SPLINTING AND THE USE OF ORTHOSES 249 Figure 10.24 Unpadded cock-up support for the boxing glove splint. (Reproduced from Bromley 1998 with kind permission.) (A) (B) Figure 10.25 (A-B) Wrist/hand splint.
250 NEUROLOGICAL PHYSIOTHERAPY (C) (D) (E) (F) Figure 10.25 (C-F) Wrist/hand splint.
SPLINTING AND THE USE OF ORTHOSES 251 are applied from just below the elbow, extending The second Soft Cast bandage is applied to down to and including the fingers. A piece of secure these slabs in place following immersion 1 inch (2.5 cm) stockinet is placed between the in tepid water and then the wet cotton bandage fingers to prevent them being squeezed together to ensure lamination of the layers. as the splint is made and another piece of 1 inch (2.5 cm) stockinet is placed over the thumb. When the Scotch Cast Plus is hard, the splint is Microfoam tape is placed over the ulnar styloid. removed by cutting longitudinally over the forearm extensor muscles and down the back of The first Soft Cast bandage is applied dry from the hand. The section over the extensor aspect of 2 inches (5 cm) below the elbow down to the the fingers and thumb is cut away to the meta- hand to include the thumb and fingers. The scis- carpalphalangeal joints. This is particularly sors are required to cut the bandage as required important at the thumb as patients with flexor to ensure a smooth fit around the wrist and hypertonus will be unable to place the thumb in thumb. a spica without assistance. A dry slab of four-layer Scotch Cast Plus is The edges of the cast are secured with zinc placed over the flexor aspect of the forearm to oxide tape and Velcro fastening attached for beyond the tips of the fingers. An additional reapplication. piece of Scotch Cast Plus, doubled over and approximately 4 inches (10 cm) in length is This cast may also be used purely to sup- applied from the tip of the thumb to the mid- port the wrist and thumb, leaving the fingers forearm over the flexor aspect. free (Fig. 10.26). In this case, the splint must finish below the palmar crease to prevent the metacarpalphalangeal joints being held in ex- tension. In summary, it is important to discuss the pro- posed splinting intervention with the occu- pational therapist. Modifications and new materials continue to be developed and, in clini- cal practice, it is often a case of trial and error to determine the most effective splint for manage- ment of hand dysfunction. Investigations to date do not indicate for whom hand splints may produce beneficial effects in reducing or limiting the effects of hypertonus (Langlois et al 1989). Figure 10.26 Wrist and thumb splint. SUMMARY The use of casts in the management of patients with neurological dysfunction should always be considered an adjunct to treatment as opposed to a treatment in its own right. Careful assessment is essential to determine the most effective interven- tion and to ensure that the patient is able to accom- modate to the support provided by the splint. Jackson (1998) commented that physiothera- pists are often reluctant to use splints in the man- agement of patients with spasticity as some practitioners believe that the restraint imposed by the cast can further exacerbate this hyper-
252 NEUROLOGICAL PHYSIOTHERAPY tonus. However, there is no scientific evidence to head injury. Fibreglass is strong, slightly more support this assumption, and reduction in con- expensive than POP (on average half the quantity tracture with no adverse effects on muscle tone of fibreglass is required to that of POP), easily has been reported (Mills 1984). moulded, rarely needs reinforcement, and sharp edges may be avoided with appropriate use of In some instances, splinting may be used after padding. An additional advantage of the fibre- injection of botulinum toxin (see Ch. 7). It is sug- glass materials, including the combination casts, gested that the weakening effect of the toxin pro- is that there is considerably less mess and there- vides the multidisciplinary team with 'a window fore reduced time spent clearing up. of opportunity' to make changes in patterns of movement, antagonistic control, muscle length As new materials, such as Soft Cast, are devel- and function (Richardson et al 1997). Splinting oped, clinicians will invariably alter their prac- may be considered as an adjunct to treatment in tice. There will almost inevitably be a disparity achieving these goals (Richardson & Thompson of views with regard to the most effective cast- 1999). ing regime and choice of materials but, in the opinion of these authors, the combination of There are many different types of splints and Soft Cast and Scotch Cast Plus can be used orthoses which may be used to obtain the desired in most situations where splinting is indi- support or maintenance of range of movement of cated. a limb. Plaster of Paris has long been the casting material of choice for patients with neurological Whichever materials are chosen, the therapist dysfunction. Sullivan et al (1988) consider plaster must follow the manufacturer's guidelines, and to be the preferred material in that 'it is strong, practice is recommended on normal subjects inexpensive, easily moulded, reinforced or prior to attempting this intervention on patients. repaired once dry, and does not splinter leaving sharp edges, as may occur with fibreglass'. The use of orthoses and casts can prove bene- ficial in the management of patients with neuro- Moseley (1997) advocates the use of fibreglass logical dysfunction. However, this is a complex casting tape when using casts in combination speciality and, in order to avoid adverse effects, with stretching to regain dorsiflexion range of advice should be sought from staff experienced movement at the ankle of patients following in this field. REFERENCES Ada L, Canning C, Paratz J 1990 Care of the unconscious Bromley I 1998 Tetraplegia and paraplegia: a guide for head injured patient. In: Ada L, Canning C (eds) Key physiotherapists, 5th edn. Churchill Livingstone, issues in neurological physiotherapy. Butterworth- Edinburgh Heinemann, London Buccholz-Moodie N, Brisbin J, Morgan A 1986 Subluxation Ancliffe J 1992 Strapping the shoulder in patients following of the glenohumeral joint in hemiplegia: evaluation a cerebral vascular accident (CVA): a pilot study. of supportive devises. Physiotherapy Canada 38: Australian Physiotherapy Journal 38: 37-40 151-157 Association of Chartered Physiotherapists Interested in Conine T, Sullivan T, Mackie T, Goodman M 1990 Effect of Neurology (ACPIN) 1998 Clinical practice guidelines on serial casting for the prevention of equinus in patients splinting adults with neurological dysfunction. Chartered with acute head injury. Archives of Physical Medicine Society of Physiotherapy, London and Rehabilitation 71(5): 310-312 Beckman J 1987 The Louisiana State University reciprocating Cusick B D 1988 Splints and casts: managing foot deformity in children with neuromotor disorders. Physical Therapy gait orthosis. Physiotherapy 73(8): 386-392 68(12): 1903-1912 Bobath B 1978 Adult hemiplegia: evaluation and treatment, Davies P M 1985 Steps to follow: a guide to the treatment of 2nd edn. Heinemann Medical Books, London adult hemiplegia. Springer-Verlag, Berlin Bobath B 1990 Adult hemiplegia: evaluation and treatment, Davies P M 1994 Starting again. Springer-Verlag, Berlin 3rd edn. Heinemann Medical Books, London Faghri P D, Rodgers M M, Glaser R M, Bors J G, Akuthota P Booth B J, Doyle M, Montgomery J 1983 Serial casting for 1994 The effects of functional electrical stimulation on the management of spasticity in the head injured adult. shoulder subluxation, arm function recovery and Physical Therapy 63(12): 1960-1966
SPLINTING AND THE USE OF ORTHOSES 253 shoulder pain in hemiplegic stroke patients. Archives of Richardson D, Edwards S, Sheean G L, Greenwood R J, Physical Medicine and Rehabilitation 75: 73-79 Thompson A J 1997 The effect of botulinum toxin on Fyfe N, Goodwill J, Hoyle E, Sandles L1993 Orthoses, hand function after incomplete spinal cord injury at the mobility and environmental control systems. In: level of C5/6: a case report. Clinical Rehabilitation 11: Greenwood R, Barnes M P, McMillan T M, Ward C D (eds) 288-292 Neurological rehabilitation. Churchill Livingstone, London Galley P M, Forster A L 1987 Human movement: an Rood M 1954 Neurophysiological reactions as a basis introductory text for physiotherapy students, 2nd edn. for physical therapy. Physical Therapy Review 34: Churchill Livingstone, London 444-449 Garland D E, Keenan M-A E 1983 Orthopaedic strategies in the management of the adult head-injured patient. Rose G 1986 Orthotics: principles and practice. Heinemann, Physical Therapy 63(12): 2004-2009 London Griffen J, Reddin G 1981 Shoulder pain in patients with hemiplegia: a literature review. Physical Therapy 61: Rose G K, Butler P, Stallard J 1982 Gait: principles, 1041-1045 biomechanics and assessment. Orlau Publishing, Host H H 1995 Scapular taping in the treatment of anterior Oswestry shoulder impingement. Physical Therapy 75: 803-812 Jackson J 1998 Specific treatment techniques. In: Stokes M Roth well J 1994 Control of human voluntary movement, (ed) Neurological physiotherapy. Mosby, London 2nd edn. Chapman and Hall, London Kent H, Hershler C, Conine T A, Hershler R 1990 Case control study of lower extremity serial casting in adult Saunders J B, Inman V T, Eberhart H D 1953 The major patients with head injury. Physiotherapy Canada 42(4): determinants in normal and pathological gait. Journal of 189-191 Bone and Joint Surgery 35A(3): 543-558 Langlois S, MacKinnon J, Pederson L 1989 Hand splints and Schuren J 1994 Working with soft cast. 3M Minnesota cerebral spasticity: a review of the literature. Canadian Mining and Manufacturing, Germany Journal of Occupational Therapy 56(3): 113-119 Stockmeyer S A1967 An interpretation of the approach of Malick M H 1982 Manual on dynamic hand splinting with thermoplastic materials. Am Rehab Ed. Newark (AREN) Rood to the neuromuscular dysfunction. American Publications, USA Journal of Physical Therapy 46: 900-961 Sullivan T, Conine T, Goodman M, Mackie T 1988 Serial Malick M H 1985 Manual on static hand splinting. New casting to prevent equinus in acute traumatic head injury. materials and techniques. Am Rehab Ed. Newark (AREN) Physiotherapy Canada 40(6): 346-350 Publications, USA Sutherland D H, Cooper L 1978 The pathomechanics of progressive crouch gait in spastic diplegia. Orthopedic Mills V 1984 Electromyographic results of inhibitory Clinics of North America 9(1): 143-154 splinting. Physical Therapy 64: 190-193 Training Council for Orthotists 1980 Classification of orthoses. Department of Health and Social Security. Moseley A M 1993 The effect of a regimen of casting and HMSO, London prolonged stretching on passive ankle dorsiflexion in Wildburger R, Zarkovic N, Egger G, Petek W, Zarkovic K, traumatic head-injured adults. Physiotherapy Theory and Hofer H P 1994 Basic fibroblast growth factor (BFGF) Practice 9(4): 215-221 immunoreactivity as a possible link between head injury and impaired bone fracture healing. Bone & Mineral 27: Moseley A M 1997 The effect of casting combined with 183-192 stretching on passive ankle dorsiflexion in adults with Williams R, Taffs L, Minuk T 1988 Evaluation of two support traumatic head injuries. Physical Therapy 77: 240-247 methods for the subluxated shoulder of hemiplegic patients. Physical Therapy 68: 1209-1214 Nene A V, Patrick J H 1990 Energy cost of paraplegic Yarkony G M, Sahgal V 1987 Contractures: a major locomotion using the Parawalker - electrical stimulation complication of craniocerebral trauma. Clinical 'hybrid orthosis'. Archives of Physical Medicine and Orthopaedics and Related Research 219: 93-96 Rehabilitation 71: 116-120 Zorowitz R D, Idank D, Ikai T, Hughes M B, Johnstone V Richardson D, Thompson A J 1999 Botulinum toxin. Its use 1995 Shoulder subluxation after stroke: a comparison of four supports. Archives of Physical Medicine and in the treatment of acquired spasticity in adults. Rehabilitation 76: 763-771 Physiotherapy 85: 541-551
CHAPTER CONTENTS Longer-term management for patients Introduction 255 with residual or progressive disability Principles of management 256 Susan Edwards Non-progressive impairment 256 The vegetative state 256 INTRODUCTION Cerebral palsy in adulthood 259 Progressive neurological and neuromuscular disorders 262 Multiple sclerosis (MS) 262 Hereditary motor and sensory neuropathy (HMSN) 266 Discussion 269 References 271 There is little dispute that people sustaining neurological damage or disease with resultant disability should receive a period of physical treatment and management following the initial onset of that impairment. The duration and timing of interventions vary considerably and are determined not only by the prognosis and perception of need but to an increasing extent by the resources available to support health care. The purpose of this chapter is to discuss the level of care which is necessary to maintain optimum physical status in people with residual or pro- gressive disability and handicap and to consider those factors which relate to management. The main emphasis for patients with chronic and progressive conditions, where functional recovery is limited, is twofold: to prevent sec- ondary complications and to maintain function at an optimal level. Compensation for neuro- logical disability is often considered to be un- desirable, the aim of treatment being to 'restore normal movement'. However, where there is dif- fuse, irreversible damage to the central nervous system or progressive deterioration, this aim may not be realistic and compensatory strategies which are appropriate for the patient should be encouraged in order to maximise function. The population comprises two categories of patients when considering long-term manage- ment: • non-progressive impairment • progressive impairment. 255
256 NEUROLOGICAL PHYSIOTHERAPY The first category includes patients following • Management is primarily concerned with 'the cerebrovascular accident (CVA), head or spinal maintenance of the optimal physical condition injury and those with cerebral palsy. For these through control of posture, movement and han- patients, although the impairment itself is non- dling techniques. It is primarily preventative in progressive, the disability and subsequent hand- nature (of secondary problems), but may be cor- icap may increase over time (Bax et al 1988). rective if such problems have already occurred'. The second category of progressive impair- • Treatment is 'a technique or modality used or ment includes patients with a wide range of con- monitored by a physiotherapist for the pur- ditions such as multiple sclerosis, Parkinson's pose of enhancing motor performance, reduc- disease, cerebellar degeneration and neuro- ing the impairments and symptoms of the muscular disorders. pathology' (Pope 1997). PRINCIPLES OF MANAGEMENT There is obvious overlap in that appropriate management of the patient forms the basis of any With the number of people with more severe recovery of functional ability and, therefore, neurological impairments surviving trauma, although it is possible to have management together with the increased longevity, due to without treatment, the reverse is not the case. medical and technological advancements, of Management of the physical condition should those with deteriorating conditions the level of underpin all forms of therapeutic intervention residual disability is increasing. In consequence, and should be ongoing for as long as is necessary. already overtaxed resources are being further Treatment may be considered to be comple- stretched. mentary to the underlying management and is usually not ongoing. Currently, physiotherapeutic intervention for people with residual or potentially progressive To illustrate the problems encountered by disability does not differ significantly from that patients and their long-term management, two provided in the acute care setting. In the case of examples from each category will be discussed: injury or exacerbation of disease, the patient is discharged home or into residential care after a • In the non-progressive category: the vegetative varying period of time in an acute hospital state following head injury; and cerebral palsy and/or rehabilitation unit at a time when most in adulthood. recovery is deemed to have taken place. While continuation of intensive therapy, such as that • In the progressive category: multiple sclerosis; advocated in the acute condition, is inappro- and hereditary motor and sensory neuropathy. priate, ongoing management is essential to maintain and possibly regain optimum func- NON-PROGRESSIVE IMPAIRMENT tion. Part of this management process is to monitor for change in the level of disability, at The vegetative state which juncture a period of more intensive therapy may be instigated. For example, despite Introduction unchanging impairment, improvements in the level of disability were demonstrated following Severe brain injury or disease may result in such inpatient rehabilitation for patients with multi- irrevocable damage to the central nervous system ple sclerosis (Freeman et al 1997, 1999, Solari that functional recovery becomes an unattainable et al 1999). goal and patients remain dependent on others for the rest of their lives. This condition was referred In order to deal with complex and long-term to as persistent or permanent vegetative state conditions it is important to clarify the terms (Jennett & Plum 1972). However, it is now 'management' and 'treatment': recommended that the terms 'persistent' and 'permanent' be dropped from the diagnosis of 'vegetative state' as these confuse prognosis with diagnosis (International Working Party 1996).
