NEURO TREATMENT

3RD YEARS
NATASHA NAIDOO
2019
 Overview

Outcomes and ICF

Bobath/NDT
Trunk Control
Upper Limb
Splinting
Early mobilisation
Transfers
24 hour management
 Outcome based Rehab: Landrum’s Levels (1995)

Return to
Productive
Activity
Community
Re-
integration
5

Residential
4
Re-
integration
Physiological 3
Maintenance
Medical
Stability 2
1
 Bobath 1990

All voluntary
When the therapist
movements should be
“inhibits the unwanted
Voluntary movements selective however, and
parts of the abnormal
performed in normal not be performed in
total pattern” then “it is
patterns, with “Inhibition facilitates primitive mass synergies
the restoration of this
facilitation if necessary, and facilitation inhibits” which would serve to
inhibitory control that
will actually inhibit reinforce the abnormal
makes permanent
hypertonicity. patterns and indeed tend
reduction of spasticity
to increase tone in the
possible”
muscles involved.
 Core principles

Individualise Functional Outcomes

Understand life roles, environments and impairments
Emphasise motor control
Active participation
Promotes effective/function movement synergies
Increase active use of the involved side (hemi)
Encourage involvement of hemi side
Allows opportunity for neuroplasticity
Reduces prevalence of learned non-use
 Core principles

Provide practice for motor learning

Repetition, Repetition, Repetition
Provide challenge as patient improves
Teach 24 hour management
Increases retention and carry-over
Functional Activities between sessions
Provide specific instructions to team members
Interdisciplinary approach
Involve family
Ward staff
 Common terms

Handling-
Technique used change muscle tone. Either facilitation or
inhibition
Facilitation
Tactile and visual feedback techniques or processes
Inhibition
Techniques or positions used to decreased spasticity or abnormal
movement patterns
Key Points of control
Hand placement to improve quality of movement or posture
Trunk, shoulder girdle, hips
Neuro developmental techniques: Inhibitory

• Do not over extend • For upper limb • Use palm of hand on

wrist external rotation, the muscle group
• Avoid “flattening” of elbow extension
the palm
• Ensure full
extension of elbow
Slow stretch – NB Deep pressure - On
Weight bearing –
slow – try to use the specific muscle
NB alignment and
reflex inhibitory groups – do not
positioning
patterns pinch or poke!!

• Mainly used for

hypertonicity
• Wrapping in muscle
group in warm
towel, bean bag for
approximately 10-15
minutes
Neural warmth Rotation, trunk NB
 Inhibitory – continued:

•to inhibit abnormal

• Establish hip-trunk
dissociation movement patterns
• Rolling and synergies
• three immersions of •In-corporate
3 seconds each bothssides of the body
following shortly Bilateral movement
after the other – in a –
Dissociation – mixture of ice and
Segments of the
body from one
water
another

Icing –
 Excitatory - continued

•draw a bottle •careful – do not

brush through increase tone in
the patients hand the hypertonic
group
Using the protective
Bottle brush – e.g. extension reaction Movement against
resistance –

•fast and wait

for the muscle
to react)

Compression
(–
 Trunk control

“Core” of function
Manifests in poor alignment in sitting, loss of
righting or equilibrium reactions, poor ability to
reach and falls
The unaffected upper limb is not free for function
used to remain upright.
 Basic considerations for Trunk control

Strengthen Weight shift

core/trunk -Anterior/
Posterior
muscles
Lateral
Rotation

Maintain postural
and alignment in
sitting/standing
Examples of simple activities in retraining trunk control

1. Creaming the lower limbs

2. Eating sitting in a chair

3. Reaching for objects in diffetent plains

4. Upper and Lower extremity dressing

5.Toileting , bedside bathing

6. Hair care.

7. Folding and placing laundry.

 Upper Limb/extremity

Important to note the following:

Degree of paresis
Volitional activation of muscles units
What is the “amount of weakness”
Loss of Fractionated movement
Voluntarily move one segment independent from another
Essential for skilled upper limb movement
Abnormal Tone
Resistance of muscle to stretch
Hypotonicity- Decreased resistance
Hypertonicity- Increased resistance
Somatosensation
Will affect the entire hemi side
Less ability to monitor and correct movement
Rule of thumb- decreased light touch-decrease in all other sensation
 Examples of simple activities in retraining the hand:

