Problem solving in neurological physiotherapy – setting the scene

History 3

Control of movement 4Neurophysiological/information processing 4Systems/distributed model 8Engineering model 8Biomechanical model 9Hierarchical model 10

Implications for the therapist 10Which therapy approach? 11Normal and abnormal tone 11Are inhibitory techniques relevant? 12Postural control 13Compensation 14Associated reactions 14

The nature of the movement disorder 15

The way forward 15Neuroplasticity 15Skill learning 16Can we predict outcomes? 16

References 17

1

Problem solving inneurologicalphysiotherapy – settingthe sceneMargaret J. Mayston

HISTORY

A therapist using a problem-solving approach tothe management of neurological patients prior tothe 1940s may have asked: How can I train theperson to use their unaffected body parts to com-pensate for the affected parts, and how can Iprevent deformity? The result was a strongemphasis on orthopaedic intervention withvarious types of splints, strengthening exercisesand surgical intervention. However, in the 1940sseveral other ideas emerged, the most popularbeing the Bobath approach. Bobath (1985) withothers, such as Peto (Forrai 1999), Kabat & Knott(1954), Voss (1967) and Rood (1954), pioneeredthe neurological approach to these disorders,recognising that patients with neurologicalimpairment, in particular stroke patients, hadpotential for functional recovery of their affectedbody parts. For the child with a neurodevelop-mental disorder, the approach was based on theidea that each child’s development could beguided by the therapist, to maximise their poten-tial for functional independence and minimisecontractures and deformities. While the Bobathapproach is one of the most used and accepted inthe UK, little has been written about it in recentyears, and there is no robust evidence for itsefficacy (Davidson & Waters 2000).

In the last few years there has been a furtherprogression in the neurorehabilitation field, withincreasing interest in different models of centralnervous system (CNS) function, skill acquisitionand training. For example, for some therapists,the emphasis for retraining of the neurologically

CHAPTER CONTENTS

3

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impaired person now is on the biomechanicalrequirements of a task (Carr & Shepherd 1998),accepting that the patient has to compensate fortheir damaged nervous system. Carr andShepherd are to be applauded for their well-researched approach; however, it should berecognised that their actual ideas for manage-ment largely arose from the work of Bobath. Theemphasis on patient participation and practice ishelpful for the cognitively and physically ableperson, but it is unclear how the approach can be used with people who have significantneurological impairments.

It must be realised that the nervous and mus-culoskeletal systems cannot be separated; theyinteract with each other to meet the demands ofboth the internal and external environment. Thusit is important to approach the person withmovement disorder with a balanced view of theneural control of movement, the biomechanicalrequirements for a task and the limitations ofCNS damage on both of these systems.

In order to use a problem-solving approach forthe treatment of people with neurological dis-ability, it is necessary to have an understandingof the control of movement, the result of damageto different areas of the CNS, neuroplasticity andways to promote skill learning.

CONTROL OF MOVEMENT

There are many models of motor control. Someexamples are neurophysiological, systems/dis-tributed model, neurobehavioural, engineeringmodel, information processing and biomechani-cal. All have value, but individually do notprovide the therapist with complete informationon which to base their practice. Therefore anunderstanding of different approaches is help-ful for the therapist working in the neuro-rehabilitation field. The most relevant of theseare discussed below.

Neurophysiological/informationprocessing

It is recognised that there is an interactionbetween central and peripheral components of

4 NEUROLOGICAL PHYSIOTHERAPY

the CNS (see Dietz 1992 for a review). Dietz(1992) points out that neuronal mechanisms are apart of biomechanical strategies but are them-selves constrained by biomechanics. This view issupported by Martenuik et al (1987) who makethe following comment: ‘While there are biome-chanical factors which constrain movementcontrol processes, there are also brain mechan-isms which are potentially complementary to thebiomechanical factors that take part in the plan-ning and control processes. We cannot neglectone at the expense of the other …’. What then dowe need to know about the neurophysiologicalcontrol of movement?

Early ideas suggested that the CNS controlledmovement primarily by reacting to sensory input(Foster 1985, Sherrington 1906). Roland et al(1980) demonstrated the presence of brain activ-ity when simply imagining a movement bystudying changes in regional cerebral blood flow.This work alongside other studies of CNS activ-ity during function (Deecke et al 1969, Shibasaki& Nagae 1984, Kristeva et al 1994) has demon-strated activity of the brain before a movementbegins, and has shown that the nervous system islargely proactive and not simply reactive, inresponse to sensory feedback. Central (feedfor-ward) mechanisms are based on innate andongoing experiences of the individual and cantake place in the absence of any kind of sensoryfeedback. Keele (1968) suggested that the CNSorganises a general plan in advance of the task tobe executed, referred to as the motor programme,on the basis of prior experience. Schmidt (1991)has taken up this idea of programme-basedmotor control, describing the comparative natureof how the brain organises the preparation andexecution of movements. Much debate has takenplace about the role of the motor programme andsensory feedback from the periphery in motorcontrol (Morris et al 1994). However, it is clearthat both central and peripheral factors areimportant in the efficient execution of motortasks.