LONGER-TERM MANAGEMENT 257 There are three prime features of the vegetative patient in some form of institution where con- state: stant nursing care is available is necessary. Irrespective of the ultimate placement, the • the patient has sleep-wake cycles immediate family and friends must be consid- • all responses can be identified as reflex patterns ered as part of the team and be involved in the • the patient makes no meaningful responses decision-making process at all stages of the patient's management. and has no awareness (Andrews 1999). Ethical considerations The term 'silent epidemic' has been used to describe people who survive brain injury in a Advances in medical science and technology are vegetative state (Klein 1982, Freeman 1992). enabling many more people to survive even the Andrews (1999) highlights the difficulty with most severe trauma, which may lead to the vege- diagnosis in that 'the only way anyone can tative state. The British Medical Association demonstrate their awareness is through a motor (BMA) Medical Ethics Committee states that function, that is, speech, facial expression, or treatment can only be justified if 'it makes possi- physical gesture. In the presence of severe ble a decent life in which a patient can reasonably spasticity, muscle inactivity and dysphasia it is be thought to have continued interest'. However, extremely difficult for even an aware person in the immediate aftermath of severe brain to demonstrate their awareness'. Childs et al damage, it is often difficult for medical staff to (1993) and Andrews et al (1996) have shown that assess the probability of meaningful recovery. It misdiagnosis is not uncommon. is debatable what a meaningful recovery is. Whatever the satisfaction it may bring to family Although a high proportion of people in a veg- and friends, the recovery of a limited degree etative state die during the first 6 months, a life of awareness may be worse than total loss of expectancy of at least 15 years is not uncommon cognitive function for the patient. (International Working Party 1996). It is therefore essential for all staff to ensure that the optimal There have been a number of legal cases level of care is provided to maintain the patient's regarding the cessation of treatment of patients dignity and hygiene. in a vegetative state. Initially these were requests to withdraw ventilation as in the Quinlan case of The management of these patients offers the 1976 (Hannan et al 1994) but, more recently, sternest challenge to all personnel involved in actions have been brought to stop nasogastric their care and there is a lack of agreement of the tube feeding (Tribe & Korgaonkar 1992). The focus that long-term management should take. findings in these cases have confirmed that these Vogenthaler (1987) stated that 'obviously living are legitimate and ethically acceptable options and vocational rehabilitation are not relevant' that the family and doctors of some patients may but Pope (1988) asks the question 'if not, then consider (Jennett 1992). what is?'. The main criterion for determining a successful outcome is the promotion of both For patients in a vegetative state, where there physical and mental recovery but, for those in a is little or no hope of functional recovery, it may vegetative state, this will never be realised. For be recommended that all active treatment should these patients, it is inappropriate to evaluate cease. The implications of such a decision may success or failure using these performance indi- have a devastating effect on patients and their cators. The patient who remains free from carers. Optimal care may be considered to be the contracture and pressure sores, and with the maintenance of the patient's bodily functions, positive release phenomena under control, can joint and muscle range of movement, tissue be considered as a static success (Pope 1988). viability, and stimulation of cognitive awareness. Withdrawal of active treatment usually refers to In some instances, it may be possible for a the more dynamic intervention such as that patient to be cared for at home, provided ade- quate support is available from the community services. In others, long-term management of the
258 NEUROLOGICAL PHYSIOTHERAPY which may be carried out by the physiotherapist. devastating for the family and financially Maintenance of joint and muscle range, con- demanding for the community (Freeman 1992). sidered by many to be the remit of the physio- therapist, is difficult and potentially damaging Most importantly, the person in a vegetative where there is excessive hypertonus (Ada et al state must be recognised as an individual, albeit 1990). Changes of position are frequently utilised with little or no cognitive awareness. Com- to minimise or control the effects of this stereo- munication is a two-way process and where typed posturing. The provision of appropriate there is no response or recognition from one support in sitting and when standing the patient party, inevitably this will affect the approach of may prove effective in reducing the influence of the other. Where there is little or no response hypertonus. This type of intervention may be over a protracted period of time, it is often dif- considered inappropriate by the medical staff ficult for carers, be they professional staff, family where there is little hope of functional recovery. or friends, to remain positive in their approach However, if outcome is measured by the preven- towards that person. It is all too easy to treat tion of deterioration as opposed to the attain- patients in a vegetative state on a routine basis ment of function, active treatment can be viewed with little thought as to how a particular inter- as a key component within the management vention may affect them. process rather than as a waste of resources on a patient who may be considered to be a hopeless Physiotherapy intervention case (Fig. 11.1). It must be recognised that this dynamic intervention may make the difference The diagnosis of the vegetative state should not between the patient being 'manageable' and the preclude treatment. Prevention of secondary patient deteriorating with the development of complications is essential to optimise potential gross contracture leading to deformity. The function and management. The principles of patient is likely to be dominated by positive treatment as described in Chapter 6 are of as neurological signs and at high risk of tissue great an importance to this patient group as to breakdown (Pope 1988). those with a more optimistic prognosis. The majority of patients will demonstrate hyper- A diagnosis of the vegetative state should be tonus, the extent, severity and distribution being used with caution. Applied too soon following dependent upon the site and extent of the area of trauma, it may lead to the denial of further damage and on the environmental influences to therapy and appropriate management. The effect which the patient is subjected (Finger & Almli can be catastrophic for the patient, emotionally 1985, Bach-y-Rita 1990). Figure 11.1 Range of possible outcomes following brain The speed at which therapy intervention is trauma (reproduced from Pope 1988 with kind permission). carried out is of vital importance; these patients often have difficulty in accommodating to change in respect of movement or position. The proprio- ceptive input provided by the physiotherapist should ensure appropriate support to facilitate a feeling of stability and security, allowing time for the patient to respond to the movement. Sudden movements, for example attempting to stand the patient without adequate preparation, may lead to an increase in tone which may preclude attain- ment of this position. Physiotherapy for people with severe brain injury is part of a 24-hour management process and cannot be viewed in isolation. The remit of the physiotherapist caring for patients in a vege-
LONGER-TERM MANAGEMENT 259 tative state is to maintain and, where appropriate, injury or illness. Jennett & Plum (1972) describe the increase range of movement to enable the optimal clinical features: '[patients] have periods of wake- level of care. Orofacial treatment as advocated in fulness when their eyes are open and move, their Chapter 6, in conjunction with the speech and responsiveness is limited to primitive postural and language therapist, is of particular value for these reflex movements of the limbs, and they never patients. Full or improved range of movement speak .... Few would dispute that in this condition throughout the body will enable more appropri- the cerebral cortex is out of action'. This state may ate seating, positioning in bed, washing, dressing prevail for years with no tangible change in the and, perhaps, the ability to stand the person with patient's condition but Berroll (1986; cited by suitable support. It is only by constant reinforce- Freeman 1992) found that a significant number of ment of correct positioning and handling that patients diagnosed as vegetative became conscious deterioration may be prevented. within 12 months of trauma. Positioning should be considered a dynamic Every effort should be made to ensure that each aspect of treatment. Prior to moving the patient patient receives appropriate stimulation to max- from one position to another, an explanation imise recovery. Many patients diagnosed as being should be given of the proposed manoeuvre. Staff in a vegetative state are often maintained in a state and /or carers should inform the patient that, for of gross sensory deprivation with the utilisation of example, the pillows are going to be removed and scarce resources on active treatment being consid- request assistance from the patient to accomplish ered inappropriate. The brain is exquisitely the movement. Mobilisation of the trunk on the responsive to the environment (Delgado 1977; pelvis may be used to influence the prevailing tone cited by Freeman 1992) and as such is dependent in an attempt to facilitate the change of position upon the management and variety offered by the (Davies 1994). At all times, patients must be environment for any positive change in outcome. stimulated to maximise any recovery in both their The use of a gastrostomy as opposed to a naso- physical and cognitive status. gastric tube and a leg bag for urine collection as opposed to a mounted catheter bag are examples The use of splinting for maintaining and of sensitive management, respecting patients' regaining joint range is of great value in the dignity in spite of their lack of awareness. management of patients in a vegetative state. For patients with severe hypertonus it is often diffi- Active intervention such as that described above cult to maintain full muscle and joint range need not necessarily mean a great increase in without using some form of splintage. The types expenditure. Education and involvement of family of splints which may be used and the situations and friends and other health care workers in in which to use them are described in detail in patient management promotes stimulation of both Chapter 10. However, splinting should not be cognitive and physical function. Prevention of loss viewed as a static intervention replacing the need of joint and muscle range provides not only easier for physiotherapy, but as a dynamic adjunct to nursing care but also greater comfort for the pa- treatment. The splinted part must accommodate tient. The management of complications such as to the cast in order for it to be effective. Any evi- pressure sores and contractures, which may arise dence of increased tone or agitation may be following severe brain injury, may prove to be indicative of discomfort and potential pressure expensive; prevention of these complications sores. In this situation, the splint must be inevitably reduces the ultimate cost of care. removed without delay in case it is the splint that is giving rise to these adverse symptoms. Cerebral palsy in adulthood Summary Introduction Many patients may be diagnosed as being in a Cerebral palsy is the result of a lesion or mal- vegetative state, often only a short time after their development of the brain; it is non-progressive in
260 NEUROLOGICAL PHYSIOTHERAPY character and exists from earliest childhood In a study looking into the health care of handi- (Bobath 1974). The management of children with capped adults (Bax et al 1988), many subjects with cerebral palsy is generally recognised as an cerebral palsy reported that their physical con- ongoing process from birth, or when the con- dition had deteriorated after leaving school; they dition is first diagnosed, to adulthood. By this had become less mobile and their contractures time the individuals should be fully equipped for more fixed. their needs in life, with equipment such as communication aids, wheelchairs and splints. Where there is diffuse brain damage, the whole Physiotherapy for those with physical disabilities body may be involved. Symptoms may include is an accepted part of management. However, for quadriplegia, visual and hearing deficits and many people with cerebral palsy, problems may intellectual dysfunction. The inability to com- intensify over time when, in many instances, municate needs, thoughts and feelings is perhaps physiotherapy is no longer available. Poor quality the most serious defect and one which may lead of management and treatment becomes increas- to an individual being labelled mentally ingly widespread when considering patients who retarded. Many people who were unable to com- have chronic, often more severe, disabilities. municate verbally were found to have normal These patients may not experience an acute intelligence once taught alternative means of episode which would, at least, bring them into communication (McNaughton 1975; cited by contact with the existing services (Condie 1991). Bleck 1987). 'Because these persons present an almost overwhelming number of problems, The paediatric services are used to dealing efforts toward rehabilitation are apt to be trun- with what are often diverse and complex prob- cated, individuals relegated to the waste-basket lems. Maintenance of range of movement and category of medical care and their potential as prevention of postural deformity are recognised persons neglected' (Bleck 1987). It is essential to as key principles of physiotherapy throughout make resources available which enable the indi- the period of growth. While at school, regular vidual to achieve an optimal level of functional standing, ongoing review of seating and postural independence consistent with the limitations supports, and provision of appropriate footwear imposed by the neurological and musculo- are examples of components of a physiotherapy skeletal impairment. programme which is supported by all personnel. However, when the child becomes an adult, such Physiotherapy intervention intervention often ceases in spite of the fact that many people show signs of physical deteriora- Many people with cerebral palsy maintain an tion when routine care is withdrawn (Bax et al independent lifestyle and do not want or need 1988). regular therapy intervention. They may be wheelchair dependent or ambulant, albeit with The term 'management' can be used to refer to an abnormal gait, but they cope with their dis- the entire process whereby patients' problems are ability and are content with their situation. identified and their needs analysed, as a result of Indeed, professional overtreatment and striving which they are subsequently admitted to an indi- to remedy deficits rather than compensate for vidually tailored programme of treatment and them may be the cause of 'mental distress', which review which continues for as long as their dis- was identified as a predominant disability in ability persists (Condie 1991). Unfortunately, this adolescents and adults with spastic diplegia is rarely the case, in spite of people with physical (Bleck 1987). disability being designated a priority group in Care in Action, the Government's 1981 handbook Many people with spastic diplegia walk inde- of policies and priorities for health and social pendently, often with flexion, adduction and services in the UK. Services for disabled people medial rotation of the hips, flexion of the knees remain confused and extremely variable with a and plantar flexion and equinus of the feet. The distinct lack of good practice (Beardshaw 1988). pelvis is usually anteriorly tilted with a marked
LONGER-TERM MANAGEMENT 261 lumbar lordosis. The arms, which often have adolescence and early adulthood, when increased minor motor deficits, are constantly active in main- weight and reduced mobility increase disability, taining balance. The abnormal stresses and strains therapy is withdrawn. It is at this time that, in imposed on the musculoskeletal system by this more severe cases, the individual may become posture may lead to arthritic changes in joints. wheelchair dependent. This is obviously a critical Some of the problems which may arise include: time from both a physical and an emotional perspective. Provision of a wheelchair should not • Poor alignment of the hip joint during stance only involve a thorough assessment as to the phase of gait results in damage to the joint sur- most appropriate chair but should also include faces. The constant pull into adduction and physiotherapy to advise and instigate an exercise medial rotation may, in severe cases, cause programme to prevent physical deterioration. displacement of the joint (Bleck 1987). In many cases there will already be some shorten- ing of the flexor muscles, and prolonged sit- • The constant flexion of the knees causes 'alta ting will exacerbate this problem. A regimen of patella' through overstretching of the patella standing and appropriate stretches should be ligament (Sutherland & Cooper 1978). Effective devised for the individual, to guard against this action of the quadriceps muscle group is never possibility. developed and, as the child becomes older and heavier, joint changes are almost inevitable. The structural and functional problems of people with cerebral palsy are often neglected • The feet may be severely deformed with and viewed as an integral part of the condition. breakdown of the medial arch and plantar This is not always the case. For example, pain, fascia through the constant forces imposed on which may result from musculoskeletal changes these structures with toe walking (Fig. 11.2). arising from the abnormal postures and move- ments, requires treatment just as it does in the • The anterior tilt of the pelvis may lead to con- able-bodied population. A detailed assessment tracture of the psoas muscle, further increasing may be able to identify a specific cause of the the lumbar lordosis. pain, which may respond to treatment. These problems may increase in severity over the years and yet, at the most vulnerable time of (A) (B) Figure 11.2 (A) Collapse of the medial arch in an adult with cerebral palsy; (B) weight-bearing surface.
