tasks) and less effective during rapid or ballistic tasks.

During initial practice, the therapist should provide precise feedback, highlighting information critical for movement efficiency. The patient should not be overloaded with excessive feedback or wordy instructions. It is important to reinforce correct performance and intervene when movement errors become consistent or when safety is an issue. The therapist should not attempt to correct all the numerous errors that characterize this stage but rather allow for trial-and-error learning. Feedback, particularly visual feedback, is important during the early acquisition phase. The learner should be directed to watch the movements closely. The learner's initial performance trials can also be video recorded for later viewing. Cued or directed viewing of the task improves learning.

During the associated and autonomous phases of learning, the patient continues to refine movement strategies with high levels of practice. Random errors decrease. As consistent errors are identified, feedback may be given and solutions generated. The focus is on refinement of skills and movement consistency in varied environments. This will ensure an overall range of movement patterns that are adaptable and match the changing demands of open environments. The patient's attention should be now focused on proprioceptive feedback, the "feel of the movement." Thus, the patient is directed to attend to the sensations intrinsic to the movement itself and to associate those sensations with the motor actions. Guided movements are counterproductive at this stage because they limit active practice. During late-stage learning, the use of distracters such as ongoing conversation or dual task training (e.g., ball skills during standing and walking) can yield important evidence of a developing level of autonomous control. It is important to remember that many patients undergoing active rehabilitation do not reach this final stage of learning. For example, in patients with TBI, performance may reach consistent levels within structured environments, whereas safe, consistent performance in open, community environments is not possible.

Feedback

The vast body of motor learning literature affirms the critical role of feedback in promoting motor learning. Feedback can be intrinsic (inherent), occurring as a natural result of the movement, or extrinsic (augmented), incorporating sensory cues provided that are not normally received during the movement. Proprioceptive, visual, vestibular, and cutaneous signals are examples of types of intrinsic feedback; visual, auditory, and tactile cues are forms of extrinsic feedback (e.g., verbal cues, manual cues, biofeedback devices such as the electromyogram [EMG], pressure-sensing devices [force plates, foot pad]). During therapy, both intrinsic and extrinsic feedback can be manipulated to enhance motor learning. The use of augmented feedback serves as an important source of information and helps the learner link associations between the movement parameters and resulting action.¹ Concurrent feedback is given during task performance, while terminal feedback is given at the end of task performance. Augmented feedback about the nature of the end result produced in relation to the goal is termed knowledge of results (KR). Augmented feedback about the nature or quality of the movement pattern produced is termed knowledge of performance (KP).¹ Although both are important, the relative usefulness of KP and KR can vary according to the skill being learned and the availability of feedback from intrinsic sources.^{65,66,67,68,69} For example, tracking tasks are highly dependent on intrinsic visual and kinesthetic feedback (KP) whereas KR has less influence on the accuracy of the movements. In other tasks (e.g., transfers) KR provides the key information about how to shape the overall movements for the next attempt whereas KP may not be as useful. Performance cues (KP) should focus on key task elements that lead to a successful final outcome.

Therapists must consider the cognitive and physical resources of patients and the complexity of the tasks to be learned in determining the type of feedback possible. Clinical decisions about feedback include the following issues:

• What type of feedback should be employed (mode)?

• How much feedback should be used (intensity)?

• When should feedback be given (scheduling)?

Choices about type of feedback involve the selection of which intrinsic sensory systems to highlight, what type of augmented feedback to use, and how to pair extrinsic feedback to intrinsic feedback. The selection of sensory systems depends on specific examination findings of sensory integrity. The sensory systems selected must provide accurate and usable information. If an intrinsic sensory system is impaired and provides distorted or incomplete information (e.g., impaired proprioception with diabetic neuropathy), use of alternate sensory systems (vision) should be emphasized. Supplemental augmented feedback can be used to enhance learning. Decisions are also based on stage of learning. Early in learning, visual feedback is easily brought to conscious attention and therefore is important. Less consciously accessible sensory information such as proprioception should be emphasized during the middle and end stages of learning. Decisions about frequency and scheduling of feedback (when and how much) must be reached. Frequent augmented feedback (e.g., given after every trial) quickly guides the learner to the improved performance but slows retention and overall learning. Conversely, feedback that is varied (not given after every trial) slows initial performance of the skill while improving performance on a retention test.^{70,71,72,73,74} This is most likely due to the increased depth of cognitive processing that accompanies the variable presentation of feedback. In contrast, the therapist who bombards the patient immediately after task completion with excessive augmented verbal feedback may preclude active information processing by the learner.^75,76 The patient's own decision making skills are minimized, while the therapist's verbal skills dominate. Winstein⁷⁷ points out that this may well explain why many studies on the effectiveness of therapeutic approaches cite minimal carryover and limited retention of newly acquired motor skills. Finally, the withdrawal of augmented feedback should be gradual and carefully paired with the patient's efforts to correctly utilize intrinsic feedback systems. Table 10.4 summarizes the types and uses of augmented feedback.

Practice

The second major influence on motor learning is practice. General principles of practice are (1) increased practice results in increased learning and (2) large and rapid improvements in performance are typically observed initially with smaller improvements noted over time. The therapist's role is to prepare the patient for practice and to ensure that the patient practices the desired movements. Practice of incorrect movement patterns can lead to a negative learning situation (interference) in which "faulty habits and postures" must be unlearned before the correct movements can be mastered. The organization of practice will depend on several factors, including the patient's motivation, attention span, concentration, and endurance, and the type of task. Making the task seem important and attainable improves motivation and commitment to practice. Patients who are involved in goal setting and recognize specific practice parameters (task purpose, schedule, limits) demonstrate improved commitment to practice. An additional factor that influences practice is the frequency of allowable therapy sessions, which is often dependent on hospital scheduling and availability of services and payment. Planning for effective use of out-of-therapy practice is important for all patients but especially so for patients with limited access to physical therapy. For outpatients, practice at home is highly dependent on motivation, family support, and suitable environment.

Therapists must consider the cognitive and physical resources of patients and the complexity of the tasks to be learned in determining the type of practice possible. Clinical decisions about practice include the following issues:

• How should practice periods and rest periods be spaced (distribution of practice)?

• What tasks and task variations should be practiced (variability of practice)?

• How should the tasks be sequenced (practice order)?

• How should the environment be structured (closed vs. open)?

• What tasks should be practiced in a parts-to-whole sequence?

Distribution: Massed Versus Distributed Practice

Massed practice refers to "a sequence of practice and rest times in which the rest time is much less than the practice time."^{1, p. 497} Fatigue, decreased performance, and risk of injury are factors that must be considered when using massed practice. Distributed practice refers to "a sequence of practice and rest periods in which the practice time is often equal to or less than the time at rest."^{1, p. 494} Although learning occurs with both, distributed practice results in the most learning per training time, although the total training time is increased. It is the preferred mode for many patients undergoing active rehabilitation who demonstrate limited performance capabilities and endurance. With adequate rest periods, performance can be improved without the interfering effects of fatigue or increasing safety issues. Distributed practice is of benefit if motivation is low or if the learner has a short attention span, poor concentration, or motor planning deficits (e.g., dyspraxia). Distributed practice should also be considered if the task itself is complex, is long, or has a high energy cost. Massed practice can be considered when motivation and skill levels are high and when the patient has adequate endurance, attention, and concentration. For example, the patient with SCI in the final stages of rehabilitation may spend long practice sessions acquiring the wheelchair skills needed for community access.

Blocked Versus Random Practice

Blocked practice refers to "a practice sequence in which all of the trials on one task are done together, uninterrupted by practice on any of the other tasks."^{1, p. 493} Random practice refers to "a practice sequence in which the tasks being practiced are ordered randomly across trials."^{1, p. 498} Although both allow for motor skill acquisition, random practice has been shown to have superior long-term effects in terms of retention.^78,79,80 For example, a variety of different transfers (e.g., bed-to-wheelchair, wheelchair-to-toilet, wheelchair-to-bathtub transfer seat) can be practiced all within the same training session. Although skilled performance of individual tasks may be initially delayed, improved retention of transfer skills can be expected. The constant challenge of varying the task demands provides high contextual interference and increases the depth of cognitive processing through retrieval practice from memory stores. The acquired skills can then be applied more easily to other task variations or environments. Constant practice will result in superior initial performance because of low contextual interference and is required in certain situations (e.g., the patient with TBI and profound cognitive and behavioral deficits who requires a high degree of structure and consistency for learning; the patient with advanced PD).

Practice Order

Practice order refers to the sequence in which tasks are practiced. Blocked order refers to the repeated practice of a task or group of tasks in order (three trials of task 1, three trials of task 2, three trials of task 3: 111222333). Serial order refers to a predictable and repeating order (practice of multiple tasks in the following order: 123123123). Random order refers to a nonrepeating and nonpredictable order (123321312). Although skill acquisition can be achieved with all three, differences have been found. Blocked order produces improved early acquisition of skills (performance) whereas serial and random order produce better retention and generalizability of skills. This is again due to contextual interference and increased depth of cognitive processing.^81,82 The key element here is the degree to which the learner is actively involved in memory retrieval. For example, a treatment session can be organized to include practice of a number of different tasks (e.g., forward-, backward-and side-stepping and stair climbing). Random ordering of the tasks may initially delay acquisition of the desired stepping movements but over the long term will result in improved retention and generalizability.

Mental Practice

Mental practice is "a practice method in which performance on the task is imagined or visualized without overt physical practice."^{1, p. 497} Beneficial effects result from the cognitive rehearsal of task elements. It is theorized that underlying motor programs for movement are activated but with subthreshold motor activity.¹ Brain mapping techniques have also revealed activation of similar brain areas during imagined movements as those activated during actual movement.^83,84 Mental practice has consistently been found to facilitate the acquisition of motor skills.^85,86,87,88 It should be considered for patients who fatigue easily and are unable to sustain physical practice. Mental practice is also effective in alleviating anxiety associated with initial practice by previewing the upcoming movement experience. Mental practice when combined with physical practice has been shown to increase the accuracy and efficiency of movements at significantly faster rates than physical practice alone.⁸⁹ When using mental practice, it is important to make sure the patient understands the task and is actively rehearsing the correct movement. Having the patient verbalize aloud the steps being rehearsed can ensure that this occurs. It is generally contraindicated in patients with profound cognitive, communication, and/or perceptual deficits.

Part–Whole Practice

Complex motor skills can be broken down into component parts for practice. The component parts are practiced before practice of the whole task is attempted. For example, during initial wheelchair transfer training the individual steps are practiced in isolation before practicing the whole transfer (e.g., locking the brakes, lifting the foot pedals, moving forward in the chair, standing up, pivoting, and sitting down). It is important to identify the key steps through accurate task analysis and to sequence them in the required order. It is also important to practice the integrated whole in conjunction with the parts practice so that the learner develops the whole idea for the required task (i.e., cognitive mapping). Delaying practice of the integrated whole can interfere with transfer effects and learning.¹ Part–whole practice is most effective with discrete or serial motor tasks that have highly independent parts. Part–whole practice is not as effective for continuous movement tasks (e.g., walking) or for complex tasks with highly integrated parts. Both require a high degree of coordination with spatial and temporal sequencing of elements. For these tasks, practice of the integrated whole will result in superior learning.

Transfer Training

Transfer of learning refers to the gain (or loss) in the capability of task performance as a result of practice or experience on some other task. Learning can be promoted through practice using contralateral extremities, termed bilateral transfer. For example, a patient with stroke first practices the desired movement pattern using the less affected extremity. This initial practice enhances formation or recall of the necessary motor program, which can then be applied to the opposite, involved extremity. This method cannot, however, substitute for lack of movement potential of the affected extremities (e.g., a flaccid limb on the hemiplegic side). Transfer effects are optimal with similarity of the tasks (e.g., identical components and actions) and environments.⁹⁰ For example, optimal transfer can be expected with practice of a UE flexion pattern first on one side, then with an identical pattern on the other side.

Practice of lead-up tasks is commonly used in physical therapy. Lead-ups are tasks or activities presented to prepare learners for a more important or complex task or activity.^{1, p. 496} The subtasks are practiced, typically in easier postures with significantly reduced degrees of freedom. Anxiety is also reduced and safety is ensured. Thus initial upright postural control can be practiced with activities in kneeling, half-kneeling, or plantigrade before standing. The patient develops the required trunk and hip extension/abduction stabilization control required for upright stance but without the demands of the full standing position or fear of falling. The more closely the lead-ups (subskills) resemble the final task, the better the transfer. For example, bridging, which involves hip extension to neutral in a supine hook-lying position, can be a lead-up to successful sit-to-stand transitions. Table 10.5 summarizes the types of practice and practice parameters.