1. Dressing – picking up a ball of socks with the affected hand.

2. Eating toast or a bread roll.

3. Drinking from a glass – bilaterally if necessary.

4. Cleaning the table.

5. Washing up, holding cutlery with the affected hand.

6. Holding the toothbrush with the affected hand while applying
toothpaste. Bilateral tooth brushing.
7. Bilateral vacuuming etc.
Note: Bilateral activity prevents associated reactions , which can increase
tone.
 Splinting

Splinting will NOT influence tone but aid in

maintaining joint integrity and tendon length
We want to prevent adaptive shortening by exposing
muscle to stress
Basic principles:
 What is the aim of your splint
 Volitional movement not splitting during the day
 Never take joint to end range
 Splinting:

There is no evidence
that splinting for the
neuro hand is effective, If a hand is hypertonic, a
but if a hand is flacid splint will help to
and painful, a resting maintain range and
splint will help to reduce comfort by preventing
pain and protect a the fingers from cutting
vulnerable joint. into the palm.

If a hand is swollen, a A soft splint will prevent

wrist brace will increase flexion contractures of
blood flow and return of the elbow. Wear for 6
fluids by opening up the hours or longer for
carpal tunnel, also maximum slow stretch
protecting a vulnerable effect.
wrist joint and possibly
preventing shoulder
hand syndrome.
 ARMS SLINGS

Use is controversial
Keeps the UL in internal rotation and elbow flexion
However if patient is ambulant gravity will have an
effect on the UL
Sling if: The is acute pain
: Less than 10 degrees shoulder flexion
: Decreased sensation, cognition, perception
The sling is NOT to be worn while in bed or sitting
Re-evaluation shoulder occur at each visit
 Early mobilisation

To start as soon as medically stable

Essential for gaining trunk control and stability
Improves psychological wellbeing.
Keep your environment in mind (staffing etc)
 Transitional movements 1:

Rolling in bed. – clasped hands

- placing the affected leg
- turning on the spot

Moving up in bed – Bunny sheet

- Australian lift
- Bum shuffle
 Transitional Movements 2:
Lying to sitting up over the side of the bed.

4. Use
1. Bridge to 3. Swing
2. Roll over unaffected
get closer to legs over
to the arm to push
side of the the side of
sidelying. up to
bed. the bed.
sitting.
Transitional movements:
Sitting to Lying.
 Transfers:

The passive transfer: (use a transfer board)

- always move patient
forwards in chair/on bed first.

- get the patient’s weight forward! Make

the package small.

- Support affected knee with your knees –

don’t block it!

- Hands behind scapulae, you lean back,

use your body weight to lift patient.
 The more active and active transfer:

The patient clasps

hands together, NB, NB!!! Check
leans forwards Once they can do the feet!! They
with his/her the above, they cannot put weight
hands onto a learn to do the on a base of
chair, therapist same by having support that is too
grabs hold of the hands clasped narrow, or an
trochanters and in the air. ankle that is
helps to shift the buckling.
bottom.
 24 Hour management

Therapy does not only occur in the therapy session

Effect recovery and honing of functional movement
happens with practice
Provide opportunities to use mastered movements
Positioning is important
Home/ward programmes
Positioning:

Correct
positioning is of
crucial
importance.
This is part of
the 24 hour
treatment
protocol that
will do your
treatment for
you when you
can not be with
the patient.
In Bed:
In the wheelchair:
 Position in sitting

Pelvis in neutral to anterior tilt

Equal weightbearing on both ischial tuberosities
Trunk erect, midline with appropriate spinal curves
Shoulders symmetrical and over hips
Head/neck neutral
Hip slightly above the level of the knees
Feet flat, equal weightbearing and under knees
As far at possible aim for 90-90-90
 War or home programmes

Auto-assisted movements
Clay putty programme
Works on the intrinsic muscles of the hand
Look at all grasps
Putty offers resistance
 References:

Steps to follow, Second Edition – Patricia M.

Davies, 2000
Muscles, nerves and movement, Kinesiology in
daily Living – Barbara Tyldesley and June I.
Grieve, 1989
Pedretti’s Occupational Therapy. Practice Skills for
Physical Dysfunction. Sixth Edition – Heidi
McHugh Pendleton. Winifred Schultz-Krohn