Central programming requires the integrationof many neural structures, both supraspinal andin the periphery, to produce the required outputto achieve the task goal. It is helpful to consider

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the wiring-type diagram which gives an idea ofhow different parts of the CNS interact (Fig. 1.1),but this gives little insight into the contributionof different systems to the control of movement.The advent of imaging techniques such aspositron emission tomography (PET) and func-tional magnetic resonance imaging (fMRI) haveenabled a window into the CNS to providegreater insight into how tasks are organised. Forexample, a recent PET study by Jueptner &Weiller (1998) shows that the cerebellum ismostly concerned with processing of sensoryinformation during an ongoing task whereas thebasal ganglia are more concerned with organisa-tion of well-learned tasks. Neurophysiologistssuggest that the CNS organises the requiredneural activity to perform a task on the basis ofpast experience, but, if prior knowledge islacking, feedback systems will play a greater role.These of necessity take longer to effect aresponse. Information needs to be transmittedfrom the periphery to supraspinal structures forprocessing and the result sent via efferent path-ways to the spinal cord and muscles acted on.

PROBLEM SOLVING IN NEUROLOGICAL PHYSIOTHERAPY 5

Feedback systems are therefore less efficient andinadequate to effect fast action.

For example, take the task of drinking from acup. There are several stages in this process. First,there needs to be a stimulus generated, eitherinternally or externally; for example, thirst or asocial situation. On the basis of past experience,the CNS organises the required strategy toachieve the goal. Perceptual aspects such as theweight, shape and texture of the cup are essentialin order for the correct grip and load forces to becomputed by the CNS. Spatial concepts areimportant for the grading and timing of posturaladjustments and the actual limb movementsrequired to take the cup to the mouth. Oral andswallowing musculature need to be coordinatedwith breathing in order to have the drink withoutchoking. A decision also needs to be made whensufficient liquid has been ingested.

Although sensory information is not necessaryfor tasks to occur, it is important for the fine-tuning and learning of any motor/postural task.Studies on the ‘deafferented man’ (neuropathy ofthe large-diameter pathways), have shown thattasks previously experienced by the individualcan be performed in the same way, but the needfor repetition results in a deterioration in the per-formance of the task, and an inability to learnnew skills (Rothwell et al 1982). This is clearlydemonstrated by the inability of the ‘deaffer-ented man’ to drive a new car because the gearswere organised differently from the car he haddriven previously (Rothwell, personal communi-cation). This highlights the importance of theperception and processing of sensory informa-tion not only for learning but also for the efficientexecution of a required task. This is importantwhen considering training neurologicallyimpaired patients who may have difficulties ofsensory perception or sensory processing.

It seems that the CNS operates in a task- orgoal-directed way, an idea embraced by thera-pists using a motor learning approach (Carr &Shepherd 1998). Studies using transcranial mag-netic stimulation (TMS) have shown that amuscle can be activated the same amount in twotasks, e.g. power and pincer grip, but that thetask is organised in a different way by the cortex;

Figure 1.1 Knowledge of how different parts of the CNSconnected to each other can be helpful in understanding thecontrol of movement. (From Kandel et al 1991, p. 539.)

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i.e. depending on the complexity of the task, orthe prior experience of the task, the CNS willselect only the necessary information for its exe-cution (Datta et al 1989, Flament et al 1993,Harrison et al 1994). These experiments haveshown that the cortex plays a lesser role in simplewell-practised movements such as power grip.

Cross-correlation analysis is a useful techniqueto study the interactions between muscles and tolearn more of the neural organisation of theiractivity. This computer-driven analysis pro-gramme analyses the times of occurrence ofmotor-unit spikes and determines the probabilityof two motoneurones firing at or around thesame time more than expected by chance alone.This technique developed by Moore et al (1970)in their study of the simple CNS of the slug(aplysia), has been successfully applied to thestudy of respiratory muscles and the control ofhuman muscle activity (Sears & Stagg 1976,Bremner et al 1991, Mayston et al 1997, Farmer et al 1998). Figure 1.2 indicates the three possible


probability histograms that can be computed.The histogram in Figure 1.2a has a short durationpeak around time zero, indicating that themotoneurone pools which innervate this musclepair receive shared synaptic input either due tobranched synaptic inputs or from branchedcommon presynaptic inputs. Figure 1.2c shows aflat histogram. From this it can be inferred thatthe probability of firing of motoneurone A & B isalways the same and if the two motoneurones dofire simultaneously such activity occurs purelyby chance alone. Figure 1.2b shows a histogramwith a short duration central trough, indicatingshared synaptic inputs which in this case are reciprocal, i.e. excitatory to one and inhibitory tothe other. In this way the reciprocal innervationcircuit described by Sherrington (1906) can easilybe demonstrated using simple surface electro-myographic (EMG) recordings and the appro-priate computer-generated software. Using thissimple technique applied to surface EMG record-ings, changes in motor-unit synchronisation fol-

Figure 1.2 Cross-correlation analysis provides a way of examining the synaptic inputs to motoneurone pools which innervatemuscle pairs.

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lowing stroke have been demonstrated (Farmeret al 1993, Nadler et al 1999a). Similarly, a lack ofreciprocal inhibition between antagonisticmuscle pairs in healthy children younger than 5 years of age has been demonstrated and foundto persist in children with spastic cerebral palsy(Mayston et al 1996, Gibbs et al 1999).