Promoting Active Patient Decision Making and Autonomy

Fundamental psychological needs of the patient include autonomy, competence, and social-relatedness. For effective planning, the therapist needs to have a clear understanding of the patient's values (beliefs and attitudes), self-perceptions, preferences, outcomes expectation, and sense of self-efficacy (a belief that the patient can accomplish the task successfully). Focus on the development of decision making skills is critical in ensuring perceived confidence, continued learning, and problem-solving success in the patient's real world environment. The therapist also needs to communicate effectively, develop rapport, and support the patient in collaborative planning. Having the patient actively involved in self-monitoring, analysis, and self-correction of movements encourages self-determined behavior. Trial-and-error learning can only be successful if the patient is challenged to think about the movement, to consider the information feedback received about the movement's performance, and to evaluate the movement outcome.⁹¹ Key questions to promote active decision making and autonomy are presented in Box 10.4.

The therapist should allow adequate time for reflection and confirm the accuracy of the patient's responses. For example, if the patient's efforts do not achieve the expected outcome, the patient can be challenged to consider why. The patient who consistently falls to the right while standing can be challenged with questions such as, "In what direction did you fall?" and "What do you need to do to correct this problem?" The therapist has an important role as a motivational coach ("We can do this together as a team"). This includes emphasizing the patient's capabilities rather than failures and pointing out successes in improving function and obstacles that have been overcome on a regular basis. Beginning and ending the therapy session with a positive and successful movement experience is also a useful strategy to improve self-efficacy.

Functional Training

Functional, task-specific training is based on careful examination of motor function and activity performance (see Chapter 8, Examination of Function). Tasks targeted during early rehabilitation include basic activities of daily living (BADL) (e.g., feeding, dressing, hygiene, and so forth) and functional mobility skills (FMS) (e.g., bed mobility, transfers, locomotion). Later in rehabilitation instrumental activities of daily living (IADL) (e.g., home chores, shopping), community mobility, and work activities are targeted, depending on the patient's level of recovery and discharge placement. Task analysis yields an understanding of task, the essential elements within the task, and the context or environment in which the task occurs (see Chapter 5, Examination of Motor Function: Motor Control and Learning, Box 5.1). The therapist then selects activities and modifies task demands based on this analysis to determine an appropriate POC.

As previously discussed, extensive practice and appropriate feedback are essential in order to reacquire skills and enhance recovery. Involved segments are targeted for training. For example, training the patient with stroke focuses on use of the more involved extremities during daily tasks whereas use of the less involved extremities is minimized (e.g., CIMT). Initial tasks are selected to ensure patient success and motivation (e.g., grasp and release of a cup for feeding, forward reach for UE dressing). Tasks are modified to permit early practice. For example, training using partial BWS and a motorized treadmill provides a means of early locomotor training for patients with stroke or incomplete spinal cord injury. Tasks are continually modified to increase the level of difficulty, promote adaptation of skills, and promote independence. For example, sit-to-stand training begins with standing up from a raised seat. Progressively lowering the seat height during training increases the difficulty of the task until the patient is able to stand up from a normal seat height. During early training assistive devices may be used to assist function (e.g., for transfer training, gait and locomotion, dressing). The goal is to transition the patient away from using such devices toward independent function as soon as the patient is able. Continued use of and dependence on assistive devices falls under the category of compensatory training (e.g., wheelchair training for the patient with complete paraplegia).

Functional training represents a shift away from some conventional rehabilitation approaches that utilize an extensive hands-on approach to promote recovery and/or substitution. Although initial movements can be assisted in functional training, active movements are the overall goal. The therapist's role is one of training coach, structuring practice and providing appropriate challenge and feedback while encouraging the patient. Task-oriented training effectively counteracts the effects of immobility and the development of indirect impairments such as muscle weakness or loss of flexibility. It also prevents learned nonuse of the involved segments while stimulating CNS recovery.

Achieving control in various different functional activities and postures is a primary focus of intervention during rehabilitation. Careful attention to the demands of the postures can effectively address the degrees of freedom problem in controlling body segments and influence the selection of lead-up skills. For example, the prone-on-elbows posture focuses on development of shoulder, upper trunk, and head control while eliminating all demands for movement control in the lower body; because the COM is low and the BOS is wide, the posture is inherently safe. The kneeling posture can be used to improve trunk and hip control without the demands for control of the knee and ankle. As with the prone-on-elbows posture, the low COM and wide BOS reduce the likelihood of falls and injury. See Table 10.6 for a summary of postures and potential treatment benefits. Refer to O'Sullivan and Schmitz's Improving Functional Outcomes in Physical Rehabilitation⁹² for a more in-depth discussion.

Intense task-oriented training may not be appropriate for every patient. Its selection is dependent on the degree of recovery and severity of motor deficits. Research findings suggest that early overemphasis on use-dependent training may actually increase the vulnerability of the brain to additional damage in animals^93,94 and in humans.^95,96,97,98 Patients who are not able to participate in task-oriented training include those who lack voluntary control or cognitive function. For example, a patient with TBI who is in the early recovery stages has limited potential to participate with this type of intensive training. Similarly, patients with stroke who experience profound UE paralysis and perceptual deficits would not be candidates for CIMT UE training. One of the consistent exclusion criteria for CIMT has been inability to perform voluntary wrist and finger extension of the more involved hand. Thus, threshold abilities to perform the basic components of the task need to be identified. Careful analysis of underlying impairments with a focus on intervention (e.g., improved strength, ROM) complements task-oriented training. For example, during locomotor training using BWS and a treadmill system, stepping and pelvic motions are guided into an efficient motor pattern. To participate in this type of training, essential prerequisites include basic head stability during upright positioning.

Environmental Context

Altering the environmental context is an important consideration in structuring practice sessions. During early learning many patients benefit from practice in a stable, or predictable, closed environment. As learning progresses the environment should be varied and incorporate more variable features consistent with real world, open environments. Practicing walking only within the physical therapy clinic might lead to successful performance in that setting (context-specific learning) but does little to prepare the patient for ambulation at home or in the community. The therapist should begin to gradually modify the environment as soon as performance becomes consistent. Consideration must be given to practice in a safe environment where the patient can learn without the risk of injury or outright failure. Simulated environments (e.g., Easy Street Environments) are found in many rehabilitation centers. They can serve as an intermediate practice environment before the patient moves to the home or community setting. It is important to remember that some patients (e.g., a patient with TBI and limited cognitive recovery) may never be able to function in anything but a highly structured environment.

Behavioral Shaping

Behavioral shaping refers to the use of techniques designed to systematically progress the level of difficulty of the tasks practiced. The therapist provides immediate and explicit feedback to shape and improve performance. Attention is directed toward the successful aspects of performance. Thus the therapist serves to direct and motivate the patient toward optimal performance. The tasks chosen should be within the capabilities of the patient. Excessive effort, which can degrade performance and motivation, is avoided. The patient is kept focused on the training activity, fully informed of progress, and continually challenged.⁹⁹

Safety Awareness Training

An important element of functional training is injury prevention or reduction. First and foremost is safety awareness training during self-care activities, postural control and balance activities, and functional mobility. For example, during postural awareness training, the patient learns to define limits of stability (LOS) during weight shifts. During anticipated or reactive perturbations, the patient learns how to react to these destabilizing forces with appropriate adjustments that maintain posture and balance. Identifying fall risk and developing strategies to reduce fall risk are important elements of functional mobility training. Instruction in the use of assistive devices and equipment is also accompanied by safety awareness training. For example, the patient with SCI learns to safely transfer into and out of the tub during bathing and to avoid risk of injury by testing water temperature before emersion. Finally, secondary prevention (efforts to decrease the severity of disability and sequelae through early diagnosis and prompt intervention) is an important component of rehabilitation. For example, prevention and management of UE overuse injury is an important component in the rehabilitation of patients with SCI who are wheelchair users.

Box 10.5 presents a summary of task-oriented training strategies to promote function-induced recovery.

Impairment Interventions

Task analysis reveals if the patient is able to perform the functional activity and its basic components. Additional examination and evaluation can reveal if a specific impairment or group of impairments is linked to the functional/task limitation. The therapist then needs to focus on specific interventions to improve performance. For example, a patient with multiple sclerosis (MS) demonstrates inability to stand up or transfer without moderate assistance of one. Lower extremity weakness in hip and knee extension is identified. Strength training of these muscles needs to be a targeted intervention. It is important to remember that resolution of the impairment may still not yield the desired functional performance. It is entirely possible that other impairments, previously masked by an inability to perform the task, were also contributing to the patient's inability to stand up independently (e.g., balance impairments). Without attention to correcting impairments, continued functional training has the potential of delaying recovery and creating a host of faulty movement patterns that later may prove difficult to unlearn. For example, early gait training in the parallel bars in which the patient with stroke requires maximal assistance of the therapist to drag the involved and splinted leg forward does very little if anything to promote active locomotor control of that limb. It is also important to remember that impairment-specific interventions must be linked to functional training. The patient needs to practice the functional activity concurrently to resolve or diminish disability. The activity can be modified to ensure patient safety and make it easier. The following section provides an overview of impairment-specific interventions.

Interventions to Improve Strength, Power, and Endurance

Muscle performance is defined as "the capacity of a muscle or group of muscles to generate forces."^{100, p. 688} Muscle strength is the "muscle force exerted by a muscle or a group of muscles to overcome a resistance under a specific set of circumstances."^{100, p. 688} Muscle power is "the work produced per unit of time or the product of strength and speed."^{100, p. 688} Muscle endurance is "the ability to sustain forces repeatedly or to generate forces over a period of time."^{100, p. 688} Muscle performance is regulated by a number of factors. Neural factors include motor unit recruitment (number, type), motor neuron firing patterns, and efficiency of cooperative synergistic patterns. Muscle and biomechanical factors include initial muscle length and tension, muscle fiber composition, fuel storage and delivery, speed and type of contraction, and movement arm. Techniques that optimize these factors while addressing the specific demands of the task and environment will yield maximum functional outcomes.

Patients undergoing neurorehabilitation commonly present with disruption of motor neurons from central pathways and reductions in muscle force production, a direct result of a UMN lesion. Weakness or paralysis can affect one side of the body (hemiparesis, hemiplegia), both lower limbs (paraparesis, paraplegia), all four limbs (tetraparesis, tetraplegia), or a single limb or segments of a limb. Patients with hemispheric stroke from an ipsilateral lesion can also demonstrate bilateral weakness with the less involved side showing mild weakness.¹⁰¹ As recovery progresses, the status of muscle strength and performance may change (e.g., the patient recovering from incomplete SCI regains muscles under voluntary control and functional performance improves). In addition, prolonged periods of disuse and immobility result in diminished neural activity, atrophy, and weakness. Older adults typically demonstrate a preferential loss of type II fibers. It is important to recognize that the patient may have been inactive before the insult or injury, resulting in preexisting deconditioning. Physical size (total body weight) and the demands of the task (e.g., stair climbing vs. walking on level surfaces) also influence the amount of strength required.

Strength Training

The benefits of strength training for patients with disorders of motor function include the following:

• An increase in the production of maximal force due to changes in neural drive (increased motor unit recruitment, increased rate, and synchronization of firing pattern of motor units, improved reaction time).

• Changes in muscle (hypertrophy of muscle fibers, improved metabolic/enzymatic adaptations, increased size and number of myofibrils, muscle fiber type adaptation).

• Increases in connective tissue tensile strength and bone mineral density.

• Improved body composition relative to body mass ratio of fat to lean.

• Improved functional performance and activity levels.

• Improved sense of well-being and self-confidence.

