Neurorehabilitation Centre at CNA, Breda, Noord-Brabant, The Netherlands
In this chapter, the treatable variables and thus the starting points for neurorehabilitation are described. In patients with a CVA, Parkinson’s disease, MS, and dementia, the symptomatology may restrict functioning. Interventions relating to mobility, muscle strength, stamina, sensory system, balance, spasticity, and cognitive rehabilitation form a starting point of the physiotherapy treatment and care of the patient with a CNS disorder. The physiotherapy care should contribute to improved general well-being and improved ability of the patient to function in his direct surroundings or in society. To assess the physiotherapy care you have offered, you must be able to make it measurable. Clinimetry is an important tool in terms of the physiotherapy care of patients.
In this chapter, the treatable variables and thus the starting points for neurorehabilitation are described. In patients with a CVA, Parkinson’s disease, MS, and dementia, the symptomatology may restrict functioning.
Interventions relating to mobility, muscle strength, stamina, sensory system, balance, spasticity, and cognitive rehabilitation form a starting point of the physiotherapy treatment and care of the patient with a CNS disorder.
The physiotherapy care should contribute to improved general well-being and improved ability of the patient to function in his direct surroundings or in society. To assess the physiotherapy care you have offered, you must be able to make that measurable (see for that also ► Chap. 6). Clinimetry is an important tool in terms of the physiotherapy care of patients.
An observation form, especially developed for patients with a CNS disorder, has been included in the appendix. The items described in this book are included in this observation form.
7.2 The CoFSSS
Balance is the ability to maintain balance in changing situations. This is necessary in order to be able to function well in daily life. Studies have shown that people with a CNS disorder decline after an intensive period of rehabilitation in their ADL. This can be blamed in part of the fact that the activity level in the period without rehabilitation is less high. As a result of this muscle strength, stamina and balance, among other things, decline (Leroux 2005). Periodic treatment of this patient group could prevent a decline in functioning.
Box 7.1 Research into Functional Gain
Research conducted among 1197 ABI patients (acquired brain injury) shows a 95% functional gain in the first 12 weeks. Thereafter, there is, however, a decline in functioning as a result of reduced physical activity (Leroux 2005). This diminished functioning especially affects balance, walking, and ADL skills. This had a negative influence on the experienced life satisfaction.
In a study group where the ABI had been incurred at least 1 year previously, an 8-week exercise program was started. This consisted of working for 1 h on strength, balance, mobility, coordination, and ROM twice a week. The result was that after 8 weeks, significant progress had taken place on the timed get up and go (TUG) test, the Berg Balance Scale (BBS), and the Stroke Impairment Assessment Set (SIAS). There was also a positive influence on the experienced life satisfaction.
In studies conducted among ABI patients in a chronic stage, where the intervention was aimed at influencing the upper extremity, similar results were also recorded.
Mobility restrictions occur frequently with CNS disorders. Studies have shown that in patients with a CVA that after 1 year there was an average increase in stiffness of 50% in the hemiplegic side (Kwakkel 1995a, b), as well as an increase in stiffness in the non-paretic side. Changes in contractility properties between actin and myosin and a change in the length of the sarcomeres are responsible for the increased stiffness. These are restrictions at the myogenic level.
Changed visco-elasticity and the formation of adhesion of noncontractile elements, such as tendons, fascia, and ligaments, are also responsible for the increase in stiffness. These are called the collagen restrictions.
In the case of the pathologies described, there can also be muscle-tone dysregulation (spasticity, rigidity, and paratonias), and as a result, it is difficult for patients to find the end positions of the joints. Consequently, the risk of myogenic and collagen contractures is clearly present. This has an effect on general functioning. Peripheral stiffness is more easily influenced by physiotherapy intervention than the centrally regulated spasticity. Preventing muscle stiffness is a starting point for physiotherapy intervention.
Finally, neurogenic restrictions can occur. Overstimulation of these structures causes pain, as a result of which any spasticity present can increase.
In ◘ Table 7.1, the various restrictions are described as well as the ways in which to differentiate which structure is responsible for the restriction and to what extent this is can be influenced.
Mobility restrictions and degree of influenceability
Through the «catch» and springy end feeling
Extending fully a number of times per day
Full length not attainable and stiff end feeling
Stretch for 6 h consecutively, 200 days (therefore splint)
Recognizable from the loss of mobility in combination with stimuli elsewhere
Extend fully a number of times per day
Severe contractures and hard end feeling
Surgical interventions if necessary
Myogenic contractures are easy to influence. Stretching to length a number of times per day is sufficient to exercise an influence on the visco-elastic properties of the myogenic structures. Muscle-mobilizing bed positions (within the NDT concept, these are discussed as spasm-inhibiting bed positions) can contribute to the prevention of myogenic restrictions. This is a key goal because when restoring function, sufficient muscle length is needed to be able to generate strength.