Early ideas underlying the Bobath conceptemphasised the importance of reciprocal inner-vation circuits in the control of antagonisticmuscle pairs and thus smooth coordination ofmovement (Bobath 1990). Bobath (1990) sug-gested that one of the problems for the patientwith increased tone was excessive co-contractionwhich resulted in stiffness and slow, difficultmovements for function. However, reports ofabnormal co-contraction in adults with spasticityprovide conflicting evidence for the presence ofsuch co-contraction following stroke with musclechanges seemingly the primary problem in the inability to produce adequate force in theagonist, rather than antagonist restraint(Bourbonnais & Van den Noven 1989, Davies etal 1996). In contrast, for children with hypertonic


cerebral palsy, abnormal co-contraction is morecommon and is likely to contribute to the limbstiffness and associated difficulties in performingpostural and voluntary tasks (Berger et al 1982,Leonard et al 1988, Woollacott & Burtner 1996). Itis thought that for ataxia pure reciprocal inhibi-tion without the usual overlap period of co-contraction at the reversal of movement directionresults in jerky uncoordinated movement(Bobath (1997) course notes).

It is important to understand reciprocal inner-vation in order to appreciate how a disturbanceof this mechanism may contribute to the move-ment problems encountered by the neurologi-cally impaired client. Reciprocal inhibition isbrought about by the reciprocal innervationcircuit described by Sherrington (1906). This isshown in the simple diagrammatic representa-tion in Figure 1.3a (Mayston 1996). It is importantto note that the inhibitory interneurone whichproduces the inhibition of activity in the antag-onistic muscle is facilitated by descending tracts, in particular the corticospinal tract. Theefficiency of this reciprocal inhibition circuit

Figure 1.3 The Ia inhibitory interneurone receives input from spinal and supraspinal sources: muscle afferent (spinal) andthe corticospinal tract (supraspinal).

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increases with maturation of the nervous systemand can be altered as a result of a cortical lesion.Reciprocal inhibition allows for the reciprocalactivity of agonist and antagonist as required.For example, biceps activity is required to bendthe elbow, usually occurring with the tricepsrelaxed (i.e. reciprocal inhibition). However, inorder to produce smooth changes in the directionof the movement, the triceps co-contracts for ashort time and then becomes the prime moverand the biceps is reciprocally inhibited. Toexplain the interaction between the agonist andantagonist when both are actively contracting,Sherrington introduced the term double recipro-cal innervation, to explain how the circuits fromeach muscle will act simultaneously (Sherrington1906). This is probably why Bobath (1990)emphasised the need for the healthy individualto have all degrees of reciprocal innervation inorder to have well coordinated muscle activityfor function. In retrospect, it is clear that Bobathplaced too much emphasis on abnormalities ofco-contraction in his explanation of adult neuro-logical dysfunction, although it seems to be sig-nificant in children with spastic cerebral palsy.This is most likely because these children retaincharacteristics of the immature CNS, includingco-contraction of the limb muscles (Forssberg1985, Woollacott & Burtner 1996).

In summary, the neurophysiological modelhelps us to understand the interactions betweenvarious neural mechanisms, both central andperipheral, and indicates in particular the impor-tance of supraspinal mechanisms for the modu-lation of spinal systems to produce the requiredcontrol of movement.

Systems/distributed model

A therapist using a systems-based model onwhich to base therapy intervention helps theneurologically impaired person to problem-solvethe achievement of a task goal, rather than tolearn movement patterns (Shumway-Cook &Woollacott 1995). The systems approach has itsorigin in the work of Bernstein (1967), who sug-gested that an understanding of the characteris-tics of the system being moved (in this case the


human body), and the internal and externalforces acting on it, were necessary in order tounderstand the neural control of movement. Hesuggested that the control of movements wasmost likely distributed throughout several coop-erative and interactive systems. This has beendescribed as the distributed model of motorcontrol. Bernstein suggested that we have manydegrees of freedom: that is, we have many jointswhich make several types of movement such asflexion, extension and rotation. In order for co-ordinated movement to occur, muscles are activ-ated together in synergies such as locomotor,postural and respiratory synergies.

To use this approach as a basis for therapy,several assumptions are made (Horak 1992). Themajor assumption is that movements are organ-ised around a functional goal and achieved bythe interaction of multiple systems such as thesensorimotor and the musculoskeletal systems.In addition, this organisation is also determinedby environmental aspects, and emphasises theimportance of the interaction between the indi-vidual and the environment. The model furtherhypothesises that the role of sensation is import-ant not only for adaptive control of movementbut also to the predictive control of movement.Accordingly, for the neurologically impairedperson, abnormal motor control results fromimpairments in one or more of the systems con-trolling movement and their resultant attempts atachieving functional goals are produced by activ-ity of the remaining systems, which are doing thebest they can. It is the therapist’s task to improvethe efficiency of the person’s compensatorystrategies to effectively perform functional tasks.While this model may be useful, some difficultyis encountered when the contribution of eachsystem needs to be identified and evaluated.