Basic principles of strengthening exercise include overload, specificity, cross training, and reversibility. The loads placed on muscle must be greater than those normally incurred (overload principle). Training effects are specific to the mode of exercise stress imposed on the exercising muscles (specificity principle). Thus, the training effects from an isometric protocol are specific to the exercising muscle and the point in the range that the muscle is holding. Effects do not carry over to improved dynamic performance (concentric or eccentric contractions). Nor will exercise training of the UEs transfer to improved LE performance. Cross training refers to a training program that includes a variety of training elements (e.g., isometric, concentric, eccentric, and endurance exercise). Cross training is used to place broadest possible demands on the neuromuscular system and overcome the effects of specificity. Reversibility principle refers to the failure to sustain the benefits of strength training if muscles are not regularly used in a maintenance program of resistance or functional exercises. Detraining effects include a reduction in muscle performance, decreased neural recruitment, and muscle fiber atrophy. The effectiveness of strength training is dependent on achieving an adequate training stimulus. Exercise guidelines for strength training are presented in Table 10.7.^{102,103,104,105}

Patients with impaired motor function may demonstrate deficits in muscle activation. Early training should focus on isometric and eccentric contractions because muscle tension is better maintained than with concentric contractions. With isometric contractions, there is improved peripheral reflex support of contraction as opposed to the spindle unloading that occurs as the muscle moves into the shortened range of a concentric contraction. Eccentric contractions also produce greater muscle force with lower rates of motor unit discharge than concentric contractions. During training, the patient is initially asked to actively hold at midrange where the greatest tension can be generated. The patient is then asked to slowly lower the limb (an eccentric contraction) and hold (an isometric contraction). Once control is achieved in both of these types of contractions, concentric contractions can be attempted. For isotonic contractions, prestretching the muscle by starting the contraction in the lengthened range optimizes tension development through increased use of viscoelastic forces (length–tension relationship) and peripheral reflex support (e.g., PNF patterns; see later definition and discussion). Weak muscles can be initially lightly resisted to facilitate contraction through proprioceptive loading (recruitment) of the muscle spindle. Control of velocity is also important to ensure efficiency of initial movement attempts. During concentric contractions, total tension decreases as velocity increases. Thus, patients may be able to generate a contraction at slow speeds but not at high speeds. For example, the patient with stroke who demonstrates limited control should be instructed to begin with slow and controlled movements. As movements become more efficient, they can be progressed to faster speeds.

Patients with UMN lesions typically exhibit spasticity. Early neurorehabilitation approaches (e.g., Bobath) viewed spasticity as a primary contributor to neuromuscular impairment. Strength training and high resistance were contraindicated because they were viewed as likely to increase spasticity (reflex hyperactivity), co-contraction, and abnormal movement patterns.¹⁰⁵ These views are no longer supported by scientific literature as investigators have shown that it is possible to increase strength without additional detrimental effects on tone and movement control.^{106,107,108,109,110,111,112}

Open-chain exercises involve an isolated segment of the limb moving in space without simultaneous motions at adjacent joints. Muscle activation occurs predominantly in the prime mover(s) crossing the moving joint. Resistance is applied to the distal moving segment, typically in non–weight-bearing positions. Closed-chain exercises involve motions in which the distal part is fixed (foot or hand) while proximal segments are moving (e.g., weight shifting in standing, bilateral short-arc squats). They are performed in weight-bearing postures and involve simultaneous actions of synergistic muscles at multiple joints. The added joint approximation and stimulation of joint and muscle proprioceptors enhances neuromuscular control and joint stabilization (co-contraction). A limitation of closed-chain exercise is the substitution of other agonist muscles for specific muscle weakness. In comparison, open-chain exercises can be used to isolate contraction of a muscle or muscle group. However, the muscles trained and movements used are not well matched to normal functional movements that utilize complex movements and multisegment linkage.¹⁰⁵

Gains in strength can be obtained through progressive resistive exercises (PRE) using free weights or fixed mechanical resistance machines. A major disadvantage of PRE is that the weight selected is determined by the amount that can be lifted by the muscle at the weakest point of the range. Isokinetic training devices offer the advantage of providing accommodating resistance throughout the range. Muscle performance is therefore not limited to the weakest part of the range. The amount of force generated is recorded, providing an important objective measure of performance. Different isokinetic protocols using concentric and eccentric contractions have been developed. The speed of movement can be predetermined. This is an important consideration for training the patient who demonstrates neuromuscular impairments in timing and velocity control. For example, the patient recovering from stroke may be unable to generate the acceleration and deceleration forces needed during the different phases of gait. This results in delayed sequencing of muscle components and a general slowing of gait. Isokinetic training that focuses on the timing of these various components can improve gait function.

Proprioceptive neuromuscular facilitation (PNF) utilizes manually resisted patterns (PNF patterns) and offers the advantage of functionally based, synergistic movements. Patterns of motion are spiral and diagonal in nature as opposed to straight planes of motion and are linked to normal functional patterns. The therapist can accommodate to the patient's specific level of weakness by providing repetitive graded resistance throughout the range and by adding additional facilitation as needed to improve or maintain performance. Effective verbal commands improve the magnitude of muscle contraction. Stretch is applied in the lengthened range to assist in the initiation of contraction and throughout the range as needed to sustain contraction. Approximation is applied to assist extensor patterns, and traction is applied to assist flexor patterns. Specific PNF techniques (e.g., dynamic reversals, repeated contractions, and so forth) are useful in improving strength. Elastic resistance bands or pulley weights can also be used to provide resistance in synergistic PNF patterns.^113,114

Strength gains can be achieved through functional training that uses task-related practice. Resistance is provided by gravity and body weight and is applied simultaneously to multiple moving segments. It can be supplemented with manual resistance of the therapist, weights, elastic resistance bands, or resistance of water during pool therapy. Activities are selected that initially focus on specific body segments and progress to involve increasingly larger segments of the body. This serves to increase the level of difficulty and the degrees of freedom that must be controlled during the movement. Benefits of functional training include improved coordination of muscles, improved postural control and balance, and improved muscle extensibility and flexibility. Functional training helps the patient develop control of synergistic muscle groups acting in multiple axes and planes of movements. It also fosters the control of varying types and combinations of muscle contractions (concentric, eccentric, isometric) that are used interchangeably during normal movement. This is a very different focus from the straight planes of motion and isolated movements commonly employed during PRE and isokinetic training. Intrinsic sensory input (somatosensory, vestibular, visual) is maximized during functional training.

Combining strength training protocols with task-specific practice is an important strategy to maximize transfer gains to functional skills. For example, strengthening of weak lower limb extensor muscles can be first achieved using an isokinetic machine that targets both eccentric and concentric contractions of the quadriceps. This training can effectively be combined with repetitive practice of functional activities also demanding similar extensor control (e.g., partial squats, sit-to-stand transfers, and stair climbing). The important consideration here is to match the strength training protocol to the requirements of the functional task in terms of ROM achieved and type, magnitude, and speed of contraction. Use of varied strength training activities and conditions also promotes development of flexibility of performance, an important goal for independence in daily life.

Muscular Endurance and Fatigue

Patients with deficits in motor function may demonstrate poor muscular endurance and fatigue. Fatigue is defined as the inability to contract muscle repeatedly over time. Thus, exercise cannot be sustained and exercise tolerance is reduced. The onset of fatigue is variable from patient to patient. Although many different factors may play a role, among the most important are the type and intensity of exercise. With the onset of fatigue, patients will demonstrate a decrement in force production progressing to total exhaustion (a ceiling effect). Fatigue can arise from neuromuscular disease affecting three primary sites: (1) the CNS (central fatigue), (2) the peripheral nerves or neuromuscular junction, or (3) the muscle itself. Examples of CNS conditions that can produce debilitating fatigue include MS, Guillain-Barré syndrome (GBS), chronic fatigue syndrome, and post-polio syndrome (PPS). The real danger of exercise training with these patients is the risk of acute exercise overdose producing exhaustion and possibly injury. Overtraining, defined as chronic overdose of exercise, is associated with both psychological and physiological decompensation, as well as musculoskeletal injury.¹⁰⁴ Overuse weakness is manifested as aching on exertion and a prolonged decrease in absolute strength and endurance as a result of excessive activity. This is often seen in patients with PPS. For example, following an exercise session the patient with PPS demonstrates prolonged weakness and fatigue that does not recover with rest. If exercise is exhaustive, the patient may be unable to get out of bed the next day or perform normal activities of daily living (ADL). Even a simple conditioning program should be carefully monitored and progressed slowly to avoid overexertion and injury.

Aerobic Training

The benefits of aerobic training for patients with disorders of motor function include the following:

• Improved cardiovascular and peripheral (muscular) endurance

• Decreased anxiety and depression

• Enhanced physical function

• Enhanced sense of well-being

A cardiovascular training program is determined based on the patient's level of deconditioning and specific symptoms. Aerobic exercises can include ergometry (two-limb or four-limb), recumbent stepper, therapeutic aquatics, and conventional weight-bearing activities such as walking. In general, moderate intensities of exercises are appropriate for most patients undergoing active rehabilitation (e.g., 40% to 70% of maximal oxygen consumption) whereas high intensities are contraindicated. For many patients, a frequency of 3 to 5 days per week with 20- to 30-minute sessions is often recommended (e.g., the patient with stroke or TBI). Alternatively, multiple 10-minute sessions can be used. Most patients will require a discontinuous protocol that carefully balances exercise with rest.¹⁰⁴ Clinical practice guidelines including exercise recommendations are available to assist the therapist in treating patients with chronic disabilities.^{115,116,117,118,119,120} ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities is particularly helpful for the rehabilitation therapist as it discusses exercise guidelines for a number of different disabilities (e.g., stroke, TBI, SCI, MS, PD, and so forth).¹⁰⁴

Effective management of patients with low endurance and fatigue includes the use of energy conservation techniques, activity pacing, lifestyle changes, regular rest periods during the day, and improved sleep through the use of relaxation techniques and medications. An activity log can be used to help the patient identify activities that are particularly exhausting and to document the effectiveness of rest. Unnecessary energy-consuming activities should be discontinued and essential activities restructured and paced to include regular rest periods throughout the day. Patients can monitor their level of general fatigue using the Borg Rating of Perceived Exertion (RPE) scale¹²¹ and should aim to keep their activities at an RPE level of "somewhat hard" (14 or lower using the 6–20 RPE scale). Ergonomic changes (e.g., seating and workstations) should be implemented to reduce energy cost of activities. Finally, stress management should be included in the educational program.¹¹⁸

Interventions to Improve Flexibility

Joint ROM and muscle flexibility must be adequate to allow for normal functional excursions of muscle and biomechanical alignment. Prolonged periods of disuse and immobility and motor dysfunction associated with neurological insult can lead to changes in muscle and joint function, postural alignment, and a host of indirect impairments. These include muscle tightness, atrophy, fibrosis, contracture, joint ankylosis, and postural deformity. Older adults demonstrate age-related changes affecting joint flexibility. These include increased viscosity of synovial fluid, stiffening of the joint capsule and ligaments, and calcification of articular cartilage.¹²²

Proactive intervention following neurological insult (e.g., stroke, TBI, SCI) is an important component of intervention. Patients with chronic and irreversible diseases (e.g., PD, MS, amyotrophic lateral sclerosis [ALS]) also need targeted intervention (tertiary prevention) to limit sequelae and degree of disability. Benefits include maintaining joint flexibility, tissue extensibility, physical ability, and function. Additional benefits include improved circulation and tissue nutrition to the limbs and pain inhibition.

Techniques include ROM exercises, passive stretching, and joint mobilization. The use of a preliminary therapeutic heat modality (e.g., hot pack) increases muscle temperature and elasticity and collagen extensibility. A warm-up period of exercise can also be used. For example, calisthenics or low-resistance cycling will gradually increase tissue temperatures and elasticity, thereby enhancing the safety of stretching. Cold modalities can be used to cool muscles and decrease muscle spasm and physiological splinting.

ROM Exercises

Range of motion is "the arc through which movement occurs at a joint or a series of joints."^{100, p. 690} ROM can be active (AROM), performed and controlled entirely by the voluntary muscular efforts of the patient, active-assisted (AAROM), requiring some degree of external assistance for voluntary efforts, or passive (PROM), performed solely by therapist or caregiver. The Guide to Physical Therapist Practice classifies the first two as therapeutic exercise whereas PROM is classified as manual therapy.¹⁰⁰ PROM is typically used when active movement is not possible (e.g., due to pain, paralysis, or unresponsiveness). AROM and AAROM have additional benefits of improving circulation, decreasing atrophy, and improving motor function. Progression should be to AROM exercises whenever possible because they are an important component of the home exercise program (HEP). ROM exercises are performed through the patient's full available range. The limb should be well supported with stable positioning of the patient to prevent joint trauma. The movements should be slow and within the patient's tolerance. Excess force and pain are contraindicated. This is especially important when working with the patient at risk for osteoporosis and heterotopic ossifications.

ROM exercises can be administered in anatomical planes of motion or in diagonal patterns of motion (PNF patterns). The latter may be more efficient because ROM can be administered throughout a limb, combining motions at more than one joint. ROM can also be achieved during functional training activities (e.g., shoulder ROM is achieved during weight shifting in quadruped or plantigrade positions). An added benefit may be the patient's lack of attention to joint motion during the activity with less protective splinting.

