Approaches to Neurorehabilitation

Authors
Affiliations

Nate Yomogida, B.S., SPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, B.S., SPT

Doctor of Physical Therapy

B.A. in Neuroscience

Incorporation into practice

Contemporary practice combines:

  1. The Remedial/ Restorative Approach
  2. The Functional/ Adaptive/ Compensatory Approach

Education:

  • Education on what deficits are
  • Which should be performed with assistance, supervision

Feedback:

  • Feedback is essential
  • Teach family how to provide verbal cueing and feedback
  • Bandwidth feedback
  • Eliminate knowledge of performance, just give knowledge of results

Environment:

  • Setting up the environment
  • Changing the environment

Patient autonomy:

  • Allowing pt to have a role in decision making!!!!

Impact of managed care:

  • We do not have time to address all underlying processes
  • Educate, be creative and resourceful

Different Approaches

Retraining Approach

The retraining approach1

  • Improving underlying skills the pt has lost (NOT a function)1
    • Skills will transfer over to function (practice pegs a bunch of times, later you should be able to grab items)1
  • Transfer of training approach → practice on one task with cognitive/perceptual req’s will enhance other tasks with similar perceptual demands1.
  • Assume: skills learned for one task can generalize to others1.
  • No specific practice done with the actual task trying you are to improve, instead practice is w/ specifically selected perceptual exercises1.

Sensory integrative approach

  • Eyres developed theory to explain relation between neural functioning and behavior of children w sensorimotor/learning problems1
  • Production of desired motor responses facilitate sensory integration, which enhances ability to produce higher level behaviors1.
  • Assumption of Treatment: by offering opportunities for controlled sensory input, therapist can promote normal CNS processing of sensory info, and elicit a specific motor response1.
  • Controlled sensory input of sensory info followed by a desired motor response in order to integrate sensations provided by the PT1.

Indication:

  • Adults1
    • Highly debated for adults1
    • Adults: includes handling or directed sensory stimulation for a desired motor response1
    • In isolation does not work well for adults1
  • USED AND fairly effective in children1
    • Introduce sensation to give sensations meaning to the child1
Example

Visual, auditory, tactile, changing body position,

Neurofunctional Approach (#neurofunctional-approach)

  • Based on principles of skill (higher level ) learning theories
  • NO transfer of training
  • Practice every day in its true context in order to recover function
  • Learning by DOING
    • No matter what it looks like, learn from mistakes
    • Just do it
  • Real world TASKS not processes
  • Compensatory skills taught if effort do not justify gains

Rehabilitative / Compensatory (functional) Approach

  • MOST WIDELY USED for adults w/ perceptual deficits
  • Direct repetitive practice of specific functional skills that are impaired
  • Address the functional problem OVER AND ABOVE THE treatment of its underlying cause
  • Educate pt on deficits, provide external cueing and REPEAT
  • Give them what they need to make it successful
  • Compensation and adaptation
  • May have limitations in transfer of techniques to other tasks bc underlying causes not being addressed
  • Person must have some baseline level of cognition in order to understand their deficit → bc big part is education on this deficit
  • Provide whatever they need to eliminate deficit, and REPEAT
    • ie) strength deficit
R hip abd weakness
  1. Give walker
  2. Teach them how to use it
  3. Repeat

(don’t do clamshells, or treat impairment)

Compensation example (patient approach)

Teach pt w/ left visual field cut to look left, scan room, give instructions or cues to remember after making them aware of deficit

Adaptation example (environmental alteration)

Patient with L/R Discrimination deficits

Place red tape on all right shoes

Cognitive Rehabilitation and the Quadraphonic Approach

  • Cognition, not all motor
  • Train pt how to structure and organize the info
  • Encourage SELF ASSESSMENT
    • Why and how did u do it that way?
    • Ask about their response
    • THEY ARE INVOLVED in thinking part of mvmt
    • Metacognition
  • Address memory, high language disorders, info processing, problem solving, awareness, judgment, decision making, perceptual dysfunction
  • Multi context treatment approach to cognition
    • Dynamic interplay between characteristics of the pt , the task and the environment of which it is performed

Strategies:

  • Analyze characteristics of task to determine if transfer of training occurred
  • Interventions inc pt self awareness , promote self assessment
  • Relate new info or skills to previously learned ones
  • Use the multiple environments to enhance transfer of training

Quadraphonic approach: - Takes cognitive rehab model (and some of neurofunctional approach) and expands it - HOLISTIC perspective - Therapist can apply both micro and macro perspectives for eval/treatemtn

References

1.
O’Sullivan SB, Schmitz TJ, Fulk GD, eds. Physical Rehabilitation. 7th ed. F.A. Davis Company; 2019.

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