Engineering model

This is well described by Miall (1995), whoexplains that the motor system has to solve prob-lems in response to changing sensory inputs,internal goals or errors in performance. He sug-gests that the motor system needs to select anappropriate action, transform control signals

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from sensory to motor frameworks, coordinate theselected movement with other ongoing behavioursand postural activity, and then monitor the move-ment to ensure its accuracy and efficacy.

In this model, the motor command is sent outto the controlled object (Fig. 1.4). In this example,the arm is the controlled object and the intendedposition of the arm is the reference. If the con-troller bases its actions on signals which are notaffected by plant output (that is the sensory con-sequences of the action) it is said to be a feedfor-ward controller; however, if comparisons arerequired – for example, between a referencesignal or changing signal due to interactions withthe environment – then it is a feedback controller.

This is useful for understanding how thenervous system can be both proactive and reac-tive, as already described in the neurophysiolog-ical model: proactive to produce activity on thebasis of past performance and knowledge of out-come; and reactive to ensure that the task isexecuted as required in the context of the chang-ing internal and external environments. How-ever, there is usually a need for error correctionbefore the command is executed and during thetask performance. As Miall (1995) suggests, thereare many examples of feedback control in physi-


ology, such as changes in muscle length whichare detected by muscle spindles relayed to bothspinal and supraspinal neural structures.

Motor systems also use this information in afeedforward way. For example, the motor com-mand is sent to both alpha and gamma systems toensure co-contraction of the extrafusal and intra-fusal muscle fibres to enable the sensitivity of themuscle spindle to respond to unexpected load.

It must be recognised that feedback systems,although necessary for skill learning and up-dating of motor performance, are slow. It takes aminimum of approximately 50–100 ms forsensory information to be processed by the CNS,which for efficient postural adjustment and finemotor control is a long time.

While this is a useful model, because itassumes that the CNS acts in a linear way, thereare some limitations when it is applied to brainlesions or neurophysiological recordings (Miall1995, Loeb et al 1999).

Biomechanical model

It is possible that an overemphasis on the neuralcontrol of movement has led to a neglect of theimportance of muscle strength, force production

Figure 1.4 Feedforward control in the ideal situation can give perfect performance: i.e. there is no error between the reference signal and the output of the system (upper panel). A feedback system can correct performance by comparing theexpected and actual outcome of a movement strategy. (Adapted from Miall 1995.)

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and movement velocity. Carr & Shepherd (1998)primarily base their therapy of neurological move-ment disorder on principles of motor learning andbiomechanics, stressing the importance of musclelength, muscle strength and activation of appropri-ate muscle synergies in a task-specific context.There is good evidence to support this view.Davies et al (1996) showed that a lack of force generation by paretic agonists was the major causeof reduced torque generation in a group of ambu-lant stroke patients. Biomechanical properties ofmuscle are also an important aspect of force pro-duction and changes in the distribution of musclefibre types may also contribute to problems offorce generation (Edstrom 1970, Dietz et al 1986,Ito et al 1996). It is well known that a muscle will produce optimal force at mid-range wheremaximal overlap of cross-bridges can occur (Roth-well 1994). Most people with neurological move-ment disorder demonstrate changes in musclelength which no doubt affects their ability toproduce adequate force to achieve an efficientmovement strategy. These changes in musclelength also alter joint alignment, which affects theability to generate sufficient torque and efficientmuscle activation patterns. It is possible that theinappropriate co-contraction of agonist and antag-onist muscles results from altered biomechanicalalignment in addition to abnormal neural control ofthe reciprocal inhibitory circuits between themuscle pair (Woollacott & Burtner 1996). Neuro-physiotherapists must therefore consider bio-mechanical principles in the assessment andmanagement of the neurologically impaired individual.

Hierarchical model

Although this model is considered outdated, it hassome value when one considers the effect of thecortex on the control of movement (Lemon 1993).While it is not thought to be useful to think ofhigher centres controlling lower centres, the cortexis known to exert considerable control over thespinal cord and acts with subcortical areas such asthe cerebellum and basal ganglia in the selection,planning and execution of motor commands(Shibasaki et al 1993, Winstein et al 1997). The


cortex though traditionally associated with thecontrol of skilled voluntary movements, has beenshown to be active during more automatic activi-ties such as swallowing (Hamdy et al 1998) andlocomotion (Schubert et al 1997, Capaday et al1999). Another departure from the traditional viewof motor control is that the spinal cord is capable ofproducing motor activity without any input fromsupraspinal centres, just as the cortex can generatecommands without feedback from the periphery.This has been well described in the work on centralpattern generators (Grillner 1985, Rossignol et al1988). The central pattern generator is defined as a‘network of neurones … able to produce a repeti-tive, rhythmic output … that is independent ofnecessary sensory feedback’ (Delcomyn 1980). Inthis way, the spinal cord via its networks ofinterneurones and motoneurones, can producerhythmical, alternating lower limb movementswhich are the basis of locomotor activity (walking).On the other hand, fractionated finger movementsnecessary for fine hand control rely on the integrityof the corticospinal tract for their efficiency and arelargely under cortical control (Lemon 1993, Olivieret al 1997). It is well known that a lesion affectingthe corticospinal tract results in deficits of inde-pendent finger movements (Kuypers 1978, Galea& Darian-Smith 1997, Farmer et al 1993).