Passive Stretching

Stretching involves the application of manual or mechanical force to elongate (lengthen) structures that have adaptively shortened and are hypomobile.¹⁰⁰ The term static stretching refers to a method of stretching in which the muscle is slowly elongated to tolerance. The end position (greatest tolerated length) is held at least 20 to 30 seconds and the stretch is repeated four to five times, depending on the patient's tolerance. The use of slow, prolonged stretch alters neural activity by minimizing muscle spindle activation and reflex contraction of the muscle being stretched. Maintaining the position at maximal end range results in the firing of the Golgi tendon organs (GTOs) with resulting inhibition of the muscle being stretched through mechanisms of autogenic inhibition. The combined effects result in improved muscle elongation. Passive stretching also affects the muscle directly, resulting in viscoelastic changes affecting muscle extensibility. Low-load stretching results in less danger of soft tissue tearing, less muscle soreness, and decreased energy requirements.^122,123,124 Frequency of stretching (number of sessions per day or per week) varies according to underlying cause, the chronicity and severity of contracture, the patient's age and level of tissue integrity and healing, and medical management (e.g., use of corticosteroids).¹⁰⁵ Optimally, stretching is daily and balanced with adequate rest in between to minimize tissue soreness. The results of stretching (i.e., newly gained range) should be combined with active exercise. The adage "use it or lose it" holds true for maintaining the benefits of both ROM and stretching exercises. Patients and/or their families/caregivers should be taught stretching exercises (i.e., self-stretching) as part of the HEP to maintain carryover outside of the clinic setting.

Ballistic stretching, defined as the use of a high-load, short-duration, intermittent stretch, is generally contraindicated for the elderly, the chronically ill, or patients undergoing active rehabilitation with neuromuscular impairments.¹²⁵ The high-velocity, high-intensity movements are not easily controlled. In addition, activation of muscle stretch receptors (muscle spindle Ia endings) results in reflex contraction and limits muscle elongation. Also, in chronic contractures, connective tissue is more brittle and tears easily. Thus, it is associated with high rates of microtrauma and injury.¹⁰⁵

Low-load prolonged stretch (LLPS) (15 to 30 minutes) can be applied using mechanical pulleys and weights or specialized orthotic devices. Prolonged positioning on a tilt table with wedges and straps can be used effectively to improve LE range (e.g., hamstrings, gastroc-soleus muscles).^126,127 Prolonged stretch can also be applied to prevent or reduce contractures using serial casting (discussed later in this chapter).

Facilitated Stretching

Facilitated stretching refers to the use of neuromuscular inhibition techniques to relax (inhibit) and elongate muscles when used in conjunction with stretching. PNF-facilitated stretching techniques include hold-relax (HR) and contract-relax (CR). The limb is actively moved to the end of PROM (range-limited position). The patient is then instructed to perform a maximal isometric contraction of the restricted, shortened muscles (antagonist pattern). The contraction should be maintained for at least 5 to 8 seconds. This pre-stretch contraction results in muscle inhibition from activation of the GTO (autogenic inhibition). This is followed by voluntary relaxation. In HR, the therapist then passively moves the limb into the new limit of range. In CR, the patient actively moves the limb to the new limit of range in the pattern against resistance. The resisted isotonic contractions of the agonist muscles focuses on all muscles in the pattern with an emphasis on rotators and provides additional reciprocal inhibition effects (i.e., agonist contraction further inhibits the tight muscle via muscle spindle activity). These techniques were originally applied while using PNF patterns though some clinicians have adopted these techniques in patterns using anatomical planes of motion.^113,114 Research has demonstrated the effectiveness and superiority of facilitated stretching techniques over static stretching techniques, particularly when active contractions are used.^128,129,130 An additional benefit is that patients frequently report less discomfort with the application of facilitated stretching techniques as compared to other stretching methods. Because the inhibitory mechanisms affect primarily muscle and depend on voluntary contraction, these techniques are not effective with very weak or paralyzed muscles or range limitation associated with substantial connective tissue changes (chronic contracture).

Stretching and Positioning for the Patient with Spasticity

The patient with UMN syndrome typically exhibits spasticity (velocity-dependent hypertonia) and hyperactive deep tendon reflexes (DTRs). Functionally the patient demonstrates poor volitional control of movements and limitations in functional skills. The limbs are typically held in fixed, abnormal postures with antigravity muscles primarily affected. For example, the UE typically assumes an abnormal flexor posture whereas the LE assumes an abnormal extensor posture. If left untreated, spasticity can lead to the development of secondary impairments such as contracture, postural asymmetries, and deformity.

Stretching and positioning are important components of management of the patient with spasticity. Patient tolerance needs to be carefully assessed. Precise handling of a spastic limb is important. The therapist should use constant, firm manual contacts positioned over bony or nonspastic areas and avoid direct pressure on spastic muscles. The limb is moved out of the shortened spastic position into the lengthened range using slow, repeated rotations of the limb. The patient's limb can then be positioned and maintained in the newly gained range to provide prolonged stretching. For example, during treatment of the patient with stroke and a spastic UE, the therapist grasps the hand over the thumb and slowly moves the elbow out into full extension with the hand open. The hand is then placed palm down on the mat to the side of the patient in weight-bearing with the elbow extended, hand open, and wrist and fingers extended. Weight shifting forward/backward during sitting can then be used to maintain inhibition and range. Although time to maintain the stretch in order to reduce spasticity is unknown, one group of researchers found 10 minutes to be optimal.¹³¹

Serial Casts

Serial casts are recommended for patients who have or are at risk for contractures as a result of decreased PROM and/or spasticity. They have been shown to improve ROM, reduce contracture, and prevent deformity.^{132,133,134,135,136,137} The therapist first positions the limb into its fully lengthened end-range. A layer of thin foam and white cotton wrap is applied first, followed by the cast material (e.g., Softcast^™, reinforced Softcast, or bivalved fiberglass). Casts are typically changed every 7 to 10 days (serial application) and are used for 1 to 6 weeks. Poor casting techniques include lack of end-range positioning of the limb, loose-fitting cast, or insufficient padding. Faulty technique may result in a lack of improvement or even increased tone, skin breakdown (especially on bony prominences), decreased circulation, and peripheral edema. Highly agitated patients (e.g., the patient with TBI) may potentially injure themselves and demonstrate increased risk of skin breakdown and cast breakage. Patients with cognitive or communication impairments should be monitored closely because they will be unable to indicate pain or discomfort and potential skin breakdown (e.g., the patient with stroke and aphasia). Casting is contraindicated in patients with severe heterotropic ossification; skin surface not intact, such as open wounds, blisters, or abrasions; impaired circulation and marked edema; uncontrolled hypertension; autonomic storming (marked increase in sympathetic nervous system activity); unstable intracranial pressure; pathological inflammatory conditions, such as arthritis or gout; or in individuals at risk for compartment syndrome or nerve impingement. Application to individuals with long-standing contractures (longer than 6 to 12 months) is also contraindicated.¹³⁸

Adjustable orthoses have also been used to provide passive, prolonged stretch with the added benefits of easy removal for hygiene and observation. These devices use a rotating adjustable dial attached to metal rods and a flexible acrylic thermoplastic base.¹³⁹ The required adjustments are easier and less time consuming than fabricating an entirely new serial cast. Dynamic orthoses, primarily used on elbow or knee flexion contractures, use a spring-loaded or hydraulic mechanism to provide nearly constant pressure.

ROM for the Patient with Hypotonia

The patient with lower motor neuron (LMN) syndrome typically exhibits hypotonia (low tone) with weak or paralyzed muscles, joint instability, and deformity. Following neurological insult, tone varies relative to recovery stage. For example, the patient with a new or recent stroke or SCI will present with initial flaccidity during the stage of cerebral or spinal shock whereas the same patient later on demonstrates emerging spasticity. In using PROM exercises for the patient with hypotonia, the therapist needs to be cognizant of end-range joint instability and the risk of hyperextension injury. Supportive and protective devices may be necessary to prevent injury to limbs and postural asymmetry during functional training.

Interventions to Improve Postural Control and Balance

Postural control is the ability to control the body's position in space for stability and orientation. Postural orientation is the ability to maintain normal alignment relationships between the various body segments and between the body and environment. Static postural control (static balance control, stability) is the ability to maintain stability and orientation with the COM over the BOS with the body at rest. Dynamic postural control (dynamic balance control, controlled mobility) is the ability to maintain stability and orientation with the COM over the BOS while parts of the body are in motion (see Table 10.2).² An intervention program to improve postural control must be based on an accurate evaluation of data obtained during examination of deficits (see Chapter 5, Examination of Motor Function: Motor Control and Motor Learning).

Training activities can be used to improve the following:

• Postural alignment, body mechanics, and static postural control

• Dynamic postural control, including musculoskeletal responses necessary for control of movement and posture

• Adaptation of balance skills for varying task and environmental conditions

• Use of sensory monitoring for postural control

• Safety awareness and compensatory strategies for effective fall prevention

Increased understanding of the range and variability of postural strategies for balance negates any simplistic view of balance based on a developmental perspective of reflex control (i.e., righting and equilibrium reactions). Overall, the organization of postural control strategies must be viewed as flexible, not rigid, involving multiple body segments and postural strategies.^140,141,142 In that context, patterns will vary according to a number of different factors, including initial conditions, balance requirements and challenges, perturbation characteristics, learning, and intention.¹⁴³ The patient needs to practice steady state, anticipatory, and reactive balance control using activities that focus on both static and dynamic postural control. Functional activities selected should be based on an accurate evaluation of the patient's abilities and needs. The activities selected should include those required for ADL, as well as those required for social participation, recreation, and work, if appropriate. Sensory selection and organization should also be a part of a balance training program. Repetition and practice are essential factors in assisting CNS adaptation.

It is important to remember that some balance training activities may cause the patient distress initially. The patient will feel threatened when placed in situations where he or she is in jeopardy of falling. The therapist should ensure patient confidence by providing a clear explanation of the nature of the task, what the challenges to balance are, and the steps the therapist will take to prevent falls in terms that are easy to understand. The patient with instability can wear a gait belt or practice standing activities wearing an overhead safety harness. The therapist needs to stand close enough to the patient to guard safely but not so close as to interfere with the activity. For the very unstable patient, two spotters may be necessary. The environment can be used to assist in keeping the patient from falling. For example, standing exercises can be performed in the parallel bars, between two tables, near a wall or two walls (corner standing), or in a pool with the patient standing in waist-high or chest-high water. Support given early in training should be withdrawn as soon as possible to allow focus on active control.

An understanding of the foundational requirements of upright postures will direct the therapist in improving postural alignment and body mechanics. Sitting is a relatively stable posture with a moderately high COM and a moderate BOS that includes contact of the buttocks, thighs, and feet with the support surface. During normal sitting, weight is equally distributed over both buttocks with the pelvis in neutral position or tilted slightly anterior. The head and trunk are vertical, maintained in midline orientation. The line of gravity passes close to the joint axes of the spine. Muscles of the cervical, thoracic, and lumbar spine are active in maintaining upright postural control and core stability. BOS can be increased by using one or both hands for additional support.

Deficits in sitting can be broadly grouped into those involving alignment, weight-bearing, and extensor muscle weakness. Changes in normal alignment result in corresponding changes in other body segments. For example, a slumped sitting posture (dorsal kyphosis and forward head) is typically the result of sacral sitting with the pelvis tilted posteriorly. The therapist should instruct the patient in the correct sitting posture and demonstrate the position to provide an accurate reference of correctness. It is important to focus the patient's attention on key task elements and improve overall sensory awareness of the correct sitting posture and position in space.

Standing is a less stable posture with a high COM and a small BOS that includes contact of the feet with the support surface. During normal quiet standing, there is minimal body sway with ankle muscle activity (dorsiflexors/plantarflexors, invertors/evertors) activated to counteract body sway. Weight is equally distributed over both feet. The line of gravity falls close to most joint axes: slightly anterior to the ankle and knee joints; slightly posterior to the hip joint; posterior to the cervical and lumbar vertebrae; and anterior to the thoracic vertebrae and atlanto-occipital joint. Natural spinal curves are present but somewhat flattened in upright stance depending on the level of postural tone (e.g., lumbar and cervical lordosis, thoracic kyphosis). The pelvis is in neutral position, with no anterior or posterior tilt. Normal alignment minimizes the need for muscle activity during erect stance.

