Positive features

Positive features describe exaggerations of normally occurring motor activity, e.g. hyperreflexia. These impairments are further classified into two groups (Sheean, 2008):

Negative features

Negative features refer to a loss or reduction in normal activity, e.g. weakness. The functional significance of the negative features in terms of their contribution to disability cannot be underestimated (Ada & Canning, 2009; Barnes, 2008; Canning et al, 2004; Landau, 1980). For example, most of the rehabilitation effort for recovery of functional movement for people with cerebral lesions (e.g. stroke) is usually directed towards the negative features because of their proportionally greater contribution to the prevailing activity limitations and participation restrictions (Carr & Shepherd, 2003). This is not to say that the positive features do not have functional consequences, but that simply reducing impairment like spasticity will not necessarily improve function unless the negative and adaptive features are also addressed (Boyd & Ada, 2008).

Adaptive features

Adaptive features are secondary impairments that develop as adaptations to the primary impairments (the positive and negative features); their combined effects have a profound influence on functional performance (e.g. the effect of shortening of gastrocnemius/soleus on walking and sit to stand) such that the adaptive features are usually considered alongside the positive and negative features as part of the clinical assessment (Carr & Shepherd, 2003). Adaptive changes result in an increased resistance to passive movement termed hypertonia. In UMNS, hypertonia should be understood simply as an increased resistance to passive movement. Further assessment should help determine whether the resistance is principally due to neural influences, e.g. hyperreflexia, or non-neural influences (local or peripheral adaptation of soft tissue structures) or a combination of the two. This is an important distinction because stiffness and contracture may exist in the absence of neural influences (O’Dwyer et al., 1996) or may be primarily due to neural activity or a combination of both (O’Dwyer & Ada, 1996). As the treatment for the neural component differs from that of the non-neural component, further clinical investigation will be required to identify the most appropriate intervention (O’Dwyer & Ada, 1996).

The characteristic features of UNMS are outlined in Table 14.2. Tables 14.3 and 14.4 provide definitions for each of the impairments.

The primary impairments of UMNS result from disruption of the supraspinal control of descending pathways that normally control excitatory and inhibitory influences on proprioceptive, cutaneous and nociceptive spinal reflexes (Sheean, 2008). These reflexes become hyperactive and account for the majority of the positive features of UMNS (Sheean, 2008). It is likely that the positive features emerge due to a combination of diminished descending cortical control in addition to plastic reorganization at spinal cord and cortical level (Sheean, 2008).

As stated previously, the clinical picture of UMNS depends primarily on the location of the lesion; the signs and symptoms of cortical UMN lesions are very different from those associated with spinal cord UMN lesions. To understand the range of clinical features that arise following UMN lesions, knowledge of the organization and function of specific descending pathways is required. The following describes the inhibitory and excitatory systems involved in spinal reflex activity.

The inhibitory system

Corticoreticular fibres, which travel with, but are separate from, the corticospinal tract, facilitate an inhibitory area in the medulla called the ventromedial reticular formation. This area gives rise to the dorsal reticulospinal tract which is located in the dorsolateral funiculus (a column of fibres in the spinal cord). The main influence of the dorsal reticulospinal tract, which acts weakly with the corticospinal tract, is inhibitory to stretch reflexes and flexor reflexes (Sheean, 2008) (see Figure 14.1A).

Figure 14.1 Clinical presentations resulting from lesions to different anatomical locations of the descending tracts.

DRT, dorsoreticulospinal tract; MRT, medial reticulospinal tract; VS, vestibulospinal tract.; + excitatory pathway; – inhibitory pathway

The excitatory system

This system is slightly more diffusely organized in the brain stem and is not under tight cortical control; the bulbopontine tegmentum is the most important area because it gives rise to the medial reticulospinal tract. This tract, acting weakly with the vestibulospinal tract, is excitatory to stretch reflexes and extensor reflexes but, like the inhibitory system, is also inhibitory to flexor reflexes (Sheean, 2008) (see Figure 14.1A).

It is already possible to see from the above how disruption to one or all of the descending pathways will disrupt the balance of the excitatory and inhibitory inputs to the spinal motor neurones. The critical features of the descending system are therefore identified by Sheean (2008) as:

Figure 14.1 A–E explains the origin of the clinical presentations resulting from lesions to different anatomical locations of the descending tracts, after Sheean (1998, 2008). Figure 14.1E refers to flexor reflex afferent (FRA) reflexes, which are described in more detail in Box 14.1.

It is essential that the neuro-physiotherapist has a thorough understanding of the pathophysiology of different neurological conditions, as the clinical presentation of the patient is influenced by the site of the lesion(s). As such, the selection of the appropriate intervention or management strategy should be critically informed by this knowledge. The remainder of this chapter reviews a range of interventions and outcome measures that may be appropriate for people with neurological impairments.