262 NEUROLOGICAL PHYSIOTHERAPY Summary mise function and prevent secondary complica- tions. To date, there is little that can be done to For those with chronic residual physical disability halt the progression of many of these diseases, the danger of secondary complications, such as but an understanding of the expected com- respiratory problems, contracture and postural plications and compensations from the primary deformity, remains throughout the course of their impairment will enable the physiotherapist to lives. The more severe the abnormal postures and intervene more appropriately. movements, the greater is the danger. Regular assessment and treatment intervention as indi- Multiple sclerosis (MS) cated is essential to prevent their occurrence. However, it must be recognised that many people Multiple sclerosis is an inflammatory, demyeli- cope adequately, even with gross disability and nating disorder which is the most common cause deformity, and do not desire ongoing therapy. of neurological disability in young adults (Thompson & McDonald 1992, Barnes 1993). A Currently, very few specialist health and co- relapsing and remitting course is common but ordinated services are organised for people who the condition may subsequently become progres- are only physically disabled, and the develop- sive, when it is termed 'secondary progressive'. ment of such services is recommended in each Between 15 and 20% of all MS patients have district health authority (Bax et al 1988). benign MS where there are few attacks early on and little if any residual disability (Weinshenker PROGRESSIVE NEUROLOGICAL 1994). Less than 10% show a primary progressive AND NEUROMUSCULAR course (Thompson & McDonald 1992). Over the DISORDERS past decade there has been a significant increase in the survival time, resulting in an almost Introduction normal life expectancy for the 'average person' with MS (Mertin 1994). Patients with progressive neurological and neuro- muscular disorders will require ongoing treat- A diagnosis of MS is dependent upon the ment and management appropriate to the stage clinical demonstration of lesions disseminated in of the disease process for the purpose of ensuring time and space and the exclusion of other con- optimum function and the prevention of sec- ditions which may produce the same clinical ondary complications. Regular reviews should picture (Thompson & McDonald 1992). Magnetic be arranged in order to monitor the condition. resonance imaging (MRI) may support the clini- cal diagnosis by identifying multiple lesions Examples of these disorders include multiple which indicate dissemination in space, but these sclerosis, muscular dystrophy, Friedreich's do not always correlate with the clinical status ataxia, spinocerebellar degeneration and the (Thompson et al 1991). hereditary motor sensory neuropathies (HMSN). The changing neurological and/or muscular The disease is characterised by multiple status usually affects the clinical signs and symp- lesions (plaques) of demyelination with differing toms and thereby the patient's functional capa- degrees of inflammation. There is a predilection bility. These conditions are often associated with for the optic nerve, periventricular areas and the a multiplicity of symptoms, the management of cervical cord but all parts of the brain and spinal which requires a coordinated, multidisciplinary cord may be involved. The functional deficit is intervention. ultimately due to abnormalities in conduction. Demyelination causes a slowing or impairment Some people, for example those with multiple of the ability of the nerve fibres to transmit sclerosis, may experience exacerbations and impulses. Both demyelination and inflammation remissions as part of the disease process, contribute to the conduction block and clinical whereas others, such as those with muscular dys- deficit (Thompson & McDonald 1992). trophy, show a steady deterioration of varying severity. The aim of physiotherapy is to maxi-
LONGER-TERM MANAGEMENT 263 The outstanding characteristic in the early stages MS, a full and accurate assessment is essential to is the patient's capacity for clinical recovery from determine the primary problems resulting from individual episodes, primarily through the resolu- the disease pathology. Compensatory strategies, tion of oedema and inflammation with some adopted by the patient in an attempt to achieve remyelination. With partial demyelination, some function, may then be analysed as to their effect- functional recovery takes place. This is mediated iveness, not only in the short term but also over a by the surviving fibres, either of the same system, protracted period of time. or of other systems, that permit learning of new strategies to compensate for the deficit. However, The initial interview between the patient and compensation for progressive axonal loss contin- the physiotherapist must be handled with great ues to become less effective as more fibres sub- sensitivity. It is essential that the physiotherapist serving a particular function are impaired, leading is fully aware of information already given to the to permanent disability (Thompson & McDonald patient. Has the patient been told of the diag- 1992). nosis? The majority of people with MS wish to know their diagnosis at an early stage, wish their The clinical manifestations of the disease are family to be informed at the same time and wish varied but often include optic neuritis, sensory and to be given adequate background information motor disturbance of the limbs and symptoms on the disease and a chance to ask their own relating to brain stem and cerebellar dysfunction questions (Barnes 1993). However, in spite of (Thompson & McDonald 1992). Cognitive distur- this, doctors occasionally delay giving a defini- bances and emotional problems are prevalent tive diagnosis and patients may learn of their (Poser 1980, Minden & Schiffer 1990). Psychiatric diagnosis in an inappropriate manner. disturbance is seen in 40-50% of patients and there is a greater incidence of suicide in the MS popula- Referral to physiotherapy in the early stages of tion (Weinshenker 1994). Fatigue is common and disability can be of great benefit, both in planning frequently disabling (Krupp et al 1988). Pain is a long-term management strategy and for instigat- often associated with MS (Barnes 1993) and ing preventive therapeutic regimens. Continued bladder symptoms occur in between 50 and 75% of monitoring with intervention as required is essen- patients (Thompson & McDonald 1992). tial to cater for the changing needs of the patient (DeSouza 1990, Mertin & Paeth 1994). Unfor- Pseudobulbar and respiratory symptoms may tunately, many patients do not receive this ongoing occur and respiratory muscle weakness, particu- care, and additional problems arising, either from larly of the diaphragm, is the most common the disease pathology or secondary to imposed cause of respiratory distress (Howard et al 1992). abnormal movement strategies, are not addressed. Bronchopneumonia is the leading cause of death An exercise programme that was designed in in MS and may be related to swallowing difficul- the early stages may, over time, become not only ties with resultant aspiration (Barnes 1993). ineffective but possibly detrimental. The course of MS is extremely variable in terms The patient must be an active participant in the of the frequency and severity of attacks, the degree planning of treatment. The patient's priorities of recovery and the development of progressive may differ from those of the therapist, and disability. Progressive onset of symptoms, second- discussion is essential to determine effective ary progression after a remitting phase, older age intervention which meets the requirements of of onset and motor symptoms at onset generally both parties (DeSouza 1990). Multidisciplinary indicate a poor prognosis (Miller et al 1992, clinics are recommended which facilitate inter- Weinshenker 1994). disciplinary cooperation (Fig. 11.3). This profes- sional cooperation is of benefit to all personnel, Physiotherapy intervention not least the patients and their relatives (Barnes 1993, Mertin 1994). The aim should be to ensure Given the complexity and variability of the clini- that there is consistency in approach to treatment cal signs and symptoms which may present in and mutually agreed goals.
264 NEUROLOGICAL PHYSIOTHERAPY Figure 11.3 The interdisciplinary rehabilitation team (adapted from Mertin 1994). Although the physiotherapist is often the key difficulties, marital discord and academic pres- player in the management of motor disorders, sures play an important role in the patient's the management of motor problems cannot be ability to cope with the disease. When the patient viewed in isolation from the other aspects of dis- is removed from his normal, possibly stressful ability which may prevail. It is important that the environment, this in itself may have a thera- physiotherapist has an understanding of the peutic effect (Poser 1980). pathophysiology of MS in that the prognosis is so variable. Physiotherapists may themselves view Treatment of patients with MS is determined MS as a progressive disease which ultimately by the presenting signs and symptoms, those leads to wheelchair dependence and perhaps affecting posture and movement being of great- death. This pessimistic attitude is not generally est relevance to the physiotherapist. The most appropriate. Although consideration must be common forms of movement deficit are associ- given to the mode of onset and type of MS, ated with hypertonus and/or ataxia along with physiotherapy intervention should be geared the secondary effects of fatigue, disuse, pain and towards the presenting signs and symptoms. sensory impairment (Barnes 1993). The primary aims of physiotherapy are to: In many instances, a period of rehabilitation may be of value in ensuring optimal function • maintain and increase range of movement following any change in the level of disability • encourage postural stability (Freeman et al 1997). Not only is this beneficial in • prevent contractures terms of reassessment and restructuring of • maintain and encourage weight-bearing therapy intervention, but of equal importance is the often dramatic remission after hospitalisa- (Ashburn & DeSouza 1988). tion. However, it must be recognised that psy- chological factors such as anxiety over financial To this end, therapy should not be restricted to passive interventions such as stretching and mobilisation of specific parts. The patient must
LONGER-TERM MANAGEMENT 265 be involved as an active participant in the pro- a normal gait pattern is recommended. Those motion of purposeful movements which are part requiring mobility aids should receive appropri- of everyday function (Mertin & Paeth 1994). ate training to ensure that these aids are used Exercise programmes are particularly useful in effectively. enabling patients to take responsibility for their own management and are often effective in For example, an ankle-foot orthosis (AFO) to maintaining range of movement and maximising control loss of adequate dorsiflexion may assist muscle power. in the prevention of unnecessary proximal com- pensation. Without such support, the patient Mertin & Paeth (1994) advocate approaches must inevitably use excessive knee flexion or that differ according to the patient's level of circumduction at the hip to clear the foot during impairment/disability as measured on the swing phase of gait. The AFO may allow for a Kurtzke Disability Status Scale (DSS). Patients more fluid and efficient walking cycle. For those are stratified as having mild (DSS grade 0-2), with ataxia, the use of a rollator walking frame moderate (DSS grade 3-5) or severe (DSS grade may prove of benefit in enabling the patient to 6-9) disability (Miller et al 1992). gain improved stability. However, it is important that the patient uses this aid as a means of For those with a score of less than 5, the balance as opposed to fixation (see Ch. 5). emphasis should be on the normalisation of pos- tural control and inhibition of compensatory Hydrotherapy is considered to be effective for strategies. Facilitation of more normal movement patients with MS (Barnes 1993) but treatment in a patterns, particularly those of standing and gait, hydrotherapy pool, where the temperature of the and an individual home programme of exercises water is often quite high, may increase fatigue. are recommended. For those with increasing The temperature of the water is important, with levels of impairment/disability, with a DSS score increased temperatures potentially slowing of greater than 6, compensatory strategies should nerve conduction (Poser 1980). Patients who be utilised and refined to improve functional enjoy exercise in water may derive more benefit independence with appropriate selection of aids from the cooler temperatures of general swim- and training in their usage. Maintenance of ming pools. muscle and joint range, improving postural control, facilitation of normal movement patterns Weights are considered to be effective in the as appropriate, and maintenance of standing management of ataxia (Morgan et al 1975), but posture should be continued as before. Adapta- these may cause fatigue and often do not have tion of the home exercise programme and the a lasting effect. The patient may accommodate training of carers are necessary to respond to the to the weights over a period of time with the changing functional status of the patient (Mertin ataxia remaining relatively unaltered. Following & Paeth 1994). removal of the weight, the ataxia may be greater than before and postural stability further com- Difficulty in walking is one of the most fre- promised (DeSouza 1990). Weights may be of quent symptoms of MS, and analysis and treat- value as a temporary aid to compensate or ment of mobility problems provides perhaps the dampen tremor, prior to or during performance greatest challenge in MS management (Barnes of a functional task. 1993). Standing is of value for virtually all patients with abnormal tone and movement. This Appropriate seating, particularly for those is effective in both maintaining and regaining with severe neurological deficit who are wheel- range of movement, stimulating extensor activity chair dependent, is essential. Detailed descrip- (Brown 1994) and in improving the body's tion of postural control and specialised seating is spatial orientation. Assessment of the primary provided in Chapter 9. cause of the gait impairment is essential in deter- mining the most appropriate intervention. For Splinting may be effective in maintaining those who are mobile without aids, facilitation of range of movement, or can be used as a cor- rective measure for regaining range (Barnes 1993, Mertin 1994).
266 NEUROLOGICAL PHYSIOTHERAPY The management of respiratory complications, muscular atrophy. Most people with HMSN have particularly in the advanced stages of MS, raises a dominantly inherited disorder associated with a ethical issues. It is important that patients who duplication of chromosome 17 (Malcolm 1993). are at risk of acute respiratory complications, associated with bulbar and spinal cord relapses, There are many different types of HMSN, the are identified early; provision of appropriate most common forms being referred to as types I support during the period of respiratory insuffi- and II (Geurts et al 1992a). Type I is characterised ciency reduces the incidence of sudden death by a demyelinating neuropathy causing slow and reduces distress (Howard et al 1992). Some nerve conduction, whereas type II is the result of patients were found to improve significantly axonal degeneration. The clinical signs and with remission and not all required continued symptoms are similar in both type I and type II, mechanical assistance. the main difference being the age of onset. Type I usually produces symptoms earlier, most com- Summary monly between the ages of 5 and 15. In type II, although symptoms may develop in childhood The likely progressive nature of the disease makes they occur more commonly between the ages of it imperative that regular multidisciplinary assess- 10 and 20 and often not until much later ment, including physiotherapy, continues for so (Harding 1993). long as patients demonstrate changes in their clinical signs and symptoms. Wherever possible, The sensory symptoms are usually less severe this monitoring should be undertaken by staff than the motor and generally occur later in life who are familiar with the patient. All too fre- (Medhat & Krantz 1988). However, impaired pro- quently, patients with MS whose condition is prioception is seen in many older patients and being regularly reviewed are seen by different may contribute to the balance problems associ- therapists at each assessment. This makes it very ated with HMSN (Harding & Thomas 1980, difficult to plan and monitor long-term treatment Geurts et al 1992b). Postural and intention tremor strategies and to evaluate the functional con- may be associated with type I HMSN (Harding sequences of the changing neurological status. It 1984). is inevitable, however, where staff are on rotation through different specialities and spend only a Clinical signs and symptoms limited period of time in any one department. Hereditary motor and sensory neuropathy, al- Standardised testing with the use of appro- though showing great variability in the severity priate outcome measures, as advocated in Chap- of symptoms, has a predictable course, affecting ter 2, is essential to monitor any change in the feet and legs and much later the hands and function and effectiveness of intervention. forearms (Harding & Thomas 1980). Hereditary motor and sensory Lower limb muscle impairment and functional neuropathy (HMSN) deficit. The lower limb weakness initially affects the intrinsic foot musculature and peroneus Introduction brevis, followed by tibialis anterior, peroneus longus and the long toe extensors, later pro- This term is used to describe a group of con- gressing to affect the plantar flexors (Mann & ditions which give rise to progressive weakness Missirian 1988, Geurts et al 1992a). This creates and wasting of the distal muscles of the legs and an imbalance of activity at the foot and ankle that of the hands (Harding 1993). Other names which may result in deformed, unstable and often may be used to describe HMSN include Charcot- painful feet, which interferes with gait (Wetmore Marie-Tooth disease, after the three neurologists & Drennan 1989). Pes cavus, equinus and who first described the condition, and peroneal clawing of the toes are typical aspects of the foot deformity (Medhat & Krantz 1988). Con- tracture of the triceps surae is common (Mann &
LONGER-TERM MANAGEMENT 267 Missirian 1988) and ankle sprains are frequently Figure 11.4 Writing without splint. reported (Barcardi & Alm 1986). Overuse of the affected muscle groups seems The progressive atrophy and the resulting to compound the weakness, many people giving deformity and functional loss are described by personal accounts of how they have never recov- Mann & Missirian (1988): ered from a bout of strenuous exercise such as painting and decorating. Being so dependent on The weakness of the tibialis anterior permits the the hands for function, it is unrealistic to expect peroneus longus to function relatively unopposed, people not to use them. which accounts for most of the marked plantar flexion of the medial side of the foot. The lack of Physiotherapy intervention function of peroneus brevis permits the tibialis posterior to function without significant opposition, Assessment and appropriate intervention by a which results in the hind foot being brought into physiotherapist is of vital importance for patients inversion (varus) and the forefoot into a certain with HMSN. One of the major problems is that degree of adduction. The deformity is further the insidious onset of the disease is often missed enhanced by the progressive contracture of the by both the patient and the clinician (Geurts et al intrinsic muscles and plantar aponeurosis, which 1992b) and, unless there is a family history of the further brings the forefoot into an adducted and disease, patients may not present for treatment plantar-flexed position. The normal long toe flexors before symptoms become established. contribute to the adduction of the forefoot because their normal antagonists, i.e., the extensor digitorum Harding (1993) stresses the importance of suit- longus and the extensor hallucis longus muscles, are able footwear and, particularly for those with weakened by the disease process. sensory impairment, the need to examine both the feet and the inside of the shoes on a regular Geurts et al (1992b) demonstrated a decreased basis to reduce the risk of ulceration. Splints are postural control in patients with HMSN, even advocated to control the foot in the plantigrade when there was full perceptual information. This position to reduce ankle instability and to allow was attributed to the lower limb paralysis and the ankle-foot deformities impairing postural sway. For those with no restriction of range of movement of the plantar flexors, a few degrees of forward body inclination was noted. Difficulties with walking arising from the pro- gressive muscle imbalance are typically those of a high-stepping gait to compensate for the lack of dorsiflexion (Geurts et al 1992a), weight-bearing over the lateral border of the foot (Bacardi & Alm 1986) and lateral instability of the ankle (Wukich et al 1989). Upper limb problems associated with HMSN. The weakness of the hands is characterised by wasting of the intrinsic hand muscles, which may progress to the forearms (Harding 1984). Sensory impairment is variable but in severe cases the numbness of the hands may result in injury such as burns to the hands (Harding 1993). The thenar and hypothenar muscles become progressively weaker and opposition of the thumb to the fingers is impaired. Functionally, these people adapt by using gross flexion for tasks requiring a pinch grip. This is illustrated by the manner in which they write (Fig. 11.4).