Impairments in standing can also be broadly grouped into those involving alignment, weight-bearing, and specific muscle weakness. Faulty postures such as forward head and kyphosis or lordosis, excessive hip and knee flexion, or pelvic asymmetries can result in decreased postural stability. Inaccurate kinesthetic awareness of true vertical and pain can affect postural position and significantly impair balance. Patients are typically unable to self-correct faulty postures. Physical therapy interventions should focus first on improving specific Musculoskeletal impairments (e.g., limited ROM, weakness). For example, active exercises to improve standing can include standing heel-cord stretches, heel-rises, toe-offs, partial wall squats, chair-rises, side-kicks, back-kicks, and marching in place using touch-down support of the hands as needed. These are sometimes referred to as the "kitchen sink exercises." Postural reeducation begins with demonstration of the correct posture. Verbal cues should focus on control of essential postural elements, that is, stable (neutral) pelvis, axial extension (e.g., "stand tall"), and normal alignment (e.g., head erect, shoulders back, weight evenly distributed under both feet). Patients can benefit from tactile cues during initial practice (manual or surface related). For example, patients can stand with the back positioned against a wall or patients with a lateral lean (e.g., patients with pusher syndrome following a stroke) can sit with their side positioned against the seated therapist or a wall. Corner standing or standing between two treatment tables can be effective for patients with significant COM distortion. Mirrors can provide important visual cues regarding vertical position. For example, the patient wears a shirt with a taped vertical line on it and is asked to match it to a taped vertical line on a mirror.² The taped lines provide useful visual feedback for achieving vertical. Mirrors are generally contraindicated for the patient with visuospatial perceptual deficits. Application of correct postures to real-life functional situations is important to ensure carryover and lasting change. Instruction in proper body mechanics should include a discussion of the activities of standing up, lifting, reaching, carrying, and arising from the floor.

Interventions to Improve Static Postural Control

Patients who demonstrate impairments in static postural control (stability) are unable to maintain or hold a steady position for a number of reasons, including decreased strength, tonal imbalances (hypotonia, spasticity, dystonia), impaired voluntary control and hypermobility (ataxia, athetosis), sensory hypersensitivity (tactile-avoidance reactions), or increased anxiety or arousal (high sympathetic "fight or flight" state). Instability is associated with excessive postural sway, wide BOS, low- or high-guard hand position, holding onto an object in the environment (handhold), and loss of balance (falls).

The therapist can select any of a number of weight-bearing (antigravity) postures to develop stability control. Typical training postures include sitting and standing (in modified plantigrade and full standing). Postures are selected on the basis of (1) patient safety and level of control and (2) importance in terms of functional tasks. The therapist varies the level of activities, selecting activities that both allow success and provide an appropriate challenge for the patient.

The therapist should focus on obtaining symmetrical, balanced weight-bearing. Patients may present with specific directional instabilities, such as weight-bearing more on one side than the other. For example, after a stroke the patient typically keeps weight centered toward the less affected side. Practice should focus on redirecting the patient into a centered position by moving toward the more affected side, both in sitting and standing positions. The patient is instructed to "hold steady" while sitting or standing tall and maintaining a visual focus on a forward target. Progression is to holding for longer and longer durations. Techniques that can be used to enhance stabilizing muscle contractions include quick stretch, tapping, resistance, approximation, manual contacts, and verbal cues. For the patient unable to actively stabilize the body, the therapist can begin with resisted isometric contractions of antagonist postural muscle groups (e.g., PNF technique of rhythmic stabilization). For example, the patient with severe instability following TBI who is unable to sit independently may need to begin practice holding a neutral trunk position first in a supported sitting position. The therapist can then progress the patient to active sitting and to postures that demand increasing amounts of upright (antigravity) postural control (standing). If an imbalance exists, the stabilizing activity can be coupled with a strengthening activity for the weak muscles. As the trunk becomes more stable, the patient is expected to assume active control in stabilizing in the posture. For a patient with hyperkinetic disorders (e.g., ataxia, athetosis), the PNF technique of stabilizing reversals is appropriate. Alternating isotonic contractions are used, allowing only very small-range movements. Progression is toward decreasing range (decrements of range) until finally the patient is asked to stabilize and hold steady against resistance in the posture.

Additional strategies to improve stability include the use of elastic resistance bands to enhance proprioceptive loading and contraction of stabilizing muscles. For example, in the prone-on-elbows position or supported sitting with elbows weight-bearing on a table, a band can be placed around both forearms. The patient is instructed to push out against the band and maintain the forearms apart against the resistance. This selectively loads and facilitates contraction of the shoulder stabilizers (abductors and rotator cuff muscles). In kneeling or standing, elastic resistance bands can be placed around the lower thighs. The patient is instructed to maintain the thighs apart against the resistance of the bands. This selectively loads and facilitates contraction of the hip stabilizers (abductors, extensors), improving stability control at the hips.

As static postural control improves, the therapist can progress the patient to stabilizing on a moveable surface (e.g., sitting on a therapy ball). Gentle bouncing on the therapy ball provides joint approximation through the vertebral joints, facilitating extensors and an upright posture. For patients requiring an additional challenge, sitting control can be practiced on other compliant surfaces (e.g., foam, wobble board, or Dynadisc^TM) placed on a platform mat. The therapist can also increase task difficulty by reducing the BOS (feet apart to feet together to sitting with single foot support [legs crossed]).

Aquatic therapy can also be used to enhance proprioceptive loading. The water provides a degree of unweighting and resistance to movement. This can be quite effective in reducing hyperkinetic movements and enhancing postural stability. For example, a patient recovering from TBI who demonstrates significant ataxia may be able to sit or stand in the pool with minimal assistance whereas these same activities outside the pool are not possible.

To improve standing control, the patient is directed to practice neuromuscular fixed-support strategies that occur at the ankle and hip joints.¹⁴² Feedback is provided to assist the patient in recruiting the correct pattern. To recruit ankle strategies, the patient practices small-range, slow-velocity shifts progressing to holding steady. Attention is directed to the action of ankle muscles to maintain the body (COM) over the fixed feet (BOS). Standing on a wobble board (moveable surface) or foam roller with the flat side down progressing to flat side up are effective activities to increase the challenge in recruiting ankle strategies. The patient is also directed to practice tasks that normally recruit hip strategies. These are recruited with larger shifts in the COM that approach the LOS and/or faster body sway motions that are characterized by early activation of proximal hip and trunk muscles. Hip flexion and extension responses are generated during anterior– posterior displacements. Lateral hip motions are generated during lateral displacements. Patients can be instructed to move their upper body forward and backward while standing on a foam roller progressing to steady holding. More challenging activities include standing with feet together, tandem standing, and single-limb stance. Tandem standing on a foam roller is an effect way to recruit lateral hip strategies.⁹⁷

Anticipatory postural adjustments should also be practiced, because predictive control must be operational for functional balance. The patient is provided with advance information about the upcoming demands of the task. For example, "I want you to catch this 5-pound weighted ball while maintaining your sitting (or standing) position." The prior knowledge serves as an important source of information in initiating the correct postural pattern. To promote generalizability, practice should occur in a variety of environments. For example, training can progress from a closed or fixed environment (e.g., quiet room) to a more variable environment (e.g., busy physical therapy gym). Training must ultimately be context specific to real-life settings of home or community to ensure functional carryover (e.g., standing at the bathroom sink or kitchen counter).

Interventions to Improve Dynamic Postural Control

Patients who demonstrate impairments in dynamic, anticipatory postural control are unable to control postural stability and orientation while moving segments of the body. A number of impairments may be contributing factors, including tonal imbalances (spasticity, rigidity, hypotonia), ROM restrictions, impaired voluntary control and hypermobility (ataxia, athetosis), impaired reciprocal actions of the antagonists (cerebellar dysfunction), or impaired proximal stabilization. Clinically, the patient demonstrates difficulty weight shifting from side-to-side, forward-backward, or diagonally. Difficulties are also apparent in moving one or more limbs while maintaining a posture (sometimes referred to as static-dynamic control). For example, one limb is moving (UE reaching or LE stepping) while the patient maintains the sitting or standing posture. In the quadruped position, the patient lifts one arm or leg or opposite arm and leg. These added movements increase the demand for stabilization control because the overall BOS is reduced and the COM must shift over the remaining support segments before the dynamic limb movement can be successful (e.g., stepping).

The therapist can select any of a number of weight-bearing (antigravity) postures to develop dynamic postural control (see Table 10.7). Postures typically selected include sitting and standing. Practice begins with movements emphasizing smooth directional changes that engage antagonist actions (e.g., weight shifts). Limits of stability should be explored. For example, in sitting or standing, the patient is instructed to slowly sway in all directions (forward-backward, side-to-side) as far as possible while still maintaining the position. The outer point at which the COM is still maintained within the BOS is termed the LOS. Loss of balance occurs when the LOS has been exceeded, for example, when the COM extends beyond the BOS. Practice of volitional body sway is important to assist the patient in developing accurate perceptual awareness of stability limits, an important component of an overall CNS internal model of postural control. Because LOS changes with different tasks, a variety of functional activities should be practiced in different environmental settings. As control improves, the movements are gradually expanded through an increasing range (increments of range). For the patient who has difficulty initiating or controlling movements, the movements can be facilitated using quick stretch, tapping, light tracking resistance, manual contacts, and dynamic verbal commands. Although active movement is the goal, guided assistance may be required for some patients during initial movement attempts.

Specific task-oriented training incorporates both reaching and stepping activities. Functionally important and motivating activities should be selected. For example, the patient practices reaching for a cup (requiring shoulder stabilization with elbow extension and wrist stabilization) while maintaining a stable sitting position. Or a bilateral UE task (e.g., folding and stacking towels) can be used while maintaining a stable standing position.

PNF extremity patterns can be used to introduce a dynamic challenge to postural stability and promote movement in synergistic patterns. For example, in sitting the patient is asked to move the UEs using a chop/reverse chop pattern in sitting. In addition to the extremity movement, the pattern incorporates diagonal and rotational movement of the trunk along with a weight shift. The patient's full attention is focused on performing the pattern and not on the stabilizing postural components. This ability to redirect cognitive attention is an important measure of developing postural control because intact postural control functions largely on an automatic and unconscious level. Movements can be active or resisted (e.g., PNF techniques of dynamic reversals [slow reversals]).⁹⁷

Therapy ball activities are effective in developing dynamic stability control in sitting. For example, the patient sits on a ball and gently moves the ball side-to-side, forward-backward, or in a combination (pelvic clock motions). Or the patient sits on the ball while performing voluntary movements of the arms or legs (e.g., alternate leg or arm raises). Progression is from unilateral to bilateral and finally to reciprocal limb movements (e.g., Mexican hat dance). Voluntary trunk motions can be practiced while sitting on the ball (e.g., head and trunk rotation with arms held out to the side). Resistance can be introduced by using elastic resistance bands, a weighted ball, or weight cuffs on the ankles or wrists. Difficulty can be increased by adding a second task (dual task training) such as catching and throwing a ball, batting a balloon, or kicking a ball. A secondary cognitive task can also be introduced (e.g., spelling forward or backward, remembering a list, counting backward by 3's).²

To improve standing control, the patient is directed to practice neuromuscular stepping strategies.¹⁴² Stepping strategies can be evoked with perturbations that provide the COM displacement. Stepping movements are accompanied by early activation of hip abductors and ankle co-contraction for medial-lateral stability during static single-limb support.¹⁴⁴ Maki and McIlroy¹⁴⁵ investigated the role of limb movements in maintaining upright stance, specifically compensatory stepping and grasping movements of the upper limbs, which they termed change-in-support strategies (as opposed to the fixed-support strategies at the ankle and hip). These investigators found that both stepping and arm movements were common reactions to loss of balance. Moreover, they were initiated well before the COM reached the LOS, contradicting the traditional view that they are strategies of last resort. They also found that stepping may actually be a preferred strategy to using a hip strategy. The direction and magnitude of change-in-support strategies were found to vary according to the magnitude and direction of the perturbation. For example, stepping may occur forward or backward in response to anterior or posterior displacements. Lateral displacements typically resulted in cross-stepping pattern, seen in 87% of lateral stepping responses, as opposed to straight side-stepping. Lateral destabilization with its increased demands for lateral weight transfer is particularly problematic for a large portion of older adults who experience falls. Arm reactions in response to whole-body instability were also found to be prevalent with activation of shoulder muscles occurring in 85% of destabilizing trials.