The view that the cortex has an importantinfluence on control of the spinal cord’s organ-isation of movement is also reflected in reflexstudies. Matthews (1991) presents a comprehen-sive review of the human stretch reflex whichconsists of a short latency component (M1) and along latency component (M2). This paperreviews the evidence from studies of latencies of reflex components, lesions and stimulationtechniques which show that the simple stretchreflex is more complex than originally proposedby Liddell & Sherrington (1924, as cited inMatthews 1991). Matthews (1991) presentsrobust evidence for a transcortical route for thetransmission of the long latency M2 component.

IMPLICATIONS FOR THE THERAPIST

Successful performance of a sensorimotor taskrequires the integrated action of the CNS.

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Descending commands from the brain interactwith spinal neuronal circuits, and incorporate thedynamic properties of muscles and activity ofsomatosensory receptors (Loeb et al 1999). Fromthe previous discussion it can be concluded thatno one model is sufficient for the therapist toapply a problem-solving approach to the man-agement of the neurologically impaired person.The musculoskeletal system is critical to the exe-cution of the motor command, in addition to thevarious cortical and subcortical areas involved inthe organisation of the task. Therapists mustunderstand the nature of the movement disorderto employ effective treatment strategies and toset appropriate goals for those individuals tomaximise the potential for functional independ-ence.

Which therapy approach?

It is thought that approximately 88% of thera-pists in the UK base their intervention on theBobath concept (Sackley & Lincoln 1996,Davidson & Waters 2000). Although there havebeen changes to the underlying basis of theconcept (Mayston 1992), the lack of relevant liter-ature has resulted in many misconceptions andcontinuation of outdated ideas, such as anemphasis on reflex activity as a basis of tone andpostural activity, a correspondingly misplacedemphasis on the inhibition of spasticity and anoveremphasis on the significance of righting andequilibrium reactions. The following discussionattempts to clarify some of the basic ideas under-lying the Bobath approach to the management ofpeople with neurological movement disorder.

Normal and abnormal tone

It is clear from the neurophysiological and bio-mechanical models of motor control that themuscles themselves are important contributorsto the concept of tone. The original idea proposedby Sherrington (1906) and adopted by Bobath(1990) that tone is the result of tonic reflex activ-ity is now outdated. Tone comprises both neuraland non-neural components (Basmajan et al1985). Various definitions lead the therapist to


realise that this is the case. Basmajan et al (1985)states ‘at rest a muscle has not lost its tonealthough there is no electrical activity in it’. Ghez(1991) describes tone as ‘a slight constant tensionof healthy muscles’. The definition by Bernstein(1967) that describes tone as a state of readinessseems a useful explanation. Different individualscan have differing states of readiness, as dopatients with movement disorder: for example,the person with hypotonia has a reduced state ofreadiness, whereas the person with spasticity/hypertonia may be said to have an increasedstate of readiness. If tone is an important aspectof the control of movement, all factors contribut-ing to it must be taken into account. Tone is notsimply produced by tonic reflex activity – vis-coelastic properties of muscle are equally impor-tant. This has significance for the movementproblems of the patient with abnormal tone. It isnow known that muscles which are thought to be hypertonic are in fact not usually overactivebut cannot generate sufficient electrical activityto exert a force about a joint or to produce amovement (Davies et al 1996).

The controversy regarding the use of the terms‘spasticity’ and ‘hypertonia’ is discussed inChapter 5, but the therapist must ask this ques-tion: Am I managing spasticity, hypertonia orboth?

An example of clinical practice may help toclarify the dilemma. Recently a 12-year-old childwas referred for physiotherapy because ofincreasing ‘spasticity’ for which baclofen (anantispastic agent; see Chapter 7) had not beenhelpful. This girl presented with increasing stiff-ness shown by an increased flexion posture of thelower limbs and resistance to extension. Is theincreased stiffness due to:

● a lack of power in anti-gravity extensormuscles and associated changes in viscoelasticmuscle properties which has resulted in con-tractures and apparently increased tone overtime, or

● is the increased stiffness due to a velocity-dependent increase in hyperreflexia?

After assessment it was clear that the majorfactor causing increased stiffness was muscle

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weakness and contracture. Therefore it was notsurprising that baclofen had no effect in this case.Careful assessment of what is true spasticity asopposed to weakness, loss of dexterity and con-tracture (stiffness) is thus essential and mayrequire specific testing, for example using EMGrecordings, in order to be accurately determined.

Are inhibitory techniques relevant?

This altered view of tone must influence the waythe therapist manages the person with abnor-mally increased tone. The EMG traces in Figure1.5a show the activity recorded from the quadri-ceps and hamstrings of a 10-year-old childduring free standing, only possible with someflexion of the hips and knees. When the child isaligned so that the hips and knees are extended,the hamstrings are no longer active and thequadriceps generate larger spike EMG, thus acti-vating larger motor units which results in moredynamic postural activity (Fig. 1.5b). Has thischild’s hypertonia been ‘inhibited’, or rather doeshe now have more appropriate alignment toallow more efficient activation of the quadricepsmuscle and hip extensors?