268 NEUROLOGICAL PHYSIOTHERAPY for a more economic gait pattern (Medhat & the toes, in addition to maintaining the foot in a Krantz 1988, Geurts et al 1992a, Harding 1993). plantigrade position and preventing lateral insta- bility. The disadvantage of this type of splint is There is little literature regarding specific that it does not permit talocrural mobility, par- physiotherapy intervention. However, with the ticularly dorsiflexion which would redress the relatively stereotyped picture which emerges as a varus deviation (Geurts et al 1992a). The use of a result of the disease process, physiotherapy treat- hinged AFO may be of benefit to allow this ment and management can be instrumental in movement into dorsiflexion, but the bulk of these preventing or minimising the expected defor- splints often makes them aesthetically unaccept- mity. For example, the progressive contracture of able. A below-knee caliper with heel socket and the intrinsic foot musculature and the plantar outside T-strap may be more effective, but these fascia may be reduced by an early programme of are more obtrusive. The choice of orthosis should massage and mobilisation of the feet to maintain be discussed between the patient, the physiother- flexibility within these structures. This inter- apist and the orthotist. Whichever type of ortho- vention may also prove effective in maintaining sis is provided, it is essential that the patient be range of movement within other muscles given a structured programme of stance and gait affected in the disease process. training (Geurts et al 1992a). Monitoring the con- tinued efficacy of the splint or insoles should be The relatively unopposed action of the gastro- carried out on a regular basis and, where the cnemius has particular consequences which may patient is dependent on the splints for ambula- be managed effectively with appropriate physio- tion, an additional pair should be provided in therapy intervention. Shortening of gastro- case of breakage. The different types of orthoses cnemius restricts dorsiflexion and may cause are described in Chapter 10. hyperextension of the knee in standing and walking, due to its action over the two joints - Documented treatment of the foot deformities the ankle and the knee. The weight tends to be usually relates to surgery, particularly that of displaced backwards, due to the inability to tendon transfer (Medhat & Krantz 1988, Wetmore transfer the weight over the full surface of the & Drennan 1989). This would still appear to be foot during stance phase of gait. Maintenance of appropriate early intervention in redressing the the centre of gravity within the base of support muscular imbalance (Mann & Missirian 1988). can only be effected by flexion at the hips. Triple arthrodesis was commonly carried out in Flexion at the hips produces an anterior tilt of the past but is now considered to be a 'salvage' the pelvis, creating an excessive lordosis if the procedure limited to those with severe rigid individual is to maintain an upright posture. deformity (Wetmore & Drennan 1989, Wukich et al 1989). Regular stretching of gastrocnemius and other affected muscle groups may go some way The use of a thumb opposition splint may towards preventing the onset of contracture. serve to maintain more normal function of the However, stretching must be used with caution, hand by facilitating opposition of the fingers to particularly where there is substantial somato- the thumb without overuse of opponens pollicis. sensory impairment, with special attention paid This splint is compact, easy to make and readily to the correct alignment of bony structures. applied or removed as the situation demands. People with early signs of hand weakness should The imbalance of muscle activity caused by the be encouraged to use this support to maintain progressive weakness can be best managed by normal hand function with opposition of the earlier rather than later use of insoles and AFOs. thumb to the fingers. Its use is illustrated in Insoles may prove effective in the redistribution Figure 11.5 as a means of improving writing. of weight across the full surface of the foot (see Ch. 10). Patients with more severe weakness may demonstrate signs of diaphragmatic weakness. The main advantage of the polypropylene This is often characterised by the patient com- AFO is that it is moulded to each individual's foot. It therefore supports the medial arch and
LONGER-TERM MANAGEMENT 269 HMSN Self-Help Group 1995, personal com- munication). By identifying the potential problems, appro- priate stretching to maintain range of movement, exercise to improve postural alignment and pro- vision of suitable orthoses may markedly reduce the onset of structural deformity. Early and con- tinuing management of these patients may substantially reduce the need for what is often painful, expensive and, in many cases, pre- ventable surgical intervention. If surgery is deemed necessary, physiotherapy is essential postoperatively to ensure a good functional outcome. Figure 11.5 Writing with splint. DISCUSSION plaining of morning headaches, interrupted The management of these patient groups raises sleep and daytime somnolence. The physiothera- several issues that relate to many with chronic or pist should be aware of this complication and, if progressive disability: it appears to be a problem, check the patient's vital capacity in both sitting and supine posi- • the timing, extent and duration of therapy tions. Sleep studies may be necessary to deter- • surgical intervention mine the extent of the problem, and ventilatory • the most effective use of finite resources. support may be required. The timing, extent and duration of physiotherapy Summary intervention The fairly clear-cut and progressive nature of this This is of particular concern, especially for those disease makes its course relatively easy to with severe residual disability such as may arise predict, and thus appropriate interventions can following severe head injury. These patients may be instigated. require physiotherapy over a period of many years in order to achieve and maintain the One of the major problems facing this group of optimal level of function. patients is the comparative rarity of the disease. Many therapists, particularly those working in Early treatment and management is rarely dis- neurology, may have heard of Charcot-Marie- puted, but the duration of this intervention is Tooth disease or HMSN but see very few people increasingly questioned (Bax et al 1988, Condie with this condition. The literature is scarce 1991). Adults with cerebral palsy illustrate this regarding physiotherapy intervention. Provision point. These people may receive ongoing care of splints is often delayed until there is estab- throughout childhood and adolescence but, on lished deformity and, when provided, they are leaving school, the therapy input is reduced, and ill-fitting, causing additional problems of pres- this may lead to a deterioration in their condition sure and skin breakdown (CMT International, with resultant loss of function. The prevention of secondary complications, such as contracture, and maximising function is the main remit of the physiotherapist (Pope 1992). Treatment to this effect should be insti- gated in the immediate aftermath of injury or at
270 NEUROLOGICAL PHYSIOTHERAPY the onset of disease. This may involve a period of be based on the assumption that the patient will intensive rehabilitation or merely advice to the make a good neurological recovery (Yarkony & patient regarding appropriate maintenance. The Sahgal 1987). timing and duration of rehabilitation is of special concern. It is important to distinguish between neural and non-neural components that contribute to For example, some patients such as those with changes in muscle and joint contracture (Ough et cervical cord injuries may benefit from an interim al 1981, Garland & Keenan 1983). Treatment period, to come to terms with their disability, using temporary paralysing agents such as prior to undertaking intensive rehabilitation. phenol or botulinum toxin may be effective in Their time in hospital may be affected by prob- determining the extent of contracture as opposed lems such as respiratory tract infections and auto- to the effects of hypertonus. These agents may nomic dysfunction. This affects their ability to also be of value in determining the effects of sur- participate in an intensive rehabilitation pro- gical intervention. For example, children with gramme and, in some cases, they may not realise spastic diplegia characteristically demonstrate their full potential prior to discharge from hospi- predominant flexion of the lower limbs. Plantar tal. In the majority of cases, the level of function flexion at the ankle provides an extensor com- attained by discharge is that which is assumed to ponent which may be essential to keep them be optimum. Patients who have been managed in upright against gravity. Surgery to elongate the a spinal injuries unit will usually be 'followed up' Achilles tendon may permanently take away this on a regular basis to ensure there are no medical extensor component, and further flexion may complications. However, it is rare for patients to ensue, which can lead to progressive crouch gait be offered an additional period of rehabilitation (Sutherland & Cooper 1978). even though their capability to benefit from this may have significantly improved. Extensive procedures have been described for the management of residual limb deformities The timing of physiotherapy intervention has following head injury (Ough et al 1981, Garland been questioned in the management of stroke & Keenan 1983). Surgical intervention should be (Partridge 1994). Providing the patient is not at considered on a holistic basis and not purely risk of deterioration, consideration should be in respect of elongating a contracted muscle or given to delaying intensive rehabilitation follow- decreasing muscular activity The functional ing sudden onset of disability. Although it is implications of surgery, particularly of muscles crucial to ensure correct maintenance by instruct- acting over more than one joint, must be consid- ing carers in appropriate methods of positioning, ered. It is important to remember that surgical handling and exercise, patients must be assessed procedures are a means to an end and not the end individually to determine the most appropriate in itself. Postoperative management is man- timing for intensive rehabilitation. datory if a successful outcome is to be achieved and must continue until such time as is necessary Surgical intervention to prevent reversal (Pope et al 1991). With some conditions, surgical intervention may Heterotopic ossification is a recognised com- be necessary to restore range of movement in a plication in patients following spinal cord injury contracted limb, stabilise a joint or transfer a (Silver 1969, Daud et al 1993) or head injury tendon to improve function. (Garland & Keenan 1983, Yarkony & Sahgal 1987, Davies 1994). It occurs predominantly around The risk of contracture is greatest for those proximal joints. Surgical excision of heterotopic with impaired cognition and hypertonus (Ough bone has had variable results (Garland & Keenan et al 1981) and increases with prolonged duration 1983) and conservative management is recom- of coma (Yarkony & Sahgal 1987). Contractures mended (Andrews & Greenwood 1993). The are best treated by prevention (Cherry 1980, incidence of recurrence following surgery is Frank et al 1984), and joint management should high, particularly in patients with hypertonus.
LONGER-TERM MANAGEMENT 271 Perioperative radiotherapy may be useful in power resources are deployed, there will be a inhibiting the recurrence of heterotopic ossifica- continuing problem. tion following surgical excision (International Working Party 1996). Surgical excision should Prevention of secondary complications is of not be performed until at least 11/2 years after primary concern and physiotherapy may be injury, when calcification is no longer an active required for an indefinite period of time to process. A bone scan should demonstrate a ensure optimal function. Ongoing assessment for decrease in activity (Garland & Keenan 1983). people with progressive neurological disorders is essential to contend with any deterioration in The surgical management, such as tendon their physical status. However, those with non- transfer and joint stabilisation, for patients with progressive impairment, such as patients with progressive neuromuscular disorders has been cerebral palsy or following stroke, brain damage discussed in relation to patients with HMSN. or spinal cord injury, may also deteriorate over Similar principles apply for others with muscle time. Abnormal tone may lead to progressive dis- imbalance. In all instances, if surgery is deemed ability due to the impoverishment of movement. necessary, physiotherapy is essential post- People who are restricted to a limited array of operatively to ensure a good functional outcome postures and movements are as vulnerable to the (Pope 1992). development of secondary complications as are those with progressive disorders. The most effective use of finite resources Therapists must produce evidence that on- Resources for health care provision are finite and going treatment for the more severely disabled it is therefore essential that further research is may significantly improve their level of function, undertaken in the field of chronic neurological with a consequent reduction in resources being disability to ensure that there is appropriate use required in the longer term. Given that these of these resources. There is an approximate ratio resources are limited, the timing of intervention of 1 chartered physiotherapist to 86 severely as discussed above is of primary concern. This is disabled people in the United Kingdom (Condie an issue of great importance and demands the 1991) and clearly, no matter how well man- urgent attention of physiotherapy researchers, as recommended in Chapter 12. REFERENCES Ada L, Canning C, Paratz J 1990 Care of the unconscious Bach-y-Rita P 1990 Brain plasticity as a basis for recovery head-injured patient. In: Ada L, Canning C (eds) Key of function in humans. Neuropsychologia 28: issues in neurological physiotherapy: physiotherapy 547-554 foundations for practice. Butterworth-Heinemann, Oxford Barnes M 1993 Multiple sclerosis. In: Greenwood R, Barnes M P, McMillan T M, Ward C D (eds) Neurological Andrews K 1999 The vegetative state - clinical diagnosis. rehabilitation. Churchill Livingstone, London Postgraduate Medical Journal 75: 321-324 Bax M C O, Smyth D P, Thomas A P 1988 Health care of Andrews K, Greenwood R 1993 Physical consequences of physically handicapped young adults. British Medical neurological disablement. In: Greenwood R, Barnes M P, Journal 296: 1153-1155 McMillan T M, Ward C D (eds) Neurological rehabilitation. Churchill Livingstone, London Beardshaw V 1988 Last on the list: community services for people with physical disabilities. King's Fund Centre, Andrews K, Murphy L, Munday R, Littlewood C 1996 London Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. British Medical Journal 313:13-16 Bleck E E 1987 Orthopaedic management in cerebral palsy. Blackwell Scientific Publications, Oxford Ashburn A, DeSouza L H 1988 An approach to the management of multiple sclerosis. Physiotherapy Practice Bobath K 1974 The motor deficit in patients with cerebral 4:139-145 palsy. Clinics in Developmental Medicine. No. 23. Spastics International Medical Publications, William Bacardi B E, Alm W A 1986 Modification of the Gould Heinemann Medical Books, London operation for cavovarus reconstruction of the foot. Journal of Foot Surgery 25: 181-187 Brown P 1994 Pathophysiology of spasticity. Journal of Neurology, Neurosurgery and Psychiatry 57: 773-777
272 NEUROLOGICAL PHYSIOTHERAPY Cherry D B 1980 Review of physical therapy alternatives for Klein F C 1982 The silent epidemic. Wall Street Journal 24 reducing muscle contracture. Physical Therapy 60: November 877-881 Krupp L B, Alvarez L A, La Rocca N G, Scheinberg L C 1988 Childs N L, Mercer W N, Childs H W 1993 Accuracy of Fatigue in multiple sclerosis. Archives of Neurology 45: diagnosis of persistent vegetative state. Neurology 43: 435-437 1465-1467 Malcolm S 1993 CMT: clearing up a mystery. Muscular Condie E 1991 A therapeutic approach to physical disability. Dystrophy Group of Great Britain and Northern Ireland, Physiotherapy 77: 72-77 London Daud O, Sett P, Burr R G, Silver J R 1993 The relationship of Mann R A, Missirian J 1988 Pathophysiology of heterotopic ossification to passive movement in Charcot-Marie-Tooth disease. Clinical Orthopaedics and paraplegic patients. 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LONGER-TERM MANAGEMENT 273 Thompson A J, Kermode A G, Wicks D et al 1991 Major Wetmore R S, Drennan J C 1989 Long-term results of differences in the dynamics of primary and secondary triple arthrodesis in Charcot-Marie-Tooth disease. progressive multiple sclerosis. Annals of Neurology 29: Journal of Bone and Joint Surgery 71-A(3): 53-62 417-422 Tribe D, Korgaonkar G 1992 Withdrawing medical Wukich D K, Usar M C, Bowen J R 1989 A long-term study treatment: implications of the Bland case. British Journal of triple arthrodesis for correction of pes cavovarus in of Hospital Medicine 48: 754-756 Charcot-Marie-Tooth disease. Journal of Paediatric Orthopaedics 9: 433-437 Vogenthaler D R 1987 An overview of head injury - its consequences and rehabilitation. Brain Injury 1: 113-127 Yarkony G M, Sahgal V 1987 Contractures: a major complication of craniocerebral trauma. Clinical Weinshenker B G 1994 Natural history of multiple sclerosis. Orthopaedics and Related Research 219: 93-96 Annals of Neurology 36: S6-S11