Training in standing should include practice of a variety of voluntary stepping movements (e.g., marching in place; anterior, posterior, lateral, or crossed side steps). Steps can start out small and gradually increase to mini-lunges or full lunges. Stepping can also be progressed from tandem stepping (e.g., forward tandem to backward tandem steps) to crossed stepping (e.g., stepping forward and across to backward and across). Upper trunk rotation and arm swing can be combined with these cross-stepping movements. Elastic resistance bands positioned around the pelvis can be used to improve the strength of stepping responses.⁹⁷ Research evidence demonstrates the effectiveness of training in improving balance control.^{146,147,148,149,150,151,152}

Interventions to Improve Reactive Balance Control

Patients with deficits in motor function and balance are also typically unable to respond effectively to external perturbations. The therapist can utilize gentle manual pulls or pushes applied to the shoulders or hips, or moving platforms, to provide perturbations. Small perturbations can be used to activate strategies designed to maintain position (e.g., ankle or hip strategies) whereas larger perturbations can be used activate stepping strategies. The therapist should vary inputs so as to not be predicable in terms of the response activated (i.e., direction, type, and speed of response). An elastic band around the hips can also be used to promote stepping strategies. The therapist maintains resistance of band against the hips and then suddenly releases the resistance, requiring the patient to take a step. Patient safety and protection against falls should be maintained during all perturbation training. Research evidence demonstrates the effectiveness of training in improving reactive balance control.^149,152 Tai Chi training has also been shown to improve balance control and stepping strategies.^153,154,155

Interventions to Improve Sensory Selection and Utilization for Balance

An important focus of balance training is utilization and integration of appropriate sensory systems. Normally three sources of inputs are utilized to maintain balance: somatosensory inputs (proprioceptive and tactile inputs from the feet and ankles), visual inputs, and vestibular inputs. Careful examination can identify the patient's use of inputs to maintain balance (e.g., Clinical Test for Sensory Interaction and Balance [CTSIB]; see Chapter 5, Examination of Motor Function: Motor Control and Motor Learning, for a discussion of this test). Training is directed to using varying sensory conditions to challenge the patient. For example, patients who demonstrate a high degree of dependence on vision can practice balance tasks with absent visual cues (e.g., eyes closed or blindfolded), with reduced visual cues (e.g., low light), or with inaccurate vision (e.g., petroleum-coated lenses on a pair of eyeglasses). Altering the visual inputs allows the patient to shift focus and reliance to other sensory inputs, in this case to intact somatosensory and vestibular inputs. Patients can practice varying somatosensory inputs by standing and walking on different surfaces, from flat surfaces (floor) to compliant surfaces (low to high carpet pile), to dense foam. A patient who is barefoot or wearing thin-soled shoes is better able to attend to sensation from the feet than if wearing thick-soled shoes. Challenges to the vestibular system can be introduced by reducing both visual and somatosensory inputs through sensory conflict situations. For example, the patient practices standing on dense foam with the eyes closed. The patient can also be directed to walk on foam with eyes closed, a condition that requires maximum use of vestibular inputs. Patients should also practice varying environmental influences such as walking outside, progressing from relatively smooth terrain (sidewalks) to uneven terrain to moving surfaces (escalator, elevator). Practice can also include standing or walking in bright or full lighting to reduced lighting. Research evidence demonstrates the effectiveness of altering sensory contexts in improving sensory selection and organization for balance.^{156,157,158,159,160}

Patients with significant sensory loss will require assistance in shifting toward the intact systems to monitor and adjust balance using compensatory training strategies. For example, the patient with LE proprioceptive losses (e.g., diabetic neuropathy) will need to learn to shift focus to the visual system for functional mobility and balance. The patient with bilateral amputations learns to rely heavily on visual inputs for control in standing and walking. If deficits exist in more than one of the major sensory systems, compensatory shifts are generally inadequate and balance deficits will be pronounced. Thus, the patient with diabetic neuropathy and retinopathy will be at high risk for loss of balance and falls. Compensatory training with an assistive device is indicated. Other patients must be encouraged to ignore distorted information (e.g., impaired proprioception accompanying stroke) in favor of more accurate sensory information (e.g., vision). Patients with low vision should practice balance activities while wearing their eyeglasses. The exception to this is when patients wear bifocal glasses, which should not be worn during balance training. The lower lens (designed for reading) can distort vision when looking down and interfere with depth perception (e.g., stair climbing).

Interventions Using Augmented Feedback

Augmented feedback can be used to during balance training (e.g., biofeedback cane with auditory signals, limb load monitor, posturography). Force-platform devices are used to measure forces and provide center of pressure (COP) biofeedback (posturography feedback). COP displacement is associated with movement of the COM or postural sway. Although COP excursion always exceeds COM sway, this relationship is close during ankle motions (ankle strategies) when the body moves like a pendulum over the feet. However, when a hip strategy is used (upper body motion focused at the hips), the COP:COM relationship becomes distorted and does not accurately reflect sway.¹⁶¹ A computer analyzes the data and provides relevant biofeedback concerning sway path and COP position on a visual monitor. Some units also provide auditory feedback.

Posturography training can be used to shape sway movements to enhance symmetry and steadiness. The patient can be instructed to increase or decrease sway movements or move the COP cursor on the computer screen to achieve a designated range or to match a designated target. It is an effective training mode for patients who demonstrate problems in force generation. For example, the patient with decreased force generation (hypometria) as typically demonstrated by individuals with PD is directed toward achieving larger and faster sway movements during posturography training. The patient with too much force (hypermetria), as typically demonstrated by the individual with cerebellar ataxia, is directed toward decreasing sway movements progressing to holding a stable, centered posture.¹⁶² Research evidence demonstrates the effectiveness of platform training in improving symmetrical weight distribution.^{163,164,165,166}

It is important to remember that although balance retraining using posturography biofeedback does improve symmetrical standing, it does not automatically transfer to balance skills during functional skills such as gait. Winstein et al¹⁶³ found that a reduction in standing balance asymmetry did not result in a concomitant reduction in asymmetrical limb movement patterns associated with hemiparetic locomotion. Given the specificity of training principle, this is not a surprising finding that platform training did not transfer to improved locomotion. Finally, a set of bathroom scales or limb load monitors can provide a low-tech, low-cost form of biofeedback weight information to assist patients in achieving symmetrical weight-bearing.

Strategies to Improve Safety and Reduce Fall Risk

Prevention of falls in the elderly and for the patient with balance deficiency is an important goal of therapy. Patient education and lifestyle counseling can help the patient recognize potentially dangerous situations and reduce the likelihood of falls. For example, high-risk activities likely to result in falls include turning, sit-to-stand transfers, reaching and bending over, and stair climbing. Patients should also be discouraged from clearly hazardous activities such as climbing on step stools, ladders, and chairs, or walking on slippery or icy surfaces. The education plan should stress the harmful effects of a sedentary lifestyle. Patients should be encouraged to maintain an active lifestyle, including a program of regular exercise and walking. Medications should be reviewed and those medications linked to increased risk of falls (e.g., medications that result in postural hypotension) should be addressed. A consultation with the physician for medication review may be indicated.

Compensatory training strategies can be utilized to prevent falls if normal strategies are lacking. The patient should be instructed in how to maintain an adequate BOS at all times. For example, the patient should widen BOS when turning or sitting down. If a force is expected, the patient should be instructed to widen the BOS in the direction of the expected force (e.g., leaning into the wind). If greater stability is needed, instruction should be provided in how to lower the COM (e.g., crouching down to reduce the likelihood of a fall). Greater stability can also be achieved if friction is increased between the body and the support surface. The patient should therefore be instructed to wear shoes with flat rubber soles for better gripping (e.g., athletic shoes). Assistive devices should be used improve balance when necessary. Consideration should always be given to using the least restrictive device while at the same time ensuring safety. Light touchdown support using a vertical or slant cane (used by individuals who are blind) has been shown to improve balance.¹⁶⁷ A fall prevention program must also address environmental factors that contribute to falls. Recommendations for reducing falls in the home environment are presented in Box 10.6.

Interventions to Improve Coordination and Agility

Coordination is the ability to execute smooth, accurate, and controlled movements. Agility is the ability to perform coordinated movements combined with upright standing balance. Ataxia is defined as uncoordinated movement that manifests when voluntary movements are attempted, influencing gait, posture, and patterns of movement. The principal causes of ataxia are cerebellar disease or lesions (e.g., cerebellar atrophy, tumor, MS, TBI, stroke, Friedreich's ataxia, chronic alcoholism). Patients with ataxia typically demonstrate impaired synergistic actions with decomposition of movement (dyssynergia), impaired ability to judge the distance or range of movement (dysmetria), and impaired ability to perform rapid alternating movements (dysdiadochokinesia), along with intention tremor and disturbances of posture and gait. Typical standing postural abnormalities include an exaggerated lumbar lordosis, anterior pelvic tilt, flexion at the hips, hyperextension at the knees, and weight placed more on the heels. Patients with ataxia also typically demonstrate mild decreases in strength (asthenia) and tone (hypotonia) and hypermobility. Postural instability in the patient with ataxia is associated with excessive postural sway, wide BOS, high guard hand position, handhold, and frequent loss of balance (falls). Motor learning is also typically slowed, given the inability of the cerebellum to timely and correctly utilize feedback to modulate movement. The reader is referred to Chapter 6, Examination of Coordination and Balance, for additional information.

Training activities can be used to accomplish the following:

• Improve postural stability and balance

• Improve accuracy of limb movements

• Improve function

• Improve safety awareness and compensatory strategies for effective movement control and fall prevention

Interventions to improve postural stability and balance have been previously discussed. Patients with ataxia generally benefit from the use of light resistance to slow limb and trunk movements, temporarily reducing dysmetria and tremor. This can include use of weight cuffs (ankle, wrist), elastic bands, weighted trunk vest, weighted walkers and canes, and water resistance (pool activities). PNF patterns are an appropriate focus of treatment because of the required synergistic actions of muscles. PNF resistive techniques of rhythmic stabilization, dynamic reversals or dynamic-reversal-hold, and resisted progression are the techniques of choice. The key issue for the therapist is to provide enough resistance to enhance proprioceptive loading and movement without producing debilitating fatigue. During training, movements should be kept slow and controlled; fast movements are considerably more problematic in terms of learning and performance. Complex gross motor skills that engage and move large segments of the body (e.g., sit-to-stand, transfers, locomotion) are particularly difficult for patients with ataxia. Fine motor skills that engage the small muscles of the hand (e.g., feeding, writing, ADL) are also difficult and can lead to functional dependence (e.g., inability to feed or dress). Augmented feedback in the form of biofeedback, rhythmic auditory stimulation (metronome, music), can be used to help modulate speed and focus attention. Devices that promote reciprocal movements and timing (e.g., cycle ergonometer, motorized treadmill with an overhead harness) can also be effective. To enhance motor learning, the patient should practice in a low-stimuli environment. Variable practice should only be attempted as skill development becomes apparent and at a much more gradual rate of progression. A distributed practice schedule is important because patients with ataxia can demonstrate low endurance and increased fatigue. For the patient with significant ataxia and postural instability, hands-on support and guidance may be necessary. Aids for mobility (assistive devices) may be necessary to ensure safety and prevent falls. There is limited research evidence demonstrating the effectiveness of physical therapy in improving ataxia.^{168,169,170,171}

Interventions to Improve Gait and Locomotion

Most patients with impaired motor function exhibit deficits in gait and locomotion, which is a complex, higher-level motor skill. Substantial rehabilitation efforts are directed toward improving gait and locomotion to restore or improve a patient's functional mobility and independence. Walking is frequently the number one goal of patients who "want to walk" above all other considerations. Ability to ambulate or use a wheelchair independently is often a significant factor in determining discharge placements (e.g., return to home or extended care facility). To establish a realistic POC, the physical therapist must accurately analyze the patient's gait and locomotor ability. Comprehensive gait analysis is discussed in Chapter 7, Examination of Gait. The functional demands of the patient's home, community, or work environment must be considered in planning successful interventions and in predicting a patient's future status. Chapter 11, Locomotor Training, provides a comprehensive discussion of training. Wheelchair training is discussed in Chapter 20, Traumatic Spinal Cord Injury.

Relaxation Training

Patients with impaired motor function typically experience a great deal of stress resulting from loss of motor control, pain, inability to perform functional tasks previously performed with ease, and loss of control in life decisions. Sympathetic nervous system responses (fight or flight) are typically heightened. (See Chapter 5, Examination of Motor Function: Motor Control and Motor Learning, for a discussion of sympathetic and parasympathetic responses.) A goal of therapy is to promote stress reduction and relaxation. A relaxation response is associated with engagement of parasympathetic responses along with an increase in alpha brain waves. Positive benefits of relaxation training include the following:

• Muscle relaxation

• Lowered blood pressure

• Reduced ischemic pain

• Enhanced awareness of emotional state and memory

• Increased energy level

• Increased sense of control

Two elements are the important components in producing the relaxation response as described by Benson:¹⁷² quiet deep breathing and attention on a single focus (thought, word, or object). The patient initially practices while lying down and later can shift to practicing while sitting or standing comfortably. The patient is directed to breathe deeply with the diaphragm moving downward as air is drawn into the lungs. The patient inhales slowly, holds the breath for a few seconds, and then slowly exhales. The patient is also directed to concentrate on a specific focus, while disengaging from all other thoughts and distractions. Relaxation training can be used throughout the day as needed (e.g., 4- to 5-minute sessions) and can be performed individually or in small groups (e.g., before a group exercise class). Use of imagery is another technique that can redirect the patient's focus from the frustrating aspects of performance or pain. With eyes closed, the patient is asked imagine a place or experience that is deeply relaxing (e.g., a sunset at the beach) and to maintain focus on that special experience. The environment should be relaxing and quiet, with softened lights.¹⁷³ Jacobson¹⁷⁴ originally described progressive relaxation exercises to promote relaxation. While resting comfortably, the patient is directed to alternately clench and release various different muscle groups, moving progressively throughout the body. This technique may not be the technique of choice for patients who experience high levels of muscle tension or muscle weakness.