In the acute and subacute phase of a CVA, muscle-mobilizing bed positions and exercises form part of physiotherapy care. It is, namely, in that phase that the first problems appear in the myogenic structures. The majority of patients do not have any functional abilities in the arm in that phase. The physiotherapist is responsible for the policy aimed at prevention of myogenic restrictions. In the post-acute phase, auto-mobilizing exercises are taught, which are carried out a number of times per day by the patient himself.
Given that in patients with Parkinson’s, MS, and dementia (later stage), there is also muscle-tone dysregulation, seeking myogenic end positions in this patient population is also important. The aim is to prevent increases in contractures. There is, namely, a hierarchy in the ontogenesis of contractures, and that is the following:
Myogenic → neurogenic → collagen → osteogenic
Neurogenic restrictions run approximately parallel with the myogenic restrictions that can arise with immobility. Through the mobility restrictions, we find that gradual anatomical adaptations of the neurogenic structures occur. Prevention of this from occurring is important, because neurogenic restrictions can cause pain and paresthesias. To prevent these structures from shortening, the nerves have to be stretched several times per day (see ◘ Table 7.1).
Shortening or entrapment of these neurogenic structures results in overstimulation, the consequence of which is a radiating pain over the course of the nerve. Entrapment or shortening of this system can be recognized from the tension tests being positive (see ◘ Figs. 7.1, 7.2, and 7.3).
Nervus ischiadicus (sciatic nerve)
Nervus medianus (medial nerve)
Nervus ulnaris (ulnar nerve)
The following peripheral nerves are sensitive to changes and are tested for length.
Collagen structures are less easy to influence than myogenic and neurogenic contractures. Influencing depends on consistent and long-term measures that must be taken. A mobilizing effect on collagen structures occurs when a strategy is implemented in which stretch is applied for 6 h consecutively for a period of 200 days to the structures that need to be lengthened. Night splints are one option. These must gradually have an ever-increasing mobilizing effect until the desired mobility is achieved (see ◘ Fig. 7.4).
Nervus radialis (radial nerve)
Subsequently ankle-foot orthotics (AFOs) are fitted to retain the mobility achieved. The influence of a central neurological lesion is permanent.
Before taking these measures, it is best to discuss the goals with the patient in depth, because it is a long-term, arduous treatment.
If there are osseous restrictions there, an operation is the only effective intervention. It is of essential importance to weigh up the pros and cons of a surgical intervention, because this entails additional risks in this patient population.
Example from Practice 7.1
Mr. S. had a motorcycle accident and was in coma for 5 weeks. When he regains consciousness, there appear to be severe central nervous system injuries. Naturally mobility restrictions have also manifested in the joints. In both hips there is a flexion contracture of 15°; as a result of which, the transfers and walking are severely impeded.
After a number of months of rehabilitation, the decision is eventually made to remove the PAOs (periarticular ossification) by means of an operation. One reason for only doing this at this stage was waiting to see what the effects were of physiotherapy. Moreover, an operation is not entirely risk-free given his comatose history.
The result of the operation is positive. As he now has a greater ability to extend in his hips, transfers are easier and walking has gained in efficiency.
Box 7.2 The Practice
A good treatment strategy does not guarantee the prevention of contractures. However, it does legitimize your actions.
In practice you regularly see contractors occurring in one patient and not in another, despite using the same treatment strategy. Obviously there are intrinsic factors present that are co-contributors to the occurrence of these contractures.
For the team treating the patient, it is important to treat the patient in accordance with the «rules.» As a result, it actually becomes transparent that everything has been done to optimize the mobility that was necessary to achieve good functionality.
Training stamina has, just like training strength, not been the center of attention for a long time. The reason for this was that it was assumed that training stamina would be too intensive and that consequently spasticity would increase. Research has shown that this is not the case (Teixeira-Salmela and Olney 1999). The intensity of training stamina is often still an obstacle. In practice it appears, as it happens, that the assumption is made that intensive training is too much of a physical burden.
What Criteria Should Stamina Training Meet?
What applies here is that stimulation of 50% of the heart rate reserve (HRR) according to Karvonen is a good training stimulation. This is built up in the elderly to 75–80% of the HRR (Bemt and Mechelen 1998b). The Ästrand test is one instrument for determining the VO2max (maximum oxygen uptake) and thus for assessing what is the starting point and whether after the training session any progress has been made.
Example from Practice 7.2
Mrs. K. is 66 years old and she has Parkinson’s disease. The request for help relates to improving her stamina. On the Ästrand test, she has a score of 23, which corresponds to moderately fit.
For the first 2 weeks, she spends time getting used to cycling with a heart rate monitor. In this period, we do that at a heart rate of 40% of Karvonen. This is calculated as follows:
Resting heart rate is 73
Maximum heart rate is 220–66 (age) = 154
40% of Karvonen then means 73 (resting HR) + 40% of (154–73) = 105. We are going to build this up gradually to 75% of Karvonen and a duration of 20 min per training session. Increasing the resistance will increase the heart rate.