CHAPTER CONTENTS The way forward Introduction 275 Financial resources for health 276 Cecily Partridge Treatment 277 Evidence-based practice 278 INTRODUCTION Research 281 Clinicians and researchers 282 This book provides physiotherapists with an in- References 284 depth understanding of many of the problems encountered by patients with neurological condi- tions and demonstrates ways of solving them. The emphasis is on the analysis of abnormal pathology and determining appropriate treat- ment interventions. Problem solving is the key to this approach not only on the part of the therapist but also by encouraging the patient's own problem-solving abilities. Treatment of neurolog- ical disorders takes place within the wider context of the delivery of health services and, here too, there are many problems to be solved to ensure patients are able to have access to optimal care. What I propose to do is to look at some of these broader issues that currently impinge on the provision of treatment for neurological patients. There will be a number of major influences on the delivery of health services in the next decade that are common to most countries in the Western world, and probably elsewhere. They include the overall increase in the demand for health services, exacerbated by the increasing proportion of elderly people in the population, the recent avail- ability of expensive super drugs and the overall scarcity of financial resources to meet these demands. The current emphasis on evidence- based practice and the overall scarcity of research in physiotherapy are also key issues, as are the patterns of delivery of services and information about the actual content of treatment. 275
276 NEUROLOGICAL PHYSIOTHERAPY FINANCIAL RESOURCES FOR ing limited resources. These include selection by HEALTH choosing to restrict funding to specific services, or limiting the number and type of treatments Because of recent advances in medicine over the that will be funded for specified conditions. last 50 years or so, many more conditions can Neurological physiotherapy is vulnerable to both now be successfully treated and, for others, of these models: if in competition with, say symptoms can be relieved or life prolonged by pathology or surgery, or with funding for cardiac the use of medication, which is sometimes services, it does not have the same immediate extremely expensive. Increasing longevity brings life-saving image and is likely to lose out. an added burden, as the elderly consume a dis- Limiting the number of treatments for patients proportionate amount of health services. As there with long-term conditions such as Parkinson's will never be unlimited resources, some form of disease, multiple sclerosis or head injury, who are rationing will always be necessary, although likely to require treatment over a prolonged health agencies are often reluctant to use the term. period, presents a problem. The therapy sessions The percentage of the gross domestic product themselves are usually on a one-to-one basis (GDP) spent on health differs between countries; with fairly lengthy treatment sessions, and are in the Western world, for example, Britain is one therefore relatively expensive. of the lowest at under 6%, Denmark 8%, Australia 8.4%, France 9.6%, Germany 14%, with the USA Health care agencies are used to funding treat- as the highest at 16%, but even those countries ment at the level of diagnostic categories, where with high percentages still report problems in the pathology and the likely outcomes of treat- deciding on priorities and meeting demands. ment are well recognised. Because the focus of physiotherapy for neurological conditions is on Difficult choices must be made between funding treating and managing the consequences of treatment for (a) different groups of people, such disease, rather than the pathology itself, the as children, the active work force and the elderly; results of treatment are likely to be more individ- (b) different conditions, such as mental health, ual, less clear cut and less familiar to administra- cancer or cardiac conditions; (c) prevention and tive managers. This again mitigates against easy medication which will relieve symptoms but not allocation of resources. cure; and (d) treatments for which there is little evi- dence of efficacy but a high demand, such as the All this places a new urgency on physio- use of hyperbaric oxygen for patients with multi- therapists to demonstrate exactly what their ple sclerosis. There is also, in some countries such treatments can achieve with different patient as the UK, an ideological problem over state versus groups, to clarify the implications of treatment private funding for health services, which is a given in different settings and to justify the need further complication. for specialist staff. It will also mean admitting what cannot be achieved. If it can be demon- Where services are provided is also an issue. strated that patients actually deteriorate without There has been a move to more provision of ser- treatment, this too will strengthen the case for vices in the community, but there is some contro- physiotherapy. Services which can demonstrate versy about where provision is most economic; in their effectiveness are clearly likely to get priority general, it is seen to be more expensive in hos- and be funded. If it can be clearly demonstrated pitals. However, moving services into the commu- that physiotherapy has a real-life value for these nity can mean that instead of receiving treatment patients, the case could be made that, as lifelong from an experienced neurological therapist in the treatment for something like diabetes is widely clinic or hospital, patients may be seen by thera- accepted, lifelong treatment for some neuro- pists who do not have comparable skills. logical conditions can be justified if it saves money by keeping patients more able and inde- National health services and health insurance pendent and increasing their overall quality of agencies have to make major decisions about life. priorities and then use different ways of allocat-
THE WAY FORWARD 277 TREATMENT definition of impairment remains similar and is at the level of systems and structures, but both the Although textbooks contain detailed explana- terms and the underlying concepts for disability tions of different methods of physiotherapy and handicap have changed. Disability is altered to treatment, little clear information is available restrictions of activity, and handicap to restric- about what physiotherapists actually do in prac- tions of participation in everyday life. Both these tice, even when working within the framework underlying concepts and the terms used are more of a particular named approach. Because neuro- patient friendly and more appropriate for neuro- logical patients are treated on the basis of the logical therapists, who usually operate at the level results of an individual assessment and progres- of activity and the facilitation of participation in sion based on the response to that intervention, everyday life. Work similar to this needs to be the scope for variability is considerable. Some undertaken in physiotherapy. As a profession, we therapists may be 'disciples' of a given approach have started to recognise this problem but, as and follow texts fairly rigorously, yet there is Stephenson et al (1998) found on discussing asso- little evidence to date that even when working ciated reactions, it can arouse strong feelings and within a named approach similar treatments are great controversy. Consultation to arrive at a con- given (Partridge & De Weerdt 1995). Other thera- sensus is clearly necessary but does present a for- pists may take a more eclectic approach, using all midable challenge. their clinical skills, often gleaned from a number of different sources. The diversity here is likely to There are many anomalies in describing be even greater. treatment and management by neurological physiotherapists. First, there is considerable A complicating factor here is the lack of an heterogeneity in the conditions treated them- agreed language for describing patient symp- selves. They may be single incidents such as toms or physiotherapy interventions. Harms stroke, spinal cord or head injury where there is Ringdahl (1998) stresses the importance of damage to the nervous system which does not of describing practice in sufficient detail. She dis- itself progress, but where there may be sec- cusses the current problems by highlighting the ondary changes resulting from dysfunction and frequent use of terms such as conventional and inactivity. Some natural resolution is expected to standard in relation to physiotherapy, whereas no occur in the early stages. The manifestation of one would think of describing any treatment as similar conditions may vary widely between 'standard psychology', or conventional 'physician patients, and in the same patient over time, as treatment'. This highlights the lack of appropriate will their individual response to their condition. and agreed terminology. Because of this diversity, the same treatment for the same condition cannot be prescribed. For A situation, somewhat similar to that of physio- those with progressive conditions, the aims of therapy, occurred in the field of rehabilitation in treatment may be more to do with maintaining the late 1970s when it was realised that there was levels of activity, or slowing the progressive loss considerable semantic confusion in describing the of activity despite increasing neurological deteri- consequences of disease. The language for disease oration. This is an area which may make a big pathology for acute conditions was well estab- difference to the patient concerned but clearly, lished but was not appropriate for describing successful outcomes are much more difficult to longer-term conditions where cure was unlikely. demonstrate. This resulted in the World Health Organisation (WHO) developing the International Classifica- The first challenge is to tackle the problem of tion of Impairments, Disabilities and Handicaps describing what physiotherapists do in their (ICIDH 1980). This was updated after wide work with patients. Because of the great diversity consultation with both professionals and patients it may be necessary to classify types of treatment and published as the Classification of in terms of their similarity. In a recent trial of Functioning and Disability (ICIDH 1999). The physiotherapy for patients with stroke, Partridge
278 NEUROLOGICAL PHYSIOTHERAPY et al (in preparation) used aims of treatment to normal movement and feel that compensatory describe the type of treatment given to patients. strategies may need to be adopted and some- It was found that therapists working within the times actively encouraged. It requires great Bobath approach used similar methods of clinical skill and judgement to know when a treatment under a given aim. Aims were much patient's optimal level of normal movement has fewer in number than the potential number of been reached and that compensation is now the treatments. best strategy: too soon, and true gains may be missed and the patient left with movements In the Bobath approach to treatment, quality of which will encourage future secondary compli- normal movement is a key aim of many of the cations; too late, and the patient may lose moti- techniques used. It is an elusive phenomenon vation to continue striving, as their efforts appear which is difficult to describe and quantify. to produce no practical benefits. It is common Quality usually refers to the extent to which practice for some therapists not to allow patients movement follows normal patterns. These pat- to stand or walk until they have achieved a level terns are familiar to those following the Bobath of 'normality' in the walking, but is there evi- (1990) approach but they are less clear to others. dence to support this and what about the psy- Even within the Bobath approach, therapists may chological effect of being held back? All these not be using the terms in the same way, as there questions need to be addressed without delay. is no agreed written language. Terms such as specific inhibitory mobilisation of muscle (SIMS) EVIDENCE-BASED PRACTICE are frequently used to describe a treatment tech- nique, yet there appears to be no reference to the The importance of evidence-based practice (EBP) term in the literature. This situation presents two is presented as somewhat novel at the beginning major problems: first, without clear definitions of of the 21st century, yet the desire to know what terms used it is difficult to explain what treat- effect treatments have, and the search for evi- ment was given; and, secondly, it is almost imposs- dence of success of treatment have a long history, ible at present to measure or monitor 'quality' of going back as far as 300 BC (Lloyd 1996). The movement in any reliable or objective way. We recent emphasis is perhaps more related to the need to demonstrate clearly the value, and vast range of treatments that have been devel- indeed the possibility, of more normal movement oped over the last decade and the limited finance in someone with a damaged nervous system. available to purchase them from health insurance or national health services. There is also the Another major question which remains to be increased expectations of the general population answered is how long do treatment effects last, about provision of health services. Evidence- and what is the extent of transfer to everyday based practice will certainly influence provision life? Remarkable changes can be achieved by of physiotherapy services in the future. physiotherapists with specialised neurological skills in demonstration sessions and in practice in Much more has been written about evidence- the clinic, but the extent to which these gains are based medicine (EBM) than about evidence- maintained and transferred to activity in daily based physiotherapy, although its important life is not known. relationship to physiotherapy has recently been highlighted by Bithell (2000). The medical litera- How does the patient who can walk with an ture provides a good starting point as there are even balanced gait under supervision in the many similarities, though some clear differences. treatment gym, walk when he is about his daily One definition widely quoted by major British business in everyday life? Getting to the shops or proponents of EBM is 'integrating individual office may take priority over maintaining a more clinical experience with the best available exter- normal gait; speed and function are surely of the nal evidence from systematic research' (Sackett essence here. In the problem-solving approach et al 1996). Others consider objective evidence to adopted in this book, the authors clearly accept that not all patients will achieve completely
THE WAY FORWARD 279 be the only real evidence and this is shown in the However, clinical opinion is the basis of prac- various hierarchies that have been developed. In tice in both medicine and physiotherapy. It seems medicine the gold standard, the double-blind rather like throwing the baby out with the bath randomised controlled clinical trial, is seen as the water to disregard the importance of clinical pinnacle of excellence (Box 12.1). In this schema, experience. It should probably not even be the least valued is clinical opinion and the new included in these empirical lists as it is, of its 'authority' is seen as the empirical evidence. nature, in a different category, and indeed may Individual clinical experience of the treating clin- vary between experts. One problem is the ician is not even mentioned. importance of well-conducted and well-designed studies, as it is not always easy for a clinician to The same is also true for the hierarchy devised decide on the rigorousness of the methods used. by Hadorn (1996), given below, where the cate- It does raise the important fact that no one gories are somewhat similar and clinical opinion method per se is sound unless well designed and is rated the lowest. Supportive evidence from carried out. well conducted: There tend to be two extremes of thinking in 1. randomised controlled trials that include the field of EBM: 100 patients or more 1. Where the proponents feel that experiential 2. randomised controlled trials with less than knowledge lacks legitimacy for guiding 100 patients medical decision making (Hadorn 1996). From this point of view, the value of expert opinion 3. cohort studies lasts only until such time as the data to make 4. case-control study EBP becomes available. Relying on expert 5. supportive evidence from poorly controlled or opinion is regarded as an 'unfortunate' feature of modern medical practice. uncontrolled studies 6. conflicting evidence, with the weight of evi- 2. For others, the whole topic is perceived dif- ferently. Grimley Evans (1995), a geriatrician, dence supporting the recommendation suggests a major fear for unconvinced clini- 7. expert opinion. cians is that the development of mandatory guidelines will be for the treatment of diseases rather than for the treatment of patients. Tonelli (1990) regards 'reliance on expert opinion' not as an unfortunate consequence of an underdeveloped evidence base in medicine but a necessary requirement for optimal practice of clinical medicine'. Bithell (2000) also supports the importance of experiential evidence in physiotherapy. Though the hierarchies of evidence provided in the medical literature are not directly applica- ble to physiotherapy, evidence does come into different categories, and is at different levels. The well-conducted randomised controlled trial (RCT) does contain elements which will control for bias and produce reliable results if rigorously conducted. In interpreting the results, however, it is important to recognise that these studies usually seek to recruit homogenous groups of