Augmented Interventions

Augmented interventions are appropriate for patients who demonstrate insufficient recovery and lack voluntary movement control (e.g., inability to initiate or sustain movement). An intensive hands-on approach (e.g., neurodevelopmental treatment) and neuromuscular/sensory stimulation can be used to "jumpstart" recovery and promote early movement. Biofeedback and electrical stimulation are also important adjuncts. Augmented interventions are contraindicated in patients with sufficient active movement control. The focus of rehabilitation for these patients should be active exercise and task-oriented training (see Tables 10.8 and 10.9).

Key decisions regarding the use of augmented interventions include the following:

• What movements might benefit from augmented intervention?

• What type of stimulation or modality should be used and how much?

• When should the stimulation/modality be withdrawn?

• How can it used to enhance active, task-oriented practice?

Continued use of augmented interventions long after they are needed can result in the patient becoming dependent. For example, a therapist who continually manually assists a patient's movements hears the patient remark to an aide that he or she is not helping correctly. It has to be done the way "my therapist" does it (i.e., "my therapist" syndrome). This patient is demonstrating an overreliance on the therapist for movement assistance. Augmented interventions can help the patient bridge the gap between absent or severely disordered movements and active movements. Once the patient develops independent voluntary control of movement, these treatment approaches are counterproductive.

Neurodevelopmental Treatment

Neurodevelopmental treatment (NDT) is an approach developed in the late 1940s through 1960s by Dr. Karel Bobath, an English physician, and Berta Bobath, a physiotherapist.^175,176 Their work focused on patients with neurological dysfunction (cerebral palsy and stroke). The essential problems of these patient groups were identified as a release of abnormal tone (spasticity) and abnormal postural reflexes (primitive spinal cord and brainstem reflexes) from higher-center CNS control with resulting loss of the normal postural reflex mechanism (righting, equilibrium, protective extension reactions) and normal movements. The therapist's primary focus in treatment was on specialized handling so that spastic and reflex patterns were inhibited and normal movements promoted. The rationale for this approach (hierarchical theory with top-down control) has been largely refuted by more recent studies on the nervous system.^177,178 Current NDT has realigned itself with newer theories of motor control (systems theory and a distributed model of CNS control). Many different factors are recognized as contributing to loss of motor function in patients with neurological dysfunction, including the full spectrum of sensory and motor deficits (weakness, limited ROM, impaired tone and coordination). Emphasis is on the use of both feedback and feedforward mechanisms to support postural control. Postural control is viewed as the foundation for all skill learning. Normal development in children and normal movement patterns in all patients are stressed. The patient learns to control posture and movement through a sequence of progressively more challenging postures and activities. NDT uses physical handling techniques and key points of control (e.g., shoulders, pelvis, hands, and feet) directed at supporting body segments and assisting the patient in achieving active control. Sensory stimulation (facilitation and inhibition via primarily proprioceptive and tactile inputs) is used as needed during treatment. Postural alignment and stability are facilitated while excessive tone and abnormal movements are inhibited. For example, in the patient with stroke, abnormal obligatory synergy movements are restricted while out-of-synergy movements are facilitated. Activities are selected that are functionally relevant and varied in terms of difficulty and environmental context. Compensatory training strategies (use of the less involved segments) are avoided. Carryover is promoted through a strong emphasis on patient, family, and caregiver education. NDT is taught today in recognized training courses.¹⁷⁹ Recent literature on the effectiveness of the Bobath approach to stroke rehabilitation has not revealed any superiority of this approach over other approaches. However, serious methodological shortcomings of the studies reviewed exist, emphasizing the need for further high-quality trials.^180,181,182

Neuromuscular Facilitation

The term neuromuscular facilitation refers to the facilitation, activation, or inhibition of muscle contraction and motor responses The term facilitation refers to the enhanced capacity to initiate a movement response through increased neuronal activity and altered synaptic potential. An applied stimulus may lower the synaptic threshold of the alpha motor neuron but may not be sufficient to produce an observable movement response. Activation, on the other hand, refers to the actual production of a movement response and implies reaching a critical threshold level for neuronal firing. Inhibition refers to the decreased capacity to initiate a movement response through altered synaptic potential. The synaptic threshold is raised, making it more difficult for the neuron to fire and produce movement. The combination of spinal and supraspinal inputs acting on the alpha motor neuron (final common pathway) will determine whether a muscle response is facilitated, activated, or inhibited. Table 10.8 lists commonly used neuromuscular facilitation techniques.

Several general guidelines are important to consider. First, facilitative techniques can be additive. For example, several inputs applied simultaneously, such as quick stretch, resistance, and verbal cues, are commonly combined during practice of a PNF pattern. These stimuli collectively can produce the desired motor response, whereas use of a single stimulus may not. This demonstrates the property of spatial summation within the CNS. Repeated stimulation (e.g., tapping) may also produce the desired motor response owing to temporal summation within the CNS, whereas a single stimulus does not. Thus, repeated stretch is used to ensure that the patient with a weak muscle is able to move from the lengthened to the shortened range. Sensory receptors vary in their adaptation over time. Generally, they can be divided into two categories, slow- and fast-adapting receptors. In treatment, fast-adapting, phasic receptors such as touch receptors and phasic Ia muscle spindle endings are generally effective in initiating and shaping dynamic movements, whereas slow-adapting, tonic receptors such as joint receptors, GTOs, and static II muscle spindle endings are effective in monitoring and regulating postural responses. The response to stimulation or inhibition is unique to each patient and dependent on a number of different factors, including level of intactness of the CNS, arousal, and the specific level of activity of the motor neurons in question. For example, a patient who is depressed and hypoactive may require a larger amount of stimulation to achieve the desired response. Stimulation is generally contraindicated for the patient with hyperactivity and high arousal. For this patient, inhibition/relaxation techniques are indicated. The intensity, duration, and frequency of simulation need to be adjusted to meet individual patient needs. Unpredicted responses can result from inappropriate application of techniques. For example, stretch applied to a spastic muscle may increase spasticity and negatively affect voluntary movement. Facilitation techniques are not appropriate for patients who demonstrate adequate voluntary control. They should be viewed primarily as a temporary bridge to voluntary movement control.

Sensory Stimulation Techniques

The term sensory stimulation refers to the structured presentation of stimuli to (1) improve attention and arousal levels and (2) enhance sensory selection and discrimination. Effects are immediate and specific to the current state of the nervous system. Activity practice using inherent or naturally occurring sensory inputs is necessary for meaningful and lasting functional change to occur. Patients with deficits in sensory function exhibit variable sensory and perceptual impairments. For example, decreased sensitivity may be evident in some older adults and in some patients with neurological conditions such as stroke or TBI. Table 10.9 lists commonly used sensory stimulation techniques.

Several general guidelines are important in using sensory stimulation. Use of appropriate intensities is important to ensure that desired responses are obtained. Excess stimulation can produce unwanted responses, including generalized arousal and sympathetic fight or flight reactions. Sensory receptors adapt over time. Certain body segments such as the face, palms of the hands, and soles of the feet demonstrate both high concentrations of tactile receptors and increased representation in the sensory cortex. These areas are highly responsive to stimulation and are closely linked to both protective and exploratory functions.

Alterations in tactile, proprioceptive, visual, or vestibular systems can affect a patient's ability to move and learn new activities. Deafferentation in animals and in humans is associated with nonuse of a limb, although gross movements are possible under forced situations. Motor learning of new movements is impaired. The therapist should maintain focus on forced training of sensory-deficient limbs even though the patient may have little interest in moving the limb. The movements obtained should not be expected to be normal because significant deficits have been noted in fine motor control in deafferentated limbs.

Sensory stimulation and retraining have been used to improve sensory function in patients with stroke-related impairments.^{183,184,185,186} Interventions include sensory reeducation, tactile kinesthetic guiding, repetitive sensory practice, and desensitization. The patient is repeatedly exposed to sensory experiences and practices sensory identification tasks (e.g., numbers, letters drawn on the hand or arm), discrimination tasks (e.g., detecting size, weight, and texture of objects placed in the hand), or passive-assisted drawing using a pencil. Intermittent pneumatic compression with an automatic intermittent pattern and electrical stimulation has also been used. The tasks were alternated between the more affected and less affected hands. Outcome measures included testing of sensory modalities (e.g., light touch temperature, two-point discrimination, sustained pressure, stereognosis, kinesthesia, and so forth) and upper limb functional tests (e.g., Motor Assessment Scale, Motor Activity Log, Frenchay Activities Index). In a systematic review of the literature, Doyle et al¹⁸⁵ found insufficient evidence to reach conclusions on the effectiveness of any intervention for sensory impairment of the UE. Limited preliminary evidence was found in support of using mirror therapy for improving detection of light touch, pressure, and temperature pain; thermal stimulation for improving rate of recovery of sensation; and intermittent pneumatic compression intervention for improving tactile and kinesthetic sensations.¹⁸⁵

Schabrun and Hillier¹⁸⁶ also found some evidence to suggest that electrical stimulation can improve sensory hand function and dexterity. While some techniques show promise, more quality research is needed. Continued practice with functionally relevant tasks is necessary to maintain the positive effects of any sensory retraining program.

Biofeedback

For patients with severe motor weakness, electromyographic biofeedback (EMG-BFB) can be used to assist the patient in regaining neuromuscular control. With careful electrode placement, it provides an accurate indication of electrical activity associated with muscular effort. It does not, however, provide an accurate indication of force of contraction. Surface electromyography (SEMG) electrodes are commonly used for recording. The signal is amplified and converted in audio and/or visual form, providing useful information about muscular performance to the patient. Patients who exhibit weak (trace, poor, or fair) muscle grades or deficient sensory feedback systems will benefit the most. Biofeedback has been used to increase the contraction of a muscle, train voluntary inhibition of muscle spasm and decrease muscle guarding.¹⁸⁷

Woodford et al. in a Cochrane Database Systematic Review of the effects of EMG-BFB for motor function recovery following stroke found evidence from a small number of individual studies to suggest that EMG-BFB plus standard physiotherapy produced improvements in motor power, functional recovery and gait quality when compared to standard physiotherapy alone.¹⁸⁸ The researchers concluded that the results are limited because the trials were small, generally poorly designed, and utilized varying outcome measures. Additional research and meta-analysis can be found by reviewing the work of Amagan et all¹⁸⁹, Basmjian¹⁹⁰, Gantz et al¹⁹¹, Hiraoka¹⁹², Moreland et al¹⁹³ and Schleenbaker and Mainous¹⁹⁴, EMG-BFB has also been shown to improve motor function following incomplete SCI.¹⁹⁵ The therapist must carefully structure the use of biofeedback with practice of desired functional movement patterns. External feedback must be gradually reduced in order to foster use of intrinsic feedback mechanisms and active movements as recovery progresses.

Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is an effective modality to stimulate contraction in very weak muscles and improve motor function. Electrodes are placed directly over the muscle to be stimulated. Contraction is elicited by depolarizing motor neurons, with larger motor units and a greater number of Type II fibers firing first. The motor units will continue to fire until the stimulus stops. NMES can be used to reeducate muscle, improve ROM, decrease edema, and treat disuse atrophy. It is effective in reducing spasticity with stimulation of the weak antagonist. Applications to the tibialis anterior muscle or to the common peroneal nerve have been shown to reduce spasticity in the plantarflexor muscles and improve dorsiflexor function.¹⁹⁶ Electrical stimulation in patients with stroke has been shown to reduce flexor tone and posturing of the hand and improve functional grasp,^{197,198,199,200} and reduce shoulder subluxation.²⁰¹

Functional electrical stimulation (FES) uses a microprocessor to recruit muscles in a programmed synergistic sequence for the purposes of improving functional movements.¹⁸⁷ Following stroke, FES of the peroneal nerve has been shown to be effective in assisting dorsiflexion (drop foot) and improving walking.^{202,203,204,205} It has been effectively combined with BWS and a treadmill.^206,207 Patients with incomplete SCI have been stimulated to exercise on bicycle ergometers (FES ergometry) and walk.^208,209

Compensatory Interventions

Compensatory training strategies allow the patient to perform a task using alternate limbs and/or alternate movement patterns. Thus, the patient is able to perform an old task in a new manner. For example, the patient with hemiplegia dresses using the less-affected UE and increased trunk movement; the patient with paraplegia regains functional rolling, transfers, and wheelchair locomotion using the UEs. Adaptive compensation is the result of alternative or new movement patterns. Substitutive compensation is the result of using different parts of the body, effectors, to accomplish the task.²¹⁰ During training, the patient is made aware of movement deficiencies (cognitive awareness is developed). Changes are then made in the patient's overall approach to functional tasks. Alternate ways to accomplish the task are suggested, simplified, and adopted. The patient practices and relearns the task using the new pattern. The patient then practices the new pattern in the environment in which the function is expected to occur. Energy conservation techniques are incorporated into practice to ensure that the patient can successfully complete all daily tasks. Adaptation of the environment is also used to facilitate relearning of skills, ease of movement, and optimal performance. For example, the patient with unilateral neglect is assisted in dressing by color-coding the shoes (red tape on the left shoe, yellow tape on the right shoe). The wheelchair brake toggle is extended and color-coded to allow easy identification by the patient.

