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the combine information about the approaches techniques used in neurological condition with their principles and clinical implication.

the combine information about the approaches techniques used in neurological condition with their principles and clinical implication.

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Manual therapy techniques

  1. 1. MANUAL THERAPY TECHNIQUES USED IN NEUROLOGICAL CONDITIONS. Presenter: Sana Rai (MPT 1st Year ) Guide: Dr. Suvarna Ganvir (PhD) Department of Neurophysiotherapy D.V.V.P.F’s College of Physiotherapy, Ahmednagar 1
  2. 2. Objectives  Introduction  Types of approaches used in neurological condition. 1. Neurodevelopmental Technique (Bobath Approach) 2. Roods Approach 3. Brunnstrom’s Approach 4. Proprioception Neuromuscular Facilitation(PNF)  Recent Advances  Summary  References 2
  3. 3. Introduction  To treat patients with neuromuscular disease, selection of appropriate treatment approach is essential.  Clinical signs and symptoms are the best indicators for selecting an approach or a combination of approaches. 3
  4. 4.  In some patients with additional system involvement might force to modify the treatment approach.  Duration and frequency of the selected approach depends on the severity and the present functional level of the patient.  Quantify the effect of this approach on functional recovery in patients. 4
  5. 5. Neurodevelopmental Treatment (NDT) Bobath Approach 5
  6. 6.  Karel Bobath & Berta Bobath developed treatment designed to increase normal movement patterns in children with cerebral palsy & adult with acquired hemiplegia.  Their treatment focuses on restoring normal movements & eliminating abnormal movements. 6
  7. 7. Principles of NDT 1. Interactive process 2. Active participation 3. Normalize the tone 4. Appreciation of normal movt 5. Functional activity 6. Task /environment modification 7
  8. 8. 1. Interactive Process  Interactive process between individual, task and environment.  Eg. Picking up an object from a desk by affected hand  Explain task to the pt, give an idea about the environment 8
  9. 9. 2. Active Participation  Instead of therapist passively doing movements  Ensure pt’s motivation and participation  Give feedback 9
  10. 10. 3. Normalize the Tone  One cannot impose normal movements on abnormal tone  Weight bearing on affected side 10
  11. 11. 4. Appreciation of Normal Movt  Normal movement is learned by experiencing what a normal movement feels like. - Sensory feedback - Vision 11
  12. 12. 5. Functional Activity  Preparation incorporated into functional activity ( promote carry-over.)  Teaching postural control  Eg. sit to stand 12
  13. 13. 6. Task /Environment Modification  Picking up object from the desk  Modify task- break into components  Modify environment – use ball, other unstable surface 13
  14. 14. Clinical Implication 1. Weight bearing on the affected side:  Most effective way to normalizing tone.  Low tone- facilitative and high tone- inhibitory.  Also provide sensory input to the hemiplegic side through proprioception. 14
  15. 15. 15
  16. 16. Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial. P M van Vliet 2005 • Conclusions: There were no significant differences in movement abilities or functional independence between patients receiving a BB or an MSB intervention. • Therefore the study did not show that one approach was more effective than the other in the treatment of stroke patients 16
  17. 17. Roods Approach 17
  18. 18.  Given by Margaret S. Rood in the year 1950  Appropriate sensory stimulation can elicit specific motor responses.  Muscle action could be “activated, facilitated and inhibited through the sensory system. 18
  19. 19. Principles of Treatment 19
  20. 20. 1. TNR and TLR can assist or retard the effects of sensory stimulation.  Tonic neck receptors lie in the muscles and skin of the neck region and response to change in the relationship of head to the neck.  The labyrinthine receptors lie in the ampullae of the semicircular canals and in the vestibule.  These receptors are affected by the position of the head in relation to gravity. 20
  21. 21. 2. Stimulation of specific receptors produce three major reactions.  The three major reactions that can be produced by stimulation of specific receptors are 1. homeostatic responses via the autonomic nervous system, 2. reflexive protective responses via spinal and brain stem circuits and 3. adaptive response that require greater integration of all regions of the nervous system. 21
  22. 22. 3. Muscles have different duties.  Heavy work muscle should be integrated before light work muscles.  The light work muscles (mobilizers) are primarily flexors and adductors used for the skilled movement patterns.  The heavy work muscles (stabilizers) are primarily extensors and abductors used for postural support. 22
  23. 23. Facilitation techniques: Inhibition technique:  Light moving touch  Fast brushing  Icing  Heavy joint compression  Stretch  Resistance  Neutral warmth  Gentle shaking or rocking  Slow stroking  Slow rolling  Light joint compression Clinical Implication 23
  24. 24. Icing:  It is used for facilitation of muscle activity and autonomic nervous system responses.  It is used for patients who exhibit hypotonia and are in a state of relaxation.  It activate the more myelinated A delta fibers causing reflex withdrawal response in the superficial muscles. 24
  25. 25. 25 Journey of a child with spastic diplegic cerebral palsy from doldrums to hope. Divya Midha (2015) case report • Conclusion: With the application of various therapeutic techniques such as Roods approach, sensory integration, and static weight bearing therapies, an improvement was brought (GMFCS Level V-IV) in the gross motor functions as well as the child's social skills. • Child may also become less irritable on tactile stimulation to his body.