280 NEUROLOGICAL PHYSIOTHERAPY subjects, which means that the results need been referred for occupational therapy, and those not necessarily be directly applicable to an with shoulder pain for physiotherapy; hence, individual patient who may have a number of the link. It is also impossible to compare physio- additional complications. therapy, occupational therapy and speech ther- apy as they have such very different aims and Randomisation is a process which seeks to deal with different aspects of the stroke patient's smooth out the effect of individual differences by problems. ensuring they are equally distributed between the treatment groups, but it is often those very It is important for physiotherapists not to feel individual differences which will be of import- constrained by the comparison between the evi- ance to the treating clinician. Questions that need dence base for medicine and that for physio- to be asked about an RCT should include: Are the therapy. Physiotherapy is not doing too badly at patients in this study similar to my patient in this stage of its professional development. terms of age, stage of disease, and other compli- Despite at least 100 years of scientific medicine, cating factors? Do I know what treatment the at present only around 20% of medical practice patients in the study received? Are the outcome is said to be evidence based (USA Office of measures used valid for the purpose and reliably Technology 1995). Medicine's claim to scientific administered, and are they related to the aims of status is also still tenuous (Munson 1981). It is treatment? It is essential that evidence be con- extremely important not to be misled by the sidered at the appropriate level and in an appro- popularity of current buzz words but to ask priate way with different criteria being used to common-sense questions. examine quantitative and qualitative research. Elimination of bias is essential in clinical trials, Evidence for the effectiveness of different yet when we want to know what patients' views forms of physiotherapy treatment is essential for are about their treatment or condition, it is that a number of reasons. Clinicians need the infor- very 'bias', their personal viewpoint, that is of mation to enable them to provide optimal treat- interest. ment. It is also important for patients to be able to make informed decisions and to do this they Many papers are published, even in learned need to be given information when entering a journals, that are seriously flawed, and therapists treatment programme to enable them to assess must be prepared to challenge them when the costs and likely benefits for themselves. necessary. One such example was published in This is of course a continuing process, as new the British Medical Journal by Brocklehurst et al information will constantly be arriving. (1978) entitled 'How much physiotherapy for patients with stroke?'. It was described as a com- Administrators and managers are interested in parative study of physiotherapy, occupational making the best use of resources, although what therapy and speech therapy. Although it looked is considered 'best' will vary from different per- like a trial and had a statistician listed as an spectives. Patients treated by physiotherapists author, on reading the paper it was clear that the are categorised by their diagnoses but the results authors had described practice in their own of physiotherapy are likely to be at the level of hospital rather than conducting a trial; there was influencing the consequences of the disease at the no random allocation of patients. The authors levels of activity restriction and participation showed a correlation between depression and (ICIDH 1999). In acute medicine, diseases can be the amount of occupational therapy, and be- 'cured' and an absence of symptoms demon- tween shoulder pain and physiotherapy. In their strated. In physiotherapy, changes achieved tend discussion they made the assumption that to be more ordinal in nature: for example, depression was caused by occupational therapy patients may achieve more activity, or feel less and shoulder pain by physiotherapy. Equally pain, which are more difficult to demonstrate valid alternative explanations for these results clearly. include the fact that depressed patients may have It is a great challenge for therapists to start this new century with a fresh outlook: not disregard-
THE WAY FORWARD 281 ing the value of clinical experience and the views to be answered, and provide hypotheses to be of authority figures, but critically assessing them; tested. Citing work that seems to explain mechan- not being afraid to challenge established practice, isms was an important stage in our develop- but using all evidence as it becomes available to ment, but we now need to test theories and make decisions about the treatment needed for hypotheses in direct relation to physiotherapy in each individual patient. This will inevitably be a the clinical situation. Until we do, the link continually changing process, taking on board remains unproven. new evidence and new insights as they become available. More recent laboratory work has been helped by the advances in technology such as positron RESEARCH emission tomography (PET) and functional mag- netic resonance imaging (fMRI). These tech- It is well recognised that overall there is a niques have great possibilities in terms of scarcity of research in physiotherapy. This is well increasing our understanding of movement and demonstrated in a meta-analysis of treatment for recovery. There is, however, still a quantum leap stroke. Langhorne et al (1996) could only find between the results of laboratory investigations seven trials which met their criteria for produc- and clinical practice and it is important not to try ing reliable results. Also in many databases such to extrapolate these results directly to practice. as MEDLINE, physiotherapy references are rela- They provide useful insights into cerebral mech- tively sparse in contrast to medicine references anisms and help to formulate hypotheses to be on the same subject. tested in further work. Other forms of laboratory work include research on normal subjects such as The scarcity of research in neurological physio- reliability and validity of active knee measure- therapy is not altogether surprising. This is a ment in healthy subjects, by Brosseau et al (1997), relatively young profession and the speciality of and Haas & Whitmarsh (1998) on the reliability neurological physiotherapy is even younger, as is of the balance performance monitor. Again, these described in the first chapter of this book. As provide useful information but may not be newcomers to research, we suffer from a lack of applicable for patient populations. appropriate methodologies to use in investiga- tions and so have borrowed from disciplines The key issue in sound research is asking such as neurophysiology, biomechanics and the the right questions that are answerable within social sciences. In the 1940s authors cited earlier the time and resources available and where the work as a physiological basis for the phenomena answers will be applicable to practice. There are they observed. For example, Brunstrom (1970) a number of hurdles for all researchers; they relied on the laboratory work of Riddock & must fit their proposals to the interests of those Buzzard (1921) on reflex movements and pos- with finance available, and try to relate to topics tural reactions, and Magnus (1926) on tonic neck of current interest. Physiotherapy is rarely a top reflexes. Bobath (1970, 1990) cites Sherrington priority among major funding agencies and its (1931) on reflex inhibition and Magoun & Rhines profile needs to be raised. (1948) on spasticity. Later work by Carr & Shepherd (1998) cites Rosner (1970) on redun- Many important questions remain to be dancy theory and Luria (1963) on behavioural answered in neurological physiotherapy at a strategy change. Affolter (1980) cites Piaget clinical level. We cling to our different treatment (1936) and Chomsky (1969). approaches yet, to date, we have been unable to demonstrate, in studies comparing different While providing possible explanations for the treatments, that there is a clear advantage of any phenomena observed, these do not in general one method over the others (Logigian et al 1983, provide hard evidence to explain the mecha- Partridge & De Weerdt 1995). Is this because of nisms involved in patients or the effects of treat- lack of information about the content of treat- ment: rather, they pose questions which need ment and therefore the possibility of a lack of mutual exclusiveness between the treatment
282 NEUROLOGICAL PHYSIOTHERAPY received by patients in the two groups? Is the CLINICIANS AND RESEARCHERS problem the use of inappropriate or insensitive outcome measures that do not relate directly to There is a gap between clinicians and researchers the aims of treatment, or is it that the use of which both need to address urgently. Clinicians named 'approaches' is not the critical factor in certainly need to acquire the skills to be able to success? Clinical skills will vary but this is rarely read the literature more critically, and to be able taken into account in clinical trials and we do not to decide which research results are relevant to yet know, except intuitively and at an anecdotal their patients. Therapist researchers also have an level, that skilled therapists achieve better obligation to write more clinician-friendly arti- results. These are really crucial questions for the cles and to moderate their language to make it future of neurological physiotherapy. more accessible, easy to read and understand- able. Learned journals have certain conventions Another factor that makes clinical evaluations and styles to which the aspiring researcher must more difficult is that because physiotherapy is conform to have a chance of publication, but now a routine part of practice, treatment/no other options are available. One way where there treatment group comparisons are considered un- may be a meeting point is through case reports. ethical. Therefore, all patients in any trial will These are often written by clinicians; they are receive their usual treatment with the experi- usually highly readable and they are starting to mental treatment given in addition to the experi- build up a knowledge base for future investiga- mental group. This diminishes the likelihood of tion in a more rigorous way Clinicians should obtaining clear differences between the treatment urge their researcher colleagues to ask and inves- groups, if they exist. To obtain sufficient numbers tigate questions that are applicable in practice. in a trial, patients with considerable hetero- They need to enter into dialogue with researchers geneity are often included, which again miti- and be confident enough to challenge them to gates against obtaining clear answers. Selecting clearly demonstrate the value of their research. more homogeneous groups may be one answer. In a recent randomised trial, Kwakkel (1999) The idea of EBP and research is clearly a selected a more homogeneous group of patients new emphasis for many physiotherapists. First, it with primary middle cerebral artery stroke. involves a major shift in thinking. Clinical prac- Extra treatment was targeted at either the arm tice tends to be based on educational texts which or leg and some significant differences were are not always well referenced, and the advice of reported in variables monitored between those 'authority figures'. Clinicians, at least in the UK, in the control and the augmented groups. How- update their clinical practice by attending ever, to achieve the total of around 100 patients, courses, rather than by reading the literature patients were recruited from seven hospitals on recent research, which presents a challenge over a 3-year period. Multi-centre trials repres- for those providing education for undergraduate ent a great deal of organisation and are very and postgraduate students as well as for prac- expensive. There is also a problem that extra- tising clinicians. polation of results from a homogeneous popula- tion to a general population is not always Kuhn (1970) in his book on the philosophy of justified. science discusses the growth and development of professions. Well-developed scientific disciplines Clearly this is an area where much more work such as chemistry and biology are seen as needs to be done. The challenges are to develop paradigmatic, where research follows a distinct appropriate methodologies for evaluating physio- agreed paradigm and there is consensus on the therapy, and to try to raise the profile of physio- models used, and a common language. Getting therapy research among potential funding to the stage of being a scientific discipline is a bodies. This is a task for both physiotherapy clin- lengthy process, often taking many centuries. icians and researchers, and also for physio- Physiotherapy is clearly a long way from this therapy managers. stage but shares common characteristics with
THE WAY FORWARD 283 professions said to be in the pre-paradigmatic pital for 3 months and still cannot walk when period. This is characterised by 'frequent and discharged will have become institutionalised deep debates over legitimate methods and solu- and may find resettlement back home more dif- tions to problems ... though these serve rather to ficult than an earlier discharge with full social define schools rather than to produce agree- support. ment.' This seems to describe the current position in physiotherapy rather accurately. Hospitals and countries vary widely in the amount and type of treatment they offer for dif- Those who have followed the early innovators ferent conditions. For example, the amount of in neurological physiotherapy have advanced the time spent in hospital following a stroke can vary early ideas but have often tended to be over from weeks to months and therapists are often influenced by the originators in a way that is com- the ones to make the decision to keep patients in monly found in the history of science. It has been longer. However, to date, there is little evidence shown that disciples who follow originators beyond the anecdotal to suggest that keeping demonstrate more rigid adherence to principles patients in hospital for months only for rehabili- (Kuhn 1970). This can cause stagnation in that tation achieves better results than earlier dis- followers are clearly reluctant to lose anything of charge home with continuing treatment when the original ideas and yet, while alive, most orig- necessary. inators continue to refine and develop their methods and ideas. A constant process of change A more flexible system could be where patients and development is necessary, both because we are consulted and their wishes taken into account are refining the art of physiotherapy but also and a type of triage principle operated. At one because new evidence and experience will con- end of the spectrum early transfer of patients stantly become available. Strict adherence to any with mild disabilities to health clubs and gymna- clinical method without evidence to support it sia would not only help to maintain fitness but means that treatment can become stuck in a time would do so in a normal atmosphere, weaning warp. What is needed is for those who follow in the patient, particularly younger ones, from hos- the footsteps of others to use their own skills to pital at the earliest opportunity. At the other end build on the earlier work and take their ideas of the spectrum there should be a recognition forward. These ideas need to be written down that for some patients with severe disabilities and updated as practice advances. It is said that long hospital stays are unlikely to be successful, we always stand on the shoulders of others to and the emphasis may have to be on prevention make our achievements, and this should be of secondary disabilities with full social support. acknowledged. However, slavish adherence over Concentrating on those patients in the middle time to the original ideas is not productive. What range, where success has been shown to be more has to be done is to describe current practice and likely (Kalra et al 1994) might be a better alloca- new developments and to submit them to clinical tion of resources. We need to have clear criteria evaluation. It is no longer legitimate to main- for deciding on allocation of patients to the dif- tain that something works without supporting ferent streams, with the opportunity to change evidence. streams should later recovery occur. Another option is for therapists to focus more specifically Therapists often feel strongly that they owe all on educating the nurses and other ward staff in patients a duty of care which should be reflected working with patients with neurological con- in terms of similar treatment time for all. How- ditions in a more formal way (Holmqvist & ever, unless programmes are tailored to individ- Wrethagen 1986). ual patient needs and to likely outcomes of treatment, they are unlikely to produce optimum The challenge is considerable but the future results. Very lengthy treatment programmes looks bright if both clinicians and researchers can which produce little effect may be demoralising come together to address the important issues for the patient. A stroke patient who stays in hos- and be prepared to think in innovative ways, and perhaps abandon some of the shibboleths that
284 NEUROLOGICAL PHYSIOTHERAPY have ruled for so long. Many of the changes now fession can grasp the opportunities now and being forced on physiotherapy practice are long hone their problem-solving skills both in the overdue, such as clearly demonstrating what clinical situation and in the wider world of does and what does not achieve good results service provision, in the future, improved treat- and being able to predict the likely outcome ment and management can be offered to neuro- of different treatment programmes. If the pro- logical patients. REFERENCES Kwakkel G 1999 Intensity of leg and arm training after Affolter F 1980 Perceptual processes as prerequisites for primary middle cerebral artery stroke: a randomised trial. complex human behaviour. International Rehabilitation Lancet 354: 191-196 Medicine 3: 3-9 Langhorne P, Wagenaar R, Partridge C J 1996 Physiotherapy Bithell C 2000 Evidence based physiotherapy. Physiotherapy after stroke: more is better? Physiotherapy Research 86: 58-60 International 1: 75-88 Bobath B 1970 Adult hemiplegia evaluation and treatment. Lloyd G E R 1996 On ancient medicine. In: Polarity and Heinemann Medical Books, Oxford analogy. Cambridge University Press, Cambridge, Bobath B 1990 Adult hemiplegia evaluation and treatment. Heinemann Medical Books, Oxford p6 Logigian M K, Samuels M A, Falconer J, Zagar R 1983 Brocklehurst J C, Andrews A, Richards B, Laycock P 1978 How much physical therapy for patients with stroke? Clinical exercise trial for stroke patients. Archives of British Medical Journal 1: 1307-1310 Physical Medicine Rehabilitation 64: 364-367 Brosseau L, Tousignant M, Budd J et al 1997 Inter and intra Luria A R 1963 The role of speech in the regulation of tester reliability of the balance performance monitor in a normal and abnormal behaviour. Pergamon Press, Oxford non patient population. Physiotherapy Research International 2: 150-167 Magnus R 1926 Some results of studies of the physiology of posture. Lancet ii: 585-588 Brunstrom S 1970 Movement therapy in hemiplegia, a neurophysiological approach. Harper and Row, Magoun H W, Rhines H 1948 Spasticity, the stretch reflex Hagerstown, New Jersey and the extrapyramidal system. C C Thomas, Springfield, Illinois Carr J H, Shepherd R B 1982 A motor relearning programme for stroke. Heinemann Medical Books, Oxford Munson R 1981 Why medicine cannot be a science. Journal of Medical Philosophy 6: 183-208 Chomsky N 1969 The acquisition of syntax in children 5-10. MIT Press, Cambridge Partridge C J, De Weerdt W 1995 Different approaches to Grimley Evans J 1995 Evidence based and evidence biased physiotherapy in stroke. Reviews in Clinical Gerontology medicine. Age and Ageing 24: 461^463 5:199-209 Haas B, Whitmarsh T 1998 Inter and intra tester reliability of Piaget J 1936 Origins of intelligence in children (reprinted the balance performance monitor in a non patient population. Physiotherapy Research International 3: 1952). International Universities Press, New York 135-148 Riddock G, Buzzard E F 1921 Reflex movements and Hadorn D C 1996 Rating quality of evidence for clinical postural reactions in quadriplegia and hemiplegia with practice guidelines. Journal of Clinical Epidemiology 49: special reference to those of the upper limb. Brain 44: 749-754 397-489 Harms Ringdahl K 1998 What is physiotherapy? Editorial. Rosner B S 1970 Brain functions. Annual Reviews in Physiotherapy Research International 3: iv-v Psychology 21: 555-594 Holmqvist L W, Wrethagen N 1986 Educational programmes Sackett D L Rosenberg W M, Gray J A, Haynes R B, for those involved in the total care of stroke patients. In: Banks M (ed) Stroke. Longman, Singapore Richardson W S 1996 Evidence based medicine: what International Classification of Impairments, Disabilities and it is and what it isn't. British Medical Journal 312: Handicaps (ICIDH) 1980 World Health Organisation, 71-72 Geneva, Switzerland Sherrington C S 1931 Reflex inhibition as a factor in the coordination of movements and postures. Quarterly International Classification of Functioning and Disability Journal of Experimental Physiology 6: 251-259 (ICIDH-2) 1999 World Health Organisation, Geneva, Switzerland Stephenson R, Edwards S, Freeman J 1998 Associated reactions: their value in clinical practice. Physiotherapy Kalra L, Smith D H, Crome P 1994 Stroke in patients over Research International 3: 69-76 75 years: outcome and prediction. Postgraduate Medical Journal 69: 33-36 Tonelli M R 1990 In defense of expert opinion. Academic Medicine 74: 1187-1192 Kuhn T 1970 The structure of scientific revolutions. University of Chicago Press, Chicago USA Office of Technology Assessment of the Congress of the United States 1995 The impact of RCTs on health policy and medical practice. US Government Printing Office, Washington DC, 1983