The word ‘inhibition’ poses many problems.Tone may be influenced (reduced) by elongatingand mobilising stiff, tight joints and muscles toenable optimal activation from the required


muscles, but this is not inhibition as understoodby physiologists. Inhibition in neurophysiologi-cal terms means that synapses are weakened dueto reduced transmitter release or that activity in asynapse is dampened down. There are manyexamples of inhibition in the CNS: for examplereciprocal 1a inhibition, lateral inhibition,Renshaw cell inhibition, pre- and post-synapticinhibition. The term ‘inhibition’ was introducedby Bobath to explain tone reduction commensu-rate with the idea that hypertonia was producedby abnormal tonic reflex activity (Bobath 1990).This view can no longer be supported. Bobaththerapists achieve tone reduction in variousways: mobilisation of tight joints and muscles,muscle stretch, practice of more normal move-ments (whole or part practice) and functionaltasks.

The changes in explanations of tone and tech-niques of handling as viewed by paediatricBobath therapists are summarised in Table 1.1which shows how the understanding of abnor-mally increased tone has changed over severaldecades. Accordingly, the explanation underly-ing the treatment technique has also changed. Ithas been suggested that therapists do not somuch need to change what they do, but torethink the explanations for what they do(Gentile, personal communication). Another mis-leading term related to ‘inhibition’ is the tech-

Standing with no assistance Standing held in alignment (TIP)

200 µV Quadriceps

200 µVQuadriceps

HamstringsHamstrings

0 50 100 150 200Time (ms)

0 50 100 150 200Time (ms)

(a) (b)

Figure 1.5 The electromyographic (EMG) activity recorded from a 10-year-old child with spastic diplegia standing withoutsupport in a typically flexed posture (a) and when held with the hips and knees extended (b). TIP = tone influencing pattern.

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nique of specific inhibitory mobilisations (SIMs)introduced by adult Bobath therapists. SIMsapparently stretch tight ligaments and tendons,and are therefore not inhibitory in the physiolog-ical sense. The activity of every motoneuronepool depends on the sum of the inhibitory andexcitatory inputs at any moment in time. It is byaltering sensory feedback due to altered task per-formance that the CNS, if it has the capacity toadapt, will then provide the neurologicallyimpaired person with the possibility to movemore efficiently or to regain lost skills. Thisneural approach to client management needs tobe integrated with a biomechanical approachwhich takes into account the importance ofmuscle length, strength and joint alignment.

Postural control

The early work of the Bobaths placed a greatemphasis on postural reactions, namely the right-ing, equilibrium and protective reactions (Bobath& Bobath 1964, 1975). They proposed that posturaladjustment took place before, during and after anaction, an idea shown by researchers in the pos-tural control field (Massion 1994, Gatev et al 1999).


Unfortunately some users of the Bobath approachare still dominated by an overemphasis on thesereactions, and even these are not always clearlyunderstood. Bobath therapy is not facilitation ofbalance reactions, although this is the perceptionof some workers (Palmer et al 1988). It is perhapsimportant to review these reactions before abroader discussion of balance. The righting reac-tions are a discrete group of reactions which areonly seen in the developing infant and in specificanimal preparations. In the mature adult theserighting reactions cannot be separated from themore complex equilibrium reactions (Bryce 1972).It is therefore incorrect to look for head righting ortrunk righting in the mature adult, but rather oneshould determine whether an individual has theappropriate activity of the head and trunk withinthe equilibrium response. The equilibrium reac-tions are either:

● invisible changes in muscle tone which enablethe maintenance of the desired posture,

● or, when greater perturbation necessitatesvisible activity, the response of the body beingto extend/elongate the weight-bearing sidewith flexion of the non-weight-bearing sidewith some rotation within the body axis. Thedegree of rotation depends on the direction ofthe perturbation. When the perturbation is toolarge or too fast then the protective reactionscome in to protect the individual from injuryand to assist in restoration of the centre ofgravity to lie within the base of support.

In summary, balance in the mature adult isachieved by equilibrium and protective reac-tions; righting reactions cannot be observed. Inthe developing infant the various righting reac-tions can be observed, but early in developmentbecome a part of the equilibrium reactions whichcommence in prone at approximately 3 monthsof age when the infant can maintain the proneposition with head lifting and weight on elbows.

For several years, balance has been viewed in afunctional way by the Bobath Centre, London,recognising that the central command for anaction includes both the postural and task-related components (Rothwell 1994). Balancereactions are complex responses based on prior

Table 1.1 Tone and techniques of handling

Abnormal Handling Aim of use of Commentpostural tone technique technique

Released Reflex Inhibition of Static – littletonic inhibiting released or noreflexes postures tonic movements;(1940s) (RIPs) reflexes often

opposite to pattern ofspasticity

Abnormal Reflex Simultaneous Emphasis tonic inhibiting inhibition, on(postural) patterns facilitation & facilitation reflex (RIPs) stimulation of posturalactivity reactions(1960s)

Abnormal Tone ‘Inhibition’, Influence neural and influencing facilitation, both thenon-neural patterns stimulation control of aspects of (TIPs) and posture and tone (1990 – biomechanical task present) influences performance