  26. 26. Brunnstrom’s Approach 26
  27. 27.  Developed by Signe Brunnstrom, a physical therapist from Sweden.  Emphasize on the development of synergy in spastic group of muscles.  This approach encourages development of flexor and extensor synergies during early recovery, with the intention that synergic activation of muscles will, with training, transition into voluntary activation of movements. 27
  28. 28. Principles of Treatment 1. When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation, and/or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement. 2. The responses of the patient from such facilitation combine with the patient's voluntary effort to produces semivoluntary movement. 28
  29. 29. 3.Proprioceptive and exteroceptive stimuli assist in eliciting the synergies. 4. When voluntary effort appears: a) The patient is asked to hold (isometric) the contraction. b) If successful, he is asked for an eccentric (controlled lengthening) contraction. c) Finally, a concentric (shortening) contraction. d) Reversal of the movement between the agonist and antagonist. 29
  30. 30. 5. Facilitation is reduced or dropped out as quickly as the patient shows voluntary control (primitive reflexes & associated reactions). 6. Correct movement is repeated. 7. Practice in the form of ADL. 30
  31. 31. Clinical Implication 1. Trunk balance in sitting :  The patient is asked to assume sitting position, lifting the affected upper extremity by the unaffected one and do actively trunk movements in all directions. 31
  32. 32. 32
  33. 33. 33 Comparison of Brunnstrom movement therapy and Motor Relearning Program in rehabilitation of post-stroke hemiparetic hand: a randomized trial. Shanta Pandian et al 2012 •BHM was found to be more effective than MRP in rehabilitation of the hand in chronic post-stroke patients. • MRP protocol comprises the use of the entire upper extremities along with the hand rather than the specific hand or finger movements in BHM
  34. 34. Proprioception Neuromuscular Facilitation (PNF) 34
  35. 35.  Technique of PNF are method of placing demands in order to secure a desired response.  Motor function can be improved using proprioceptive neuromuscular facilitation (PNF), and approach initially developed by Dr. Herman kabat and Maggie knott. 35
  36. 36. Principles of PNF 36
  37. 37. 1. All human beings have potentials that are not fully developed.  The normal person has a vast and untapped neuromuscular potential, which may be developed through environmental influences and voluntary decisions or tapped during stressful episodes.  Based on this philosophy, the therapist always strives to treat function, motivate the patient to achieve higher levels, and uses the patient’s strengths to minimize his or her weaknesses. 37
  38. 38. 2. Normal motor development proceeds in a cervocaudal and proximo distal direction.  Motion develops from proximal points to distal points.  During treatment, the head and neck are treated first because they influence the movement pattern of the body.  Next, the trunk is treated, because it provides the foundation of function.  After adequate control of the head, neck, and trunk is established, fine motor skills may be developed. 38
  39. 39. 3. Early motor behavior is dominated by reflex activity. Mature motor behavior is reinforced or supported by postural reflex mechanisms.  During treatment, reflexes may be facilitated to support weak muscles by choosing a specific developmental posture, initiating part of a  functional activity or pattern, or involving the head and trunk with extremity patterns. 39
  40. 40. 4. The growth of motor behavior has cyclic trends as evidenced by shifts between flexors and extensor dominance.  During functional activity, movements alternate between flexion and extension.  This reciprocal relationship leads to stability and balance of postures.  In treatment, the reciprocal relationship of flexors and extensors may be facilitated to re-establish stability and balance. 40
  41. 41. 5.Goal-directed activity is made up of reversing movements  Normal movements are rhythmic and reversing.  Reversing movements establish an equilibrium among activities and establish a balance and interaction between antagonists.  Treatment must facilitate movement in both directions to enhance functioning. 41
  42. 42. 6. Normal movement and posture depend on “synergism” and a balanced interaction of antagonists.  Functional movement relies on a balance of reflex activity, flexor-extensor dominance, and reversing movements.  During treatment, imbalances among these factors are corrected to restore normal patterns of motion and postural responses. 42