Index A treatment strategies, 81 Autonomic dysfunction, effects of, 128 Arm swing in walking, 57 Autoregulation, 123 Abdominal binders, 129 Awareness, demonstration of, 257 Abdominal muscles Parkinson's disease, 106-107 Axial dystonia, 108 Assessment, 21-26 paralysis, 128 B trunk stability, 197 background information, 22 Abduction roll/wedge, 243 clinical examination, 22, 23-24 Back slabs, 96,143-144, 235 Achilles tendon clinical interview, 22, 23 application, 236, 237, 240-241 shortening, 221 case history, 176 surgery, 181, 270 developing treatment plan, 24-25 Actin filaments, 44, 45 documentation, 25 Baclofen, 11,12,164 Actin-myosin bonds, 44 interpretation of findings, 24 intrathecal, 96, 157,159 Action potential, 44 oral, 157-158 Agnosia, visual, 74 reassessment, 25-26 Akinesia, 106 Assisted coughing, 128,129 Balance, 13-14, 40^41 Alta patella, 261 Associated movements, 98 Barbiturates, high dose, 125 Alzheimer's disease, 72 Associated reactions (ARs), 14-15, 95, Barthel Index, 27 Amnesia, 73 Basal ganglia 97-99 Animal studies, motor training, 15 disorders, 104-105 Ankle clinical implications, 99 chorea and athetosis, 110-114 Associated Reactions Scale, 24 and foot, serial casting, 235 Association of Chartered function, 5 mobility in walking, 58 Beck Inventory of Depression (BDI), movements, 149-150 Physiotherapists Interested in strategy, 40, 41 Neurology (ACPIN), 230 84 Ankle-foot orthoses (AFO), 221, Asymmetrical dystonic spasms, 113 Bed, positioning in, 133-136 Asymmetrical movement, 212 222-227, 268 Asymmetry, 41 prone lying, 135 anterior shell AFO, 225-226 Ataxia, 100-104,160 side-lying, 134-135 below-knee calipers, 225 supine lying, 133-134 hinged,224-225 cerebellar, 101-103, 214 Bedfast state, 195 finger-nose test, 38 Behaviour problems, head injury, 178, case history, 176 sensory, 100 inversion deformity, 224 179, 180, 181 multiple sclerosis, 265 treatment strategies, 102-104, 161 Behavioural Inattention Test (BIT), 79 posterior leaf AFO, 222-224 drug therapy, 162 Below-knee calipers, 225, 268 splint flexibility, 223 surgery, 162 Below-knee casts, 97, 231-235 toe-off orthosis, 226 Anterior support below-knee cast, 231, weights, 102, 265 anterior support below-knee cast, vestibular, 100-101 234, 235, 236, 237, 238 236, 237, 238, 239 Athetosis, 110-114 Anticipatory postural adjustments, 38, application, 231-232 clinical presentation, 111 case histories, 178,180 40, 41, 47, 62 communication and eating posterior support below-knee cast, Anxiety, 83, 84, 85, 86 Aphasias, 77, 78 problems, 111, 112-113 231, 232-234, 235 Apomorphine, 163 management, 114 serial casting of foot and ankle, 235 Apraxia Benzhexol, 163 posture and gait problems, 113-114 Benzodiazepines, 158, 164 clinical signs, 80-81 Athrodesis, triple, 268 Benztropine, 163 neuropsychological tests, 80 Atrophy Bernstein, systems approach, 8 Bias, eliminating, clinical trials, 280 in hypertonia, 92-93, 99 Bilateral vestibular lesions, 104 prevention or reversal, 45 Attention 285 clinical observations of deficits, 76 neurological tests of, 75-76 treatment of deficits, 76-77
286 INDEX Biomechanical model, 9,10 Carr and Shepherd approach, 4, 5, 10 Charcot-Marie-Tooth disease, 266 Biperiden, 163 Case histories, 169-187 Checklist, patient assessment, 23 Bite reflex, 145 Chemoregulation, 123 Blepharospasm, 108,109,164 discussion, 186-187 Chest clapping, 126 head injury, 177-183 Chorea, 110, 111 treatment, 110 multiple sclerosis, 183-186 Bobath right hemiplegia, 170-174 see also Athetosis spinal lesion, 174-177 'Chunking', 75 approach, 3,11,16,100, 278 Casts Clinical examination, 22, 23-24 postural control, 13-14 application, 230-231 Clinical interview, 22, 23 tone and techniques of handling, below-knee, 97, 231-235, 236, 237, Clinical reasoning, 1, 24 12,13 Clinical skills, 282 238, 239 Clinical trials, 279-280, 282 assessment, 98 correcting knee flexion deformity, Clinical ultility, outcome measures, 28 co-contraction abnormalities, 7, 8 Clonazepam, 158,160,164 'postural sets', 46-47 237, 238 Co-contraction, muscle, 7, 8,15, 38 reciprocal innervation, 37 elbow, 245-248 Cognitive affective syndrome, Body cavity pressures, 198 general principles, 230 Body stability, 37-38 hand and wrist combination, cerebellar lesions, 102 Body structure, 196-197 Cognitive function, 69 Body weight, distribution, 198 249-251 Botulinium toxin, 58, 95, 109, 110,157, long-leg, 96, 176, 235-237, 240-241 tests of, 71 serial casting, foot and ankle, 235 Cohort studies, 279 159-160,164, 165, 270 summary, 251, 252 Collar and cuff, 239, 242 advantages and disadvantages, 160 see also Splints Combination casts, 249-251 splinting after injection, 251 Catastrophising, 84 Communication Boxing glove splint, 249 Central pattern generators (CPGs), 10, Bradykinesia, 106 athetosis, 111, 112-113 Brain injury, traumatic, 121-127 60 cerebral palsy, 260 case history, 177-183 personalised booklet, 171 combination Central programming, 4-5 with unconscious patients, 131 Cerebellar ataxia, 101-103 Community services, resource issues, pyramidal/extrapyramidal dysfunction, 164-165 treatment, 102-103 276 emotional distress, 84 Cerebellum Compensation, 14 extensor response, 96-97 Complete spinal cord transection, 96 insight, 83 function, 5 Computers, 111 intracranial dynamics, 122-123 lesions of, altered reciprocal Cone/volar splint, 249 intracranial hypertension, Connective tissue, 197 management, 124-125 innervation, 38 Consciousness orofacial movements, 144-146 Cerebral blood flow (CBF), 122, 123 physiotherapy intervention, 125-127 Cerebral palsy level of, 124 residual limb deformities, surgery, regaining, vegetative state patients, 270 abnormal co-contraction, 7 respiratory system effects, 124 in adulthood, 259-262 259 triceps surae shortening, 231 see also Unconscious patients see also Vegetative state physiotherapy intervention, 'Constraint induced movement Breathing exercises, 128 260-262 British Medical Association (BMA), therapy', stroke patients, Medical Ethics Committee, 257 athetosis, 96, 111, 113 148-149 British Medical Journal, physiotherapy combination Contractile properties, muscle, 44 for stroke article, 280 Contractions, fleeting, 111 Bromocriptine, 163 pyramidal/extrapyramidal Contractures, 270 Buspirone, 162 dysfunction, 164-165 Cortex controlling posture, 192 control of movement, 10 c dislocation of hip, 113 functional maps in, 39 duration, physiotherapy plasticity, 15 Cabergoline, 163 role in power grip, 6 Cadence, walking analysis, 56-57 intervention, 269-270 Corticobasal degeneration, 163 Calcification in muscle, 131 'extensor thrust', 194 Corticoreticular neurones, 91 Calcium concentration, 44 muscle synchronisation, lack of, 15 Corticospinal tract lesions, 10, 91 Calipers, 220 posture, 200 Cough reflex, suppression of, 124, 126 Coughing, assisted, 128,129 below-knee, 225 extensor response, 96 Cross-correlation analysis, 6-7, 39 long leg, 221 head position when tired, 199 Cuff support, 242-243 Cerebral perfusion pressure (CPP), case history, 177 D Cannabinoids, 159 122,127 Carbamazepine, 155, 162, 164 Dantrolene, 158 Carbidopa, 164 Cerebral vasculature, factors affecting, Databases, 281 123-124 'Deafferented man', 5, 45 Cerebrospinal fluid (CSF), 122 Cerebrovascular accident (CVA) see Stroke Cervical cord injury, 127,128,130 duration, physiotherapy intervention, 270 Cervical dystonia, 108,109, 110,164 treatment, 110 Cervical lordosis, 199 Chailey Levels of Ability, 201, 206-207
INDEX 287 Decerebrate posturing, 105 drug therapy, 164 F Decision-making, patient involvement, pathophysiology, 108-109 spastic, 90 Facial muscles 26 treatment, 109-110 hypertonia, 145 Decorticate posturing, 105 Dystonic spasms, 111, 113 massage/ mobilisation, 146 Demand for health services, 275 Dementia, 72 E Family, involving in goal setting, 30, 169-170 reading scores, 71 Eating treatment strategies, 72-73 facilitating, postural strategies, 194 Fasciles, 44 Demyelination, multiple sclerosis, 262, problems, athetosis, 111, 112-113 Fast-twitch glycolytic (FG), type IIB 263 Elbow fibres, 42, 43, 44 Denervated muscle, effect of exercise, hypertonia at, 92 Fast-twitch oxidative glycolytic (FOG), mobilisation of, 148 46 passive movements, stroke type II fibres, 42, 44 Dependency on others, effect of, patients, 131 Fatigue, cerebellar dysfunction, 102 Feedback systems, 5, 9 180-181 Elbow casts, 245-248 Depression, 83, 84, 86 cautionary note, 247-248 sensor-motor, 39, 40 Feedback to patient, 31-32 head injury, 178,179 Elderly people, 275, 276 Feedforward mechanisms, 4, 9, 39, 40 Desensitisation of mouth, 112-113,145 Electromyography (EMG) Feeding, postural strategies to Diaphragmatic weakness, 268, 269 Digit Span subtest of WAIS-R, 75-76 activity in spastic diplegia, 12 facilitate, 194 Digit Symbol, 71 assessment for botulinium toxin Feet see Foot Disability Fibreglass casting tape, 230, 252 injection, 160 Finger-nose test, 38,101 definition, 26 postural muscle fibre activation, 44 Flexion moment, 221 outcome measures, 30 reciprocal innervation studies, 6-7 Flexor hypertonus Disinhibition, 81, 82 Elevation of head Distance judgement, impaired, 79 head, neck and shoulder alignment, back slabs, 144 Distractibility, 76 lower limbs, use of KAFOs, Distributed model, motor control, 8 134 Documentation of assessment, 25 high ICP, 126 228-229 Dopamine antagonists, 107 Emotional distress prone lying, 135 Dorsal reticulospinal tract (DRT), 91 clinical observations of, 84-85 standing, using tilt table, 139 Dorsal splint, 248 neuropsychological tests of, 83-84 supine lying, 133, 134 Dorsiflexion bandage, 226-227 treatment strategies, 85-86 upper limb, 148, 245 Double reciprocal innervation, 8 Endotracheal tube, stabilising, 125 wrist and fingers, 148-149 Double-blind randomised controlled Energy-conserving strategies, posture, Flexor spasms, incomplete cord trials, 279 190,191 lesions, 91 Drinking, stages in process, 5 Engineering model, motor control, Flexor withdrawal response, 95-96 Drop out casts 'Floppy children', 113 8-9 Focal dystonia, 108, 109, 110,164 elbow, 245-248 Equilibrium reactions, 13, 37, 40 Foot leg, 242 Erector spinae muscles, 197 Drug treatments, 155-165 Errorless learning technique, 75 and ankle, serial casting, 235 ataxia, 160-162 Ethical dilemmas deformity combination length of therapy interventions, 177 in cerebral palsy, 261 pyramidal / extrapyramidal vegetative state, 257-258 in HMSN, 266, 268 dysfunction, 164-165 Ethyl alcohol, 162 insoles, 221-222, 268 costs, 276 Evidence-based practice, 278-281, mobilisation, 149-150 extrapyramidal disorders, 162-164 mobility, walking, 58 spasticity, 157-159 282 positioning for standing, 138 Duration, physiotherapy intervention, Examination, 22,23-24 pronated, 222 269-270 Executive function support, 210, 211 'Dynamic success', 28 Force-velocity relationship, 45 Dysarthria, case history, 180 clinical observation, dysexecutive Forces, 220 Dysdiadochokinesia, 101 syndrome, 81-82 Forward lean position, 205, 212 Dysexecutive syndrome, 81-82 Frenkel's exercises, 104 Dysgraphias, 77 neuropsychological tests of, 81 Functional Independence Measure, Dyskinesia, 111 treatment strategies of dysfunction, 27 peak-dose levodopa, 163 82 Functional magnetic resonance Dyslexias, 77 Experiential knowledge, 279 Dysmetria, 101, 214 Expert opinion, 279 imaging (fMRI), 5, 15, 281 . Dysphasia, 98 Extensor hypertonus Dysreflexia, autonomic, 128 G Dyssynergia, 101 prone lying, 135 Dystonia, 15, 105,107-110 supine lying, 133,134 Gabapentin, 158 Extensor response, 96-97 Gag reflex, 145 classification and prevalence, 108 'Extensor thrust', 194 clinical presentation, 109 Extrapyramidal disorders, drug suppression of, 124 treatment, 162-164
288 INDEX Gait, 60 injury see Brain injury, traumatic tongue, 145 analysis, 23 Heel height, 221 trunk mobilisations, 136 apraxia, 81 Heel raise, 228 see also Hexor hypertonus athetoid patients, 113 Hemidystonia, 108 Hyperventilation, intracranial characteristics of normal, 56-58 Hemiplegia cycle, 56 hypertension, 124 definitions of, 56 case study, 170-174 Hypotonia, 11, 38, 89 muscle activity standing/sitting, 95 and joint range, 58 acute cerebellar lesions, 102 summary, 59 Trendelenberg gait, 58 associated reactions, 99 re-education, 60 trunk mobilisation, 136 mobilisation of trunk, 136 Trendelenberg, 58 Hereditary motor and sensory prone lying, 135 shoulder girdle/upper limb Gastrocnemius shortening, 268 neuropathy (HMSN), 266-269 Gene expression/muscle fibre type clinical signs, 266-267 problems, 146-147 physiotherapy intervention, 267-269 supine lying, 133 determination, 43-44 surgery, 271 supported sitting, 52 Generic disability assessment scales, Heredodegenerative dystonia, 108 Hypoxaemia, 124 Heterotopic ossification, 131,179,182, Hypoxia, 125 27 'Geste antagoniste', 109 247,248 I Glenohumeral joint, 61 surgery, 270 Imagery, using in memory subluxation, 146-147 perioperative radiotherapy, 271 dysfunction, 75 Glenoid fossa, 61, 62 Glycine, 158 Hierarchical model, motor control, 10 Imaging techniques, 5, 15, 89-90, Goal setting, 29, 30-32 Hinged ankle-foot orthosis (AFO), 281 case histories 224-225 Immobilisation, effect on muscle head injury, 181 fibres, 45 hemiplegia, 171-172,174 case history, 176 spinal cord lesion, 175 Hinged toe-ankle orthosis, 225 Impairment Hip, 197 definition, 26 formulating objective goals, 31 outcome measures, 30 involving patient and family, 30, dislocation, cerebral palsy, 113 flexion Impulsivity, 81, 82 169-170 Incomplete cord lesions, 91,170 providing feedback, 31-32 reduced, seating considerations, Golf swing, posture and movement 210 case history, 174-177 Incontinence following meningioma coordination, 36-37 testing, 201 Graded Naming Test (GNT), 77 removal, 171 Graded resistance exercises in flexor contractures, 134,177 Inductive reasoning, testing, 72 mobility, walking, 58, 59 Infants hypertonia, 99 Grasp reflex, 96 strategy, 40,41 experience of posture, 14 Grasping, 62, 63 Hip-knee-ankle-foot orthoses righting reactions, 13 Grip size, 63 rolling, 46 Grip strength, 45 (HKAFOs), 221 Inhibitory techniques, relevance, Gross domestic product (GDP), Hospital, length of stay, 283 Hospital services, resource issues, 276 12-13 percentage spent on health, 276 Huntington's disease, 111 Innervation ratio, 42, 45-46 Ground reaction force, 220 Hydrotherapy, multiple sclerosis, 265 Insight, 82-83 Guillan-Barre, syndrome, 131 Hypercapnia, 124,125 Insoles, 221-222, 268 Gums, massage, 146 Intellectual function, 70-73 Gymnastic ball, use of, 97,136-137 respiratory failure, 127 Hyperinflation, manual, 126 clinical observations of general loss, case history, 179 Hyperoxygenation, 125 72 Hypertonia, 11, 90, 91, 93-99 H treatment of loss, 72-73 aims, physiotherapy intervention, Intention tremor, 101 Hamstring strengthening, 175 99-100 Intermediate type IID/X fibres, 42 Handicap Intermittent positive pressure associated reactions, 97-99 definition, 26 co-contraction, anatagonistic breathing (IPPB), 128 outcome measures, 30 Internal capsule lesions, 91 Hands muscles, 15,38 The International Classification of athetoid, 112 evolution, 91-92 muscles of Impairments, Disabilities and extensor response, 96-97 Handicaps (ICIDH), 26, 27, innervation ratio, 42 facial muscles, 145 277 weakness in HMSN, 267 Intracranial compliance, 122 Head flexor withdrawal response of leg, Intracranial hypertension, 122, as body segment, 196 95-96 123-124 controlling position, 204 management, 124-125 elevation, 126,134 forceful movements, damage, 131 Intracranial pressure (ICP), 122 grasp reflex, 96 effect of suctioning, 125 Isoniazid, 162 non-neural components, 92-93 positive support reaction, 93-95 prone lying, 135 shoulder girdle/upper limb problems, 147,148 spastic diplegia, 12 supine lying, 133-134 supported sitting, 52