One of the major criticisms of this approach is that the focus on less-involved segments may suppress recovery for certain patients and contribute to learned nonuse of impaired segments. For example, the patient with stroke fails to learn to use the more involved extremities. Compensatory training should not become the focus of treatment in patients with potential for recovery. It is important to remember that given appropriate training, motor improvements can continue well into the chronic stages (e.g., patients with stroke). Compensatory training can also lead to development of splinter skills, which are skills acquired in a manner inconsistent with skills the individual already possesses. Splinter skills cannot be easily generalized to other task variations or to other environments.

A compensatory training approach may be the only realistic approach possible when recovery is limited or the patient presents with significant impairments and functional limitations with little or no expectation for additional recovery. Examples include the patient with complete SCI or the patient recovering from stroke with severe sensorimotor deficits and extensive co-morbidities (e.g., severe cardiac and respiratory compromise or memory deficits associated with Alzheimer's disease). The patient in the latter example is severely limited in the ability to actively participate in rehabilitation and to relearn motor skills.

Patient/Client-Related Instruction

Patient/client-related instruction is an important component of any rehabilitation plan of care. Components include instruction and training of patients/clients about the following:

• Current condition (pathology/pathophysiology, impairments, activity limitations, and participation restrictions)

• Accommodations to deficits in communication, cognitive, behavioral, or emotional impairments

• Anticipated goals and expected outcomes

• Strategies and preferred interventions to enhance performance and function

• Risk factors for pathology/pathophysiology and prevention of additional impairments, functional limitations, and participation restrictions

• Strategies and preferred interventions to enhance health, wellness, and fitness

Patients with deficits in motor function need to recognize the importance of repetitive practice both in-therapy and out-of-therapy to bring about meaningful recovery. Relevant tools to ensure high levels of practice include a behavioral contract, a caregiver contract, a daily schedule, an activity log or home diary, and a home skill assignment. These tools serve to focus the patient on the POC and ensure full, active participation in reaching successful outcomes. Patient skills in self-evaluation, problem solving, and decision making are promoted to foster independence. This empowerment serves to improve quality of life and prepare the patient for the life-long adjustments needed when living with a disability. If patient independence is not possible because of the complexity of deficits and limitations in recovery, education of family, friends, and caregivers assumes paramount importance.

This chapter has outlined a conceptual framework for rehabilitation of the patient with deficits in motor function based on an understanding of the normal processes of motor control, motor learning, and recovery. Clinical decision making is based on a thorough examination of the patient's deficits in terms of impairments, activity limitations, and participation restrictions. The unique problems of each patient require that the therapist also recognize a number of interrelated factors, including individual needs and changing status, motivation, goals, concerns, and potential for independent function. The diversity of problems experienced by patients with disordered motor function negates the idea that any one intervention or group of interventions could be successful for all patients. Broad categories of interventions have been presented, with a major emphasis on training functional skills and promoting motor learning. Interventions also need to promote adaptability of skills for function in real-world environments. In selecting interventions, the therapist must consider those that have the greatest chance of success. The choice of interventions must also take into consideration other factors, including ability to deliver care, cost-effectiveness in terms of length of stay and number of allotted physical therapy visits, age of the patient, co-morbidities, social support, and potential discharge placement. Carefully planned and structured education empowers the patient and ensures skills for life-long learning and adjustment.

Questions for Review

1. Differentiate between the terms motor control and motor learning. How can impairments in motor control be distinguished from those of motor learning?

2. Differentiate between the three stages of motor learning. How do training strategies differ during each stage?

3. Define neuroplasticity. What are some of the mechanisms of neuroplasticity (changes in brain function) seen during recovery of function?

4. Discuss feedback strategies designed to improve retention and generalizability. How do they differ from strategies that optimize initial learning and performance?

5. Define function-induced recovery. Give an example of an intervention that could be used to promote function-induced recovery for the patient with incomplete paraplegia.

6. Identify three augmented interventions that can be used to calm the patient with traumatic brain injury who is demonstrating high arousal and agitated behavior.

7. Define compensatory training. Identify two compensatory training strategies for the patient with left hemiplegia and severe unilateral neglect.

HISTORY

The patient is a 36-year-old man who sustained a traumatic brain injury following a motorcycle accident. On admission to a local hospital, the patient was found to have a left frontal laceration with an underlying linear skull fracture. Computed tomography scan revealed edema, a right basal ganglia contusion, and a left frontal contusion. The patient was comatose on admission. His acute hospital course was complicated by increased intracranial pressure and severe spasticity. A gastric tube was inserted.

The patient's neurological status did not substantially improve at the acute hospital. He was transferred to a rehabilitation hospital 4 weeks after injury for intensive rehabilitation. He had a brief readmission to the acute hospital during his sixth week after injury for stabilization of acute hypothermia and hypothyroidism. He was then returned to the rehabilitation facility for continued intensive rehabilitation. His medications consisted of Tegretol (200 mg po qid), multivitamins, and Colace.

PART I: PHYSICAL THERAPY EXAMINATION FINDINGS (INITIAL ADMISSION TO REHAB, 4 WEEKS AFTER INJURY)

Behavior/cognition: He is functioning at Rancho Levels of Cognitive Functioning (RLOCF) Level V Confused-Inappropriate. The patient is able to respond to simple commands fairly consistently. With increased complexity of commands or lack of any external structure, responses are nonpurposeful, random, or fragmented. Highly distractible and lacks ability to focus on a specific task. Memory is severely impaired; often shows inappropriate use of objects. May perform previously learned tasks with structure but is unable to learn new information. Easily frustrated and responds with disinhibited behaviors (name calling and swearing).

Language–communication: Unable to examine.

Social: Married with no children. Wife is a registered nurse and very supportive of her husband.

Vital signs: Heart rate 60 beats per minute; blood pressure 122/70 mm Hg; respiratory rate 14 breaths per minute; O₂ saturation level is 92.

Sensation: Localizes to pinprick with withdrawal.

Passive range of motion:

• Right upper extremity (RUE) is limited in elbow ROM (0° to 70°); left upper extremity (LUE) elbow ROM is 10° to 100°.

• Both lower extremities (BLEs) are within normal limits except for ankle dorsiflexion 0° to 5° on R and 0° to 10° on L.

Motor Function

Tone (Modified Ashworth Scale grades [M-AS]): Severe flexor tone and spasms of the trunk that result in the patient moving in bed from a supine to a left-side-lying, curled-up (fetal) position, M-AS = 4.

• RUE extensor tone, M-AS = 3

• Right lower extremity (RLE) extensor tone, M-AS = 3

• LUE flexor tone, M-AS = 3

• Left lower extremity (LLE) extensor tone, M-AS = 2

Reflexes:

• Frequent asymmetrical tonic neck reflex posturing with head rotated to the right

• Flexor withdrawal reflexes bilaterally in response to pain (delayed on the left with decreased intensity of response)

• Positive support reflex on the left

• Hyperactive deep tendon reflexes throughout

• At times, the lower extremities scissor (extend and adduct), especially when upper body flexor tone increases

Voluntary movements:

• The patient is agitated with restless movements and is frequently diaphoretic.

• Limited head or trunk control, dependent sitting.

• Movement of RUE is spontaneous, purposeful at times, and out-of-synergy.

• Movement of the RLE is spontaneous, nonpurposeful, and out-of-synergy.

• LUE: no active movement.

• LLE movement: demonstrates abnormal obligatory extensor synergy pattern.

Coordination: Unable to assess

Balance—sitting:

• Static: Poor; requires handhold support and moderate assistance; demonstrates sacral sitting with posterior tilt of the pelvis

• Dynamic: Poor; unable to accept challenge or move without loss of balance

Balance—standing:

• Static: Poor; requires maximal assist of two persons to stand in the parallel bars with splint on LLE

• Dynamic: Unable to weight shift or step

  • Gait and locomotion (wheelchair [w/c]): Unable

• Skin: Multiple healed lacerations on the knees and calves and pressure sores bilaterally on the lateral malleoli and calcanei from bivalve positioning splints.

• Bladder and bowel: Incontinent of bowel and bladder, and has external catheter in place.

• Functional activities: Max assistance in all ADL, FIM level 2.

PART I (QUESTIONS 1–3)

1. Identify and prioritize the problems in motor function presented in this case in terms of impairments and activity limitations based on initial admission data (4 weeks after injury).

2. Identify the goals of physical therapy intervention for this patient at this point in his recovery (initial admission).

3. Identify the motor learning strategies and two treatment interventions appropriate for this patient at this point in his recovery (initial admission).

PART II: REEXAMINATION 12 WEEKS AFTER INJURY

Behavior/cognition: He is functioning at Rancho Levels of Cognitive Functioning (RLOCF) Level VII Automatic-Appropriate. He appears appropriate and oriented within the hospital setting; goes through daily routine automatically, but frequently robot-like. Shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure is able to initiate social and recreational activities. Judgment remains impaired.

Language–communication: The patient is dysarthric; speech is usually intelligible but difficult to understand and delayed in onset. Auditory comprehension is good.

Vital signs: Within normal limits (WNL).

Skin: Lacerations are healed.

Sensation:

• Vision and hearing are WNL.

• LUE: Absent sensation.

• LLE: Impaired sensation, decreased proprioception.

• RUE and RLE: Intact

Range of motion:

• RUE: elbow ROM 0° to 90°; LUE: elbow ROM 5° to 110°

• BLEs: WNL except for ankle dorsiflexion bilaterally of 0° to 15°

Motor function

Tone (modified Ashworth Scale grades, M-AS):

Trunk: Tone in the trunk is WNL except for occasional flexor spasms

• RUE and RLE: Extensor tone, M-AS = 1

• LUE: Flexor tone, M-AS = 2

• LLE: Extensor tone, M-AS = 1

Reflexes:

• Exhibits strong associated reactions in the LUE and increased flexor posturing with stressful activities.

Voluntary movements:

• RUE and RLE: Demonstrates purposeful, full, isolated motions through available ROM against gravity. Strength is grossly F+ in the RUE and RLE.

• LUE: Limited voluntary movement; extensor synergy predominates.

• LLE: Movement is purposeful; strength is grossly F.

• Head and trunk: Movement is functional and strength is grossly F.

Coordination:

Exhibits moderate ataxia in trunk.

Demonstrates moderate impairment in finger-to-nose and toe-tapping test in RUE; LUE not tested.

Balance—sitting:

• Static: Good, able to maintain balance without handhold support, limited postural sway

• Dynamic: Good, able to accept moderate challenge and move without loss of balance

Balance—standing:

• Static: Fair, requires handhold support to stand in the parallel bars, occasional minimal assistance

• Dynamic: Fair, accepts minimal challenge; able to balance while turning head/trunk

Functional Activities:

• Bed mobility: Rolls to right and left with supervision (S)

• Supine-to-sit and sit-to-stand: Moderate assistance × 1, FIM level 3

• Transfers: Moderate assistance × 1 in stand-pivot transfers, FIM level 3

• Wheelchair locomotion: Maneuvers manual wheelchair with close S for safety, FIM level 5

• Gait: Walks in parallel bars 10 ft with moderate assistance × 1, FIM level 3

• Dressing and grooming: Minimal assistance × 1, FIM level 4

PART II (QUESTIONS 4–6)

• 4. Identify and prioritize this patient's motor function problems in terms of impairments and activity limitations (12 weeks after injury).

• 5. Identify the goals and outcomes of physical therapy intervention for this patient at this point in his recovery.

• 6. Identify the motor learning strategies and two treatment interventions appropriate for this patient at this point in his recovery.