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experience in addition to the CNS response tounexpected perturbations occurring during taskexecution (Horak & Nashner 1986). There seemsto be much controversy about how balanceshould be trained in people with neurologicalmovement disorder. Should balance be trainedseparately or as part of the task goal? For thedeveloping infant the experience of a postureprecedes the attainment of postural control inthat posture. For example, an infant is propped insitting to practise using their hands before inde-pendent sitting is possible. Thus, for somepatients, it could be reasonable to assume that itis necessary to give them the idea of the posturalactivity required for a task and then to add in thetask component. Both components need to bepractised simultaneously for the training to beeffective. Similarly, testing of sitting balance isnot achieved by testing righting and equilibriumreactions, but rather by assessing the person’spossibilities to reach in all directions for objectsor to carry out activities as in the performance oftasks of daily life. This ability relies not only onsensorimotor activity but also on the perceptualability of the individual (Massion 1994), whichshould be considered as part of the posturalmechanism to be taken into account duringtherapy and the goals adjusted accordingly. If aperson’s instability is primarily caused by a per-ceptual deficit, simply training balance reactionswill not address the main problem.

It would be preferable to view balance as anadaptable background to skill performance andto train it in the appropriate functional context,rather than emphasising the different groups ofreactions (righting, equilibrium and protective)as being responsible for postural control.

Compensation

Compensation is another term which has differ-ent meaning for therapists, neurologists andmovement scientists. If the nervous system isdamaged in some way, then there will necessar-ily be compensation by the system for thedamage sustained. This can take many forms,which may include plastic changes such asmuscle adaptation and cortical reorganisation.


How the patient moves in response to their neu-rological reorganisation is another question.Shepherd & Carr (1991) suggest that the way inwhich the neurologically impaired personattempts to achieve a goal represents the best thatcan be done given the state of the neural andmusculoskeletal systems. The questions wemight ask are: How much does the person needto compensate? Can they function more effi-ciently and compensate less? For example, astroke patient will prefer to use the unaffectedside, only using the stroke-affected side whenabsolutely necessary and only if physically possi-ble. However, the work of Bobath (1990) and evi-dence provided by Taub & Wolf (1997) hasshown that by training of the stroke-affected sideit is possible that, for some patients, fewer com-pensatory movements will be required becausemore effective movement is possible on thestroke side. No therapist should try and stop apatient moving in a certain way unless they canreplace it with an alternative strategy whichachieves the same goal. Concern for quality ofmovement needs to be realistic.

Associated reactions

Associated reactions (see Chapter 5) are anotherexample of confusion in neurophysiotherapy andrepresent one of the greatest controversies andpossibly mysteries in the neurological therapeu-tic world in the UK (Stephenson et al 1998).

Early positioning and the avoidance of effortwere advocated by Bobath (1990) to reduce theeffect of associated reactions which in the long-term might lead to contracture and reduce thepotential for functional recovery. The main fea-tures of the management of these reactions in themore able client were:

● The client should be taught strategies toreduce them when they occurred. For exam-ple, using the sound arm to stretch out theaffected side.

● To train more normal activity of the affectedside to reduce effort and therefore the severityof the associated reactions. It was suggestedthat improving balance on the stroke-affected

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side could lead to less effort in the main-tenance of balance and less increase of tone inthe upper limb associated with the need tobalance.

However, there is no evidence to suggest thatpreventing a person who has had a stroke frommoving in the early stages of recovery will influ-ence spasticity and associated reactions; in fact, itmay be detrimental to the client’s potential forCNS recovery and thus functional recovery.

THE NATURE OF THE MOVEMENTDISORDER

It would seem that therapists have become soenthusiastic in the control of tone that otherfactors, such as weakness and dexterity, haveassumed less importance. But a purely biome-chanical view cannot be supported either. Neuraldamage that results in dysfunction of corticaland subcortical areas, particularly the descend-ing tracts, reduces neural drive onto themotoneurone pool and results in reduced forcegeneration which will not necessarily beregained. Thus there will always be a degree ofweakness and loss of power. Muscle imbalancewill be accompanied by muscle shortening,another contributor to lost ability to generateforce – for example in walking (Ada et al 1998).

It has been shown in children with cerebralpalsy (CP) that the inability selectively to activatemuscles is in part due to a lack of synchronisa-tion of muscles (Gibbs et al 1999). Axons usuallybranch to innervate several motoneurone poolsto bring about the cooperative action of themuscles for a required task (Bremner et al 1991),or are activated synchronously if flexible strate-gies are required by the task (Gibbs et al 1995).This is one aspect of function of the corticospinaltract known to be disrupted when there is braininjury. Abnormal synchronisation of motor unitactivity has been demonstrated in people withdystonia (Farmer et al 1998) and those withhemiplegic stroke (Farmer et al 1993, Nadler et al1999), although the functional significance of this is unclear Another aspect of the movementdisorder associated with spasticity in children is


co-contraction of antagonistic muscle pairs(Leonard et al 1991, Woollacott & Burtner 1996,Gibbs et al 1999). There are varying reports of co-contraction of antagonistic muscle pairs in adultswith hypertonia, but the phenomenon seems lesscommon. It is likely that weakness and alteredviscoelastic properties of muscle are a more likelyexplanation of the stiffness experienced and feltin adult patients with increased tone (Gowland etal 1992, Davies et al 1996).