After 8 weeks of training, we repeat the Ästrand test, and this time Mrs. K. scores 28, which corresponds to reasonably fit. This motivates her to keep going, because apart from the improved score, she also shows improvements on the Patient-Specific Functional Scale measured with the aid of the VAS. She is less rapidly tired and therefore can do more.
Arguments in Favor of Stamina Training
On the basis of biological aging processes, the VO2max declines as from the 30th to 50th year of life by 1% per year. After the 50th year of life, this is even faster. This can be improved by about 15% by good training (Bemt and Mechelen 1998b).
People with a CNS disorder generally have less motivation to undertake activities. This results in an accelerated decline in stamina. A study among CVA patients showed that training stamina leads to a reduction in blood pressure and to improvements in muscle strength (NHSS 2001). Training stamina also has also a positive effect on the aerobic capacity, measured with the Ästrand test.
As stamina is easily influenced, training stamina is certainly a starting point for treating people with a CNS disorder.
For a long time, strength training was counter-indicated in CNS disorders. The reason for this was the assumption that the degree of spasticity would increase through strength training. During the training, there are associated reactions and movements in synergistic patterns. After finishing training, these disappear immediately.
Studies have however shown that there is no increase in spasticity as a result of strength training (Teixeira-Salmela and Olneyl 1999). There was not only improvement in function, but the patients also scored better at a functional level. The results of the study also showed an increase in gait speed and improvements in the fluidity of movement when walking.
What Criteria Should Strength Training Meet?
If the intention is to improve muscle strength, then as a minimum a strength stimulus has to be administered of 50% of 1 RM, that is the maximum weight that someone can lift in one go. Because this is very difficult to determine, a number of repetitions equate to a certain percentage of 1 RM (◘ Fig. 7.2). The fewer the repetitions the patient can make, the more accurate the estimation test. In ◘ Table 7.2, you can see what the maximum weight is that someone can lift in one go. It is possible to draw up a training program on the basis of these values. With elderly persons, you work toward a strength stimulus of 75 to 80% of 1 RM (Bemt and Mechelen 1998a).
Table that can be used to draw up a program for strength training
Number of repetitions
3–5 repetitions ≈ 90% of 1 RM
8–11 ≈ 80% of 1 RM
12–22 ≈ 70% of 1 RM
20–30 ≈ 60% of 1 RM
Test weight in kilograms
Therefore, 100% equates to
Therefore, 100% equates to
Therefore, 100% equates to
Therefore, 100% equates to
Example from Practice 7.3
Studies have shown that strength can be vastly increased in the elderly. The reason for this is that the elderly frequently starts at a lower starting point. Imagine you are training a top sportsman; he has already put in such a massive amount of work on training that he is probably at the ceiling of his motor skills. The elderly person is not and certainly not if there is a CNS disorder.
Mr. P. is 74 years old and has a CNS disorder. He has never played sports, and since he has had this CNS disorder, he has been less active. The request for help made by Mr. P. is to improve his walking.
Using the leg press 1 RM of the quadriceps is determined. He can push a weight of 50 kg. If we look at ◘ Table 7.2, eight repetitions correspond to 80% of 1 RM. If we look further in the table, 1 RM should correspond to 63 kg.
When drawing up a training program, you always start with a familiarization period of 2 weeks with the elderly. You do this because they can then work on their technique on the leg press. The training starts with 50% of 1 RM; this means with a weight of 30 kg. You make three series of 12 repetitions. This is then gradually built up in increments of 2 weeks, i.e., 55%, 60%, up to 75–80% of 1 RM.
In between it is important to assess what the 1 RM is at that moment, because you may assume that the strength is increasing.
In this way training can provide an improvement in the function. It is important to know whether the patient is experiencing functional progress. This can be assessed using the Patient-Specific Functional Scale questionnaire and the VAS (visually analogue scale). In this the patient indicates three activities that he would like to see improved. Using the VAS, a score can be determined at the start in respect of satisfaction with the activities concerned. After 6 weeks, an improvement in the function can be expected, and the progress on the 1 RM and the Patient-Specific Functional Scale can be measured (see ◘ Fig. 7.5).
Tool for drawing up a program for strength training
Three Arguments in Favor of Strength Training
As a result of biological aging processes, muscle strength decreases. Between the 30th and 70th year of life, strength decreases by 30%. After the 70th year, this decline is more rapid and can be 10% per decade. Because most people with a CNS disorder are elderly, these processes play a role in the occurrence of muscle strength loss (Bemt and Mechelen 1998a).
People with a CNS disorder generally have less motivation to undertake activities. Because of this there is an accelerated decline in muscle strength.
Through these three negative influences on muscle strength on the one hand and easy influenceability of muscle strength on the other side, training muscle strength is certainly a starting point for the treatment of people with a CNS disorder. It is certainly true now that it has been demonstrated that there is no unfavorable effect on spasticity and training leads to improvements at the activity level (Teixeira-Salmela and Olney 1999).
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