INDEX 289 J long leg calipers, 177, 221 Midline alignment, 47, 48 long leg casts, 235-237 Mobile spasms, 111 Journal publications, flaws in, 280 long leg cylinder, 242 Models, motor control, 4-10 Juvenile-onset dystonia, 164 mobilisation, 149 orthoses, 221-230 biomechanical model, 9, 10 K stability in sitting, 198 engineering model, 8-9 'windswept', 132, 133,149, 210 Key point diagram, muscle tone Lower motor neurone (LMN), 127 hierarchical model, 10 distribution, 24 Lying controlling posture, 215-216 neurophysiological / information Kinetic tremor, 101 posture assessment, 201 processing, 4-8 Knee, 197 prone, 49-50,135 recruitment of muscle activity, 37 systems/distributed model, 8 casting to correct flexion deformity, side-lying, 50-51,127,134-135 Modified Ashworth Scale, 23-24 237, 238 supine, 48-49,134-135 Moments, 220 Lysuride, 163 Motor learning, 39-40 flexion contractures, seating problems, 211 M in cerebellar dysfunction, 102 Motor overflow, 98 hyperextension, 227-228 Management, neurological Motor pattern generators (MPGs), positive support reaction, 94 dysfunction, 130-150 105 mobility, walking, 58 basic principles, 130-132 testing extension, 201 movements, 144-150 Motor programme, 4, 39 unstable, 220 Motor training, 15-16 Knee-ankle-foot orthoses (KAFOs), elbow joint, 148 Motor units, 42 foot and ankle, 149-150 221, 227-229 lower limb, 149 abnormal synchronisation of, 15 Kneel standing, 176,177 orofacial, 144-146 recruitment order, 44 Kurtzke Disability Status Scale (DSS), shoulder girdle and upper limb, Mouth, desensitisation, 112-113,145 Movement 265 146-148 Kyphosis, seating considerations, wrist and fingers, 148-149 control of, 4-10 positioning, 132-144 disorders 211-212 in bed,133-136 sitting, 136-137 ataxia, 38, 100-104 L standing, 137-144 basal ganglia disease, 104-105 Mannitol, 125 chorea and athetosis, 110-114 L-5-HTP, 164 dystonia, 107-110 Language function Manual hyperinflation (MH), 126 nature of, 15 Massage, facial muscles and gums, 146 rigidity, 105-107 clinical observation of dysfunction, Mattresses, 134 summary, 114-115 77 Mean arterial pressure (MAP), 122, normal see Normal movement, neuropsychological tests of, 77 123, 126 analysis treatment of dysfunction, 77-78 Mechanical properties, muscle, quality of performance, 23, 60 Lateral C-shaped posture, 212 Movements Latissimus dorsi, 95 44-45 elbow joint, 148 Leg dystonia, 108 Mechanical ventilation foot and ankle, 149-150 Length-tension relationship, 44-45 lower limb, 149 Lesch-Nyhan syndrome, 214 disconnection during suctioning, orofacial, 144-146 Levodopa, 163, 164 125 shoulder and upper limb, 146-148 Lignocaine, blunting ICP responses, wrist and fingers, 148-149 prone lying, 135 Multi-centre trials, 282 126 weaning off ventilator, 130 Multiple sclerosis (MS), 69, Limbic system, function in motor withdrawing support in vegetative 262-266 control, 38 state, 257 ataxia, 160, 161, 162 Lingual dystonia, 108 Medial reticulospinal tract (MRT), 91 Loading response, walking, 59 MEDLINE, 281 ondansetron, 162 'Locking mechanism' of shoulder, Memantine, 158 case history, 183-186 Memory function emotional distress, 84 61-62,146 extensor response, 96 Long leg calipers, 221 clinical observations of dysfunction, high amplitude tremor, 213 73-74 insight problems, 83 case history, 177 intellectual loss, 72 Long leg casts, 235, 236, 237 head injury, case history, 181 lateral funiculi demyelination, 91 Long leg cylinder, 242 tests of, 73 multidisciplinary team, 263, Long-term goals, 31, 170 treatment of dysfunction, 74-75 Meningioma, post-surgical 264 head injury case history, 181 hemiplegia case study, 171 hemiplegia, 170-174 physiotherapy intervention, Lower limbs Metatarsophalangeal joints, 150 below-knee casts, 97, 231-235, 236, Miall, engineering model, 8-9 263-266 Microtears in muscle, 131 spasticity, 156, 157 237, 238, 239 impairment in HMSN, 266-267 baclofen, 158,159 botulinium toxin, 159, 160 phenol, 159 surgery, 162 Multisystem atrophy, 163
290 INDEX Muscle fibres, 42-43 Normal movement, analysis, 35-63 Paired-associate memory, 74 changes following neurological approach, 46-48 Pallidotomy, 163 damage, 92, 93 body segment rotation, 46 'Para-walker', 230 consequences, 93 key points of control, 47, 48 Parallel elastic element, 44 effect of immobilisation, 45 midline alignment, 47, 48 Paralysing agents, brain-injured gene expression/fibre type postural sets, 46-47 determination, 43-44 features, normal movements patients, 124,125,126 recruitment order, 44 balance reactions, 40-41 Parapyramidal tracts, 91 nerve-muscle interaction, 42-46 Parkinsonism, 162 Muscle synergies, 37, 40 postural tone, 36-37 Parkinson's disease, 104,162 Muscle tone reciprocal innervation, 37-38 sensory-motor feedback and drug treatment, 163 abnormal, 11-12, 89, 90 feedforward, 39^10 posture, 107 assessment and description, 23-24 movement sequences, 53-63 rigidity, 105 normal, 11-12 moving from sitting to standing, 54-55 aims of physiotherapy, 106-107 postural, 36-37 supine lying to sitting, 54 clinical presentation, 106 see also Hypertonia; Hypotonia upper limb function, 61-63 Muscles walking, 56-61 shuffling gait, 57 contractile properties, 44 specific positions, 48-53 surgery, 162, 163 interactions, cross-correlation prone lying, 49-50 Partial pressures, 02 and C 0 2 , 1 2 3 side-lying, 50-51 Passive movements analysis, 6-7 sitting, 51-52 mechanical properties, 44-45 standing, 52-53 brain injured patients, 127 shortening, 15, 46 supine lying, 48-19 in neurological dysfunction, stiffness, 92 Myoclonus, 164 o 131-132 Myofibrils, 44 Myofilaments, 44 Object Assembly, 71 Past experience and task performance, Myosin filaments, 44, 45 Ondansetron, 162 5 Myositis ossificans, 148, 247 Oral apraxia, 81 Orofacial movements, 144-146, 259 Patient's perspective of needs, 24-25 N Oromandibular dystonia, 108 Patronising patients, avoiding, 78 Orphenadrine, 163 National Adult Reading Test-Revised Orthoses, 219, 220 Pelvis, 197 (NART-R), 71 instability in sitting, 198 classification, 221 obliquity, seating considerations, Neck of femur fracture, 96 clinical application, 220-221 Neglect, 79, 80 lower limb, 176, 221-230 209-210 Nerve-muscle interaction, 42-46 upper limb, 238, 239, 242-253 rotation in walking, 59-60 Neural activity, heightened, 212 see also Casts; Splints Neurogenic pulmonary oedema, 124 Oswestry standing frame, 139-140 Performance IQ, 71 Neurological approach see Bobath: case history, 180 Pergolide, 163, 164 Otoliths, 100 approach Outcome measurement, 26-29 Periodic movements of sleep (PMS), Neuromuscular diseases, 127, 128, 262 available measures, 29, 30 164 Neurophysiological / information determining evaluation purpose, 26, Peroneal muscular atrophy, 266 processing, 4-8 27 Persistent vegetative state see Neuroplasticity, 15-16 ensuring rigorous process, 29 Neuropsychology, 69-87 interpreting results, 29 Vegetative state selecting measures, 28-29 Phenol, 58, 159, 270 attention, 75-77 selecting outcomes to measure, 27, Photographs of posture, 200, 201 conclusions Physical Ability Scale, 201, 202 28 Picture Arrangement/Completion clinical observation, 87 Outcome prediction, 16-17 neuropsychological tests, 86-87 'Overlearning', 75 subtests, 71 treatment strategies, 87 Overwork weakness, 46 Piracetam, 164 emotional distress, 83-86 Plantar flexors, 58, 92 executive functions, 81-82 P insight, 82-83 hypertonia, 94, 97 intellectual function, 70-73 Paced Auditory Serial Addition Task, mobilisation, 138 language function, 77-78 76 Plaster of Paris (POP), 230, 247, 252 memory function, 73-75 Plasticity, 15-16 praxis, 80-81 Pain management, head injury case Pneumonia, 124 spatial processing, 78-80 history, 178,179 Positioning visual perception, 78 Nocturnal myoclonus, 164 in bed,133-136 Non-invasive ventilation (NIV), 130 in high ICP, 126-127 Non-progressive impairment, prone lying, 49-50, 135 in respiratory muscle dysfunction, management, 255, 256-262 discussion, 269-271 128 side-lying, 50-51,134-135 sitting, 51-52,136-137 standing, 52-53, 137-144 supine lying, 48-49,133-134 in vegetative state, 259 in wheelchair, right hemiplegia, 173 Positive end-expiratory pressure (PEEP), 124 Positive support reaction, 93-95
INDEX 291 Positron emission tomography (PET), implications for therapist, 10-15 Referring patients, 22 associated reactions, 14—15 for counselling, 86 5,15, 281 compensation, 14 Post anoxic action myoclonus, 164 inhibitory techniques, relevance, Reflexes Posterior below-knee cast, 231, 12-13 studies of, 10 normal and abnormal tone, 11-12 testing, outcome prediction, 16-17 232-234, 235 postural control, 13-14 Posterior leaf ankle-foot orthosis which therapy approach, 11 Rehabilitation centres, 170 Reliability, outcome measures, 28 (AFO), 222-224 nature of movement disorder, 15 Research, 281-282 Postural drainage, 126 the way forward, 15-17 Postural sets, 46-47 Procyclidine, 163 clinicians and researchers, 282-284 Postural sway, ataxic patients, 100,101 Progressive Resistance to passive movement, 89 Postural tone, normal, 36-37 Resources, 276 Postural tremor, 101 neurological / neuromuscular Posture, 189,190-195 disorders, management, 255, effective use of, 271 256, 262-269, 277 Respiratory centre compromise, 124 assessment, 199-201 discussion, 269-271 Respiratory complications, multiple in athetosis, 113-114 see also Multiple sclerosis (MS) biomechanics of seated, 196-199 Pronated feet, 222 sclerosis, 266 Prone lying, 49-50 Respiratory dysfunction, treatment factors influencing stability, bed-bound patients, 135 Prone standing table, 142 respiratory muscle impairment, 197-198 Propofol, 125 127-130 primary areas of deviation, Propranolol, 162 Prosopagnosia, 74 traumatic brain injury, 121-127 198-199 Protective reactions, 13, 40 Responsiveness, outcome measures, see also Seating, special Psycholinguistic Assessments of building stable, 201-207 Language Processing in 28 matching ability to required Aphasia (PALPA), 77 Retinal slip, 103 Psychologist intervention, head injury, Richter standing frame, 141-142 support, 206-207 178 Righting reactions, 13, 40 objectives, 202 Psychology see Neuropsychology Rigid ankle-foot orthosis (AFO), 223 step-by-step approach, Pulmonary oedema, neurogenic, 124 Rigidity, 105-107 'Pusher syndrome', 97 Rivermead Behavioural Memory Test, 202-206 Q 73 complications associated with 'bad', Rollator, use of, 103,104 195 Quality of life measures, 30 Rolling, development in children, 46 Quinlan case, 257 Ropinirole, 163, 164 compromise, 212-216 Rotation aesthetics versus efficacy, 214 R client versus carer needs, 214 of body segments, 46 counter-strategies, 215-216 Radiotherapy, 271 in walking, 57 prescriptive practice checklist, Randomisation, 280 215 Randomisd controlled trials (RCT), s support versus freedom of 279-280, 282 SAM system, 205, 206, 211 movement, 213-214 Reaching, 62 Sarcomeres, 44, 45, 46 Scapula support versus mobility, 214 cerebellar ataxia, 101 conclusions, 216 Reading increased excursion, 148 positioning of, 61-62 control of, 13-14, 40-41,130 ability, 71 retraction of, 147 learning, 192-193 improving attention in, 76 Scientific properties, outcome deficit in sitting, 193 Reasoning abilities, testing, 72 energy-conserving strategies, 190, Reassessment, 25-26 measures, 28 Reciprocal gait orthosis, 230 Scoliosis, idiopathic, 197 191 Reciprocal inhibition, 7-8 Scotch Cast Plus, 230, 252 reduced Seat heights, 55 as prerequiste to movement, 191, Seating, special, 189,190, 207-208 192 in dystonia, 108-109 in hypertonia, 91 purpose, 207-208 strategies to maximise performance, Reciprocal innervation, 6, 7-8, 37-38, sit-to-stand wheelchairs, 209 193-195 specific problem-solving, 209-212 41 Power grip, cortex role in, 6 Recognition Memory Test (RMT), 73, foot support, 210, 211 Practising skills, 16 pelvic obliquity, 209-210 Pramipexole, 163 74 reduced hip flexion, 210 Praxis, 80-81 Record keeping, 25 windswept lower limbs, 210 Pre-morbid intellect, 71 when to use, 207 Prehension, 62-63, 147 Secondary brain injury, 121-122 Preparation for function, 16 Sedation, brain-injured patients, 124, Pressure, 220 125 Pressure sensors, sole of foot, 94 Pressure sores, foot, 96 Segmental myoclonus, 164 Primary brain injury, 121-122 Selegiline, 163 Primary generalised idiopathic Self-inflicted damage, 214 dystonia, 164 Problem-solving, 3-17, 170, 275 control of movement, 4-10 history, 3-4
292 INDEX Semicircular canals, 100 Spatial processing 'Static success', 28 Sensory ataxia, 100 Step length, 56 clinical observations of impairment, Stepping strategy, 40, 41 treatment, 104 79-80 Straddle/forward lean posture, 205 Sensory information, 4, 5 Strapping shoulder, 243, 244 Sensory retraining, focal dystonia, neuropsychological tests, 78 Stretch reflex, studies of, 10 treatment of impairment, 80 Stretching shortened muscles, 46 110 Specific inhibitory mobilisations Stride length/width, 56 Stroke Sensory stimulation, 15 (SIM), 13, 278 Sensory-motor feedback and Speech problems abnormal co-contraction, 7 aerobic exercise, 99 feedforward, 39-40 athetosis, 111, 112 back slabs, 144 Series elastic element, 44 head injury, 180 botulinium toxin, 159 Shaking, 126 Spielberger State-Trait Anger British Medical Journal article, 280 'Shared records', 25 'constraint induced movement Sherrington, reciprocal innervation Inventory (STAXI), 84 Spinal cord therapy', 148-149 circuit, 6, 7, 8 glenoid fossa, downward facing, 62 Shock central pattern generators (CPGs), grip strength reduction, 45 10, 60 improving balance, 14-15 period of, 91 length of hospital stay, 283 spinal, 127 incomplete cord lesions, 91,170 muscle fibre changes, 93 case history, 174-177 passive elbow movements, 131 Short-term goals, 31, 170 physiotherapy research, 281, 282 head injury case history, 181 motor activity production, 10 reflex testing as outcome predictor, hemiplegia case study, 171,174 Spinal cord injury (SCI), 127 16-17 Shoulder, 61-62,197 autonomic dysfunction, 128 strength training, 99 mobilisation, 146-148 botulinium toxin, 159 timing, physiotherapy intervention, supports, 238, 239, 242-244 breathing exercises, 128 270 Side-lying, 50-51 duration, physiotherapy training affected side, 14 Subjective Memory Questionnaire bed-bound patients, 134-135 intervention, 270 turning brain-injured patients, 127 heterotopic bone formation, 131 (SMQ), 83 intrathecal baclofen, 159 Subluxation of shoulder, 238, 239 Sit-to-stand wheelchairs, 209 Suctioning, 125-126 Sitting weaning from ventilator, 130 Supine lying, 48-49 Spinal shock, 127 gymnastic ball, use of, 136-137 Spine, as body segment, 197 bed-bound patients, 133-134 moving to from supine lying, 54 Splints, 46, 219 moving to sitting, 54 moving to standing, 54-55 Surgical stockings, 130 clinical application, 230-231 Swallowing reflex, 145 with positive support reaction, Swedish knee cage, 228 95 following head injury, 178 Symmetry, position of, 41 Systemic arterial blood pressure posture in HMSN, 267-268 assessment, 201 in multiple sclerosis, 265 (SABP), 123,127 biomechanics of, 196-198 Systems approach, 8 correct, 190,191 physical principles, 230 deficit, 193 summary, 251 T in vegetative state, 259 supported, 51-52 wrist and hand, 248-251 T-roll, use of, 134 see also Casts Temporary orthoses, 230 trunk mobilisations, 136 Sprinters, 57 unsupported, 51 AFOs, 223 Skill learning, 16 Stand-up wheelchair, 142 Tension tests, 132 Sliding board, 172, 173 Standardisation, outcome measures, Terminology, 277-278 'Sliding filament' hypothesis, 44 Test of Everyday Attention (TEA), 76 Slow-twitch oxidative (SO), type I 26, 28-29 Tetrabenazine, 164 Standardised assessments, 23 Tetraplegia fibres, 42, 43, 44 Standing, 37, 47, 52-53 abdominal binders, 129 increase in number, 93 athetoid position, 114 respiratory function, 128 Slumped posture, 198-199 Thalamic stimulation, 162 SMART criteria, goal setting, 31 correct posture, 190,191 Thalamotomy, 162,163 SOAP format, record keeping, 25 daily, 215 Thermoplastic materials, 230 Soft Cast, 230, 252 Thiopentone, 125 Somatosensoy system, 41 in extensor response, 97 Thixotropy, 45,156 Spasmodic dysphonia, 108, 164 moving from sitting, 54-55 Thoracic joint movement, 62 Spasms Thorax, as body segment, 195 in positive support reaction, 95 dystonic, 111, 113 principles of, 137-144 mobile, 111 back slabs, use of, 143-144 Spastic diplegia, 214, 260-261, 270 Oswestry standing frame, 139-140 Spastic dystonia, 90 prone standing table, 142 Spasticity, 11,12, 90 stand-up wheelchair, 142 standing frame with motorised assessment, 23-24 lifter, 141-142 definition, 90 tilt table, 138-139 drug therapy, 157-160 using two or more therapists, impact and aggravating factors, 156 142-143 see also Hypertonia vegetative state, 258 State-Trait Anxiety Inventory (STAI), 84
INDEX 293 L-threonine, 158 function, 61-63 Visual perception, testing and Thumb opposition splint, 248, 268, 269 impairment in HMSN, 267 treatment, 78 Tilt table, 97,138-139 mobilisation, 146-147 Tilted posture, 205 orthoses, 238, 239, 242-253 Visuomotor incoordination, 101 Titubation, 101 Upper motor neurone syndrome Volar splint, 248 Tizanidine, 158 Toe-off orthosis, 226 (UMN), 45, 90-100,156 w Tone see Hypertonia; Hypotonia; definition, 90-100 neural components, 91-92 Walking, 56-61, 99 Muscle tone non-neural components, 92-93 foot and ankle, 58 Tongue, hypertonia, 145 specific pathology associated with gait characteristics, 56-58 Tonic spasms, intermittent, 111 gait cycle, 56 Topographical memory dysfunction, hypertonus, 93-99 hip, 58, 59 knee, 58 74 V multiple sclerosis, 265 Torsion dystonia, 110 muscle activity and joint range, Torticollis, spasmodic, 108, 109, 110, Validity, outcome measures, 26, 28 58 Valproic acid, 164 neural control, 60 164 Vari-table, using, 173-174 pelvis, 59-60 treatment, 110 Vector, 220 Tracheal stimulation, increased ICP, Vegetative state, 256-259 Walking aids, 60 influence on postural adjustments, 125 ethical considerations, 257-258 41 Transcranial magnetic stimulation features, 257, 259 physiotherapy intervention, Walking base, 56 (TMS), 5-6,16 Weakness, cerebellar dysfunction, Treatment terminology, 277-278 258-259 Tremor, 101 Velocities of locomotion, 57 102 Ventilation Wechsler Adult Intelligence high amplitude, 213 Triage principle, duration/type of manual hyperinflation (MH), 126 Scale-Revised (WAIS-R), mechanical, 125, 130,135, 257 70-71 therapy, 283 non-invasive (NIV), 130 Digit Span subtest, 75-76 Triceps surae, 92 Ventricular drain, 124 Wedges, use of, 133, 134 Verbal IQ, 71 Weight distribution, 198 contracture, 97,133 Verbal and Spatial Reasoning Test Weights, use of, 102, 265 shortening, 94, 138, 231 Wheelchairs Triple arthrodesis, 268 (VESPAR), 72 cerebral palsy, 261 Truncal tremor, 101 Vertical displacement, gait cycle, 58 sit-to-stand, 209 reducing, 102 Vertigo, 101 stand-up, 142 Trunk Vestibular ataxia, 100-101 see also Seating, special maintaining movement, 132 Windswept lower limbs, 132, 133, 149, measuring symmetry, 201 treatment, 103-104 210 mobilisations, 136 Vestibular system inputs, 41 Withdrawal of treatment, 257-258 stability in sitting, 197-198 Vestibulocerebellar lesions, 101 World Health Organization (WHO), Vestibulospinal tract (VST), 91 26, 27, 277 u Vibrations, 126 Wrap-around tray/bolster, 204 Vigabatrin, 158 Wrist and hand splints, 248-251, Unconscious patients, 124, 125 Viscoelastic properties, muscle, 11, 15, 252 verbal instruction, 131 see also Vegetative state 89 Wrist and thumb splint, 253 Visual agnosia, 74 Writer's cramp, 108,164 Unilateral neglect, 79, 80 Visual inputs, 41 Written information, goals set, 31 Unilateral vestibular lesions, 103-104 Visual Object and Space Perception Upper limb Battery (VOSP), 78, 79 as body segment, 195-196
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