THE WAY FORWARD

Neuroplasticity

Plasticity underlies all skill learning and is a partof CNS function in healthy and brain-damagedindividuals at any age (Leonard 1998).

The advent of imaging techniques such as PETand fMRI in conjunction with neurophysiologicalrecordings in primates and humans has providedevidence of the plasticity of the CNS. In a studyof monkeys following amputation of digit 3, itwas shown that adjacent areas of the sensorycortex expanded to take over the representationof the lost digit (Merzenich et al 1984). Plasticityof the sensory cortex has also been inducedthrough behavioural training. The tips of thesecond and third fingers were stimulated with arotating disk, which resulted in an expansion ofthe sensory representation of those digits(Jenkins et al 1990). This suggests that sensorystimulation, if given effectively and oftenenough, can expand sensory areas of the cortexand may have implications for therapy.

Plastic changes have also been demonstratedin the motor system as a result of motor training.Recent work by Nudo and his group (Nudo et al1992) has shown that training a hand expandedthe cortical areas represented by the muscles executing that task. A later study by his grouphas shown that lesioning the motor cortex of amonkey and then training motor activity duringrecovery resulted in greater recovery of skill thanthe untrained group, and reduced loss of corticaltissue in the area surrounding the infarct (Nudoet al 1996). The effect of training of a novel motor skill in healthy human adults has also

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demonstrated changes in sensorimotor function(Nadler et al 1998). In this study subjects weretrained to simultaneously flex the index finger(first dorsal interosseous; 1DI) and abduct thefifth finger (abductor digiti minimi; ADM).Before, during and after the training period, cuta-neomuscular reflexes in response to stimulationof the digital nerves of the index finger wererecorded. After a short period of training (2–3days), the long-latency components of the reflexwere significantly larger. This indicates that thesensory fields of the two muscles had expandedand come to lie closer together in the sensorycortex, so that the sensory input now reached thetwo muscles rather than just the 1DI. This corre-late of Nudo’s work in training motor skill inmonkeys (Nudo et al 1992) suggests that motortraining and skill learning can be detected usingsimple reflex testing and may be useful as ameans of monitoring the effects of therapy inclients with neurological disability.

Skill learning

Practice is fundamental for motor learning andimproving skill in both healthy and movement-impaired individuals (Taub et al 1993, Winsteinet al 1997). Two other principles of equal signifi-cance are active participation and working toachieve meaningful goals. Therapy programmesshould be based on these three principles and canbe enhanced by ‘preparation’.

The Bobath approach has been much criticisedfor its use of preparation for function (Shepherd1995, Carr & Shepherd 1998), but this has beenmisunderstood. Preparation given as a treatmentis of no value on its own, and must be incorpo-rated into useful activity (Bobath 1965, unpub-lished notes). It includes the following:

● mobilisation of tight connective tissue and/orjoints

● elongating muscles to enable activity from abetter biomechanical advantage, to achievebetter body alignment for more efficientbalance and muscle activation

● practice of task-component parts to enable thepatient to get the idea of the movement required


● practising in a functional task which thepatient wants to achieve. To do this requiresrealistic goal setting.

Bobath (personal communication) suggested thatit is what the neurologically impaired person cando with some assistance that is their potential.However, it is of little use to the person if thesepotentially achievable skills can only be practisedwith the therapist’s help. When required, it isappropriate and important to enlist the help ofothers to enable the person to practise activitieswhich are possible, with a little help, to achieveindependently. Equally it is of no use to theperson to be prevented from trying to practiseactivities because there is a danger of increasingspasticity through the occurrence of associatedreactions. Indications are that early training willenable less secondary loss of cortical tissue andthus enable greater possibilities for recovery(Nudo et al 1996).

Can we predict outcomes?

Part of the realistic setting of goals (see Chapter2) depends on having realistic expectations of theindividual’s optimal potential based on the ther-apist’s expertise. However, neurophysiologicaltests such as TMS and reflex testing may also beused to predict recovery. Turton et al (1996) intheir study were able to identify two patientgroups (A = rapid recovery; B = slow and incom-plete recovery) and further categorised them onthe basis of EMG recordings and responses toTMS. While responses to TMS could be elicitedfrom all muscles in group A from the outset, inthe slow recovery group, the ability to elicit TMSresponses was commensurate with the subse-quent activation of hand muscles. In this wayTMS provided a prognostic test for the return ofmuscle activity.

Nadler et al (1999b) studied the cutaneomus-cular reflexes (see Jenner & Stephens 1982) of asmall cohort of people who had a stroke. Theirresults suggest that those subjects in whom alarge short-latency reflex response is recorded areunlikely to make a good recovery. Similarly,stroke patients who present with transient mirror

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movements early in recovery usually regaingood function of that side (clinical observation).

However, not all therapy departments haveaccess to these diagnostic and prognostic tools;therefore, for the moment, the clinical experience


and the problem-solving ability of the therapistin the context of a knowledge and understandingof current research literature remains the mainway to determine realistic goals for each client’smanagement.

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Problem solving in neurological physiotherapy – setting the scene

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