  43. 43. 7. Developing motor behavior is expressed in an orderly sequence of total patterns of movement and posture.  Motor behavior develops in a specific sequence.  Combined movements of the neck, trunk, and extremities also progress in a specified sequence.  Treatment must progress in a similar fashion 43
  44. 44. 8. Normal motor development has an orderly sequence but lacks a step-by-step quality (overlapping results).  Although development of motor behavior is sequential, one activity is not perfected before another more advanced activity is initiated; overlapping occurs.  In treatment, this overlapping may be used to facilitate progress. 44
  45. 45. 9. Improvement of motor ability depends on motor learning.  Motor learning is enhanced through the use of multisensory inputs.  Auditory, visual, and tactile stimuli are used to progress learning.  Treatment that uses these multisensory inputs may optimize learning opportunities, thereby maximizing the patient’s progress toward more complete functional ability. 45
  46. 46. 10. Frequency of stimulation and repetition of activity are used to promote and retain motor learning and for the development of strength and endurance.  The motor learning process requires repetition or practice of the task to be learned.  In this way, learning is enhanced through repetitive tasks, and through a repetitive therapeutic exercise program. 46
  47. 47. 11. Goal-directed activities coupled with techniques of facilitation are used to hasten learning of total patterns of walking and self-care activities.  Realistic functional goals are continually set for the patient throughout treatment.  Activities that have meaning for the patient are more effectively integrated into motor learning. 47
  48. 48. Clinical Implications  In patient with Parkinsonism strengthening the patient’s weak, elongated extensors muscles while ranging the shortened, tight flexor muscles.  In upper extremities, bilateral symmetrical D2 flexion patterns are ideal to counteract kyphosis.  while for lower extremities D1 extension pattern to counteract the typical flexed, adducted position 48
  49. 49. 49 Proprioceptive NeuromuscularFacilitation (PNF): Its Mechanisms and Effects on Range of Motion and MuscularFunction. Kayla B. Hindle et al (2012) Research indicates that PNF stretching, both the CR and CRAC methods, are effective in improving and maintaining ROM, increasing muscular strength and power, and increasing performance, especially after exercise. However, proper protocol and consistency must be followed to attain and maintain the benefits of PNF techniques.
  50. 50. 50 Perspective of Neuro Therapeutic Approaches Preferred for Stroke Rehabilitation by Physiotherapists Gajanan Bhalerao (2016) • Conclusion: 96% of therapists are well aware of neuro approaches, but face difficulty practicing them. •PNF and CIMT are most commonly preferred and practiced approaches, followed by NDT , Brunnstorm, Roods and MRP. • This study suggests that the physiotherapists are still practicing more of traditionalapproachesthan task specific approachessuch as CIMT and MRP. • The study further shows that majority of the therapists i.e.87% have not had any additional training and that 90% are keep on acquiring additional knowledge about these approachesthrough some workshop or a seminar.
  51. 51. Summary  Introduction  Types of approaches used in neurological condition. 1. Neurodevelopmental Technique (Bobath Approach) 2. Roods Approach 3. Brunnstrom’s Approach 4. Proprioception Neuromuscular Facilitation(PNF) 51
  52. 52. References  Manual TherapyApproachesIn NeurophysiotherapyBy: Suvarna Ganvir and Shyam Ganvir.  Physical Rehabilitation5th Edition By Susan B.O’Sullivan.  Van Vliet PM, Lincoln NB, Foxall A. Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial. Journal of Neurology, Neurosurgery & Psychiatry. 2005 Apr 1;76(4):503-8.  Midha D, Uttam M, Neb M. Journey of a child with spastic diplegic cerebral palsy from doldrums to hope. Indian Journal of Cerebral Palsy. 2015 Jul 1;1(2):127. 52
  53. 53.  Pandian S, Arya KN, Davidson ER. Comparison of Brunnstrom movement therapy and Motor Relearning Program in rehabilitation of post-stroke hemiparetic hand: a randomized trial. Journal of bodywork and movement therapies. 2012 Jul 1;16(3):330-7.  Hindle K, Whitcomb T, Briggs W, Hong J. Proprioceptive neuromuscular facilitation (PNF): Its mechanisms and effects on range of motion and muscular function. Journal of human kinetics. 2012 Mar 1;31:105-13.  Bhalerao G, Shah H, Bedekar N, Dabadghav R, Shyam A. Perspective of Neuro Therapeutic Approaches Preferred for Stroke Rehabilitation by Physiotherapists. Indian Journal of Physiotherapy and Occupational Therapy-An International Journal.2016 Jan;10(1):47-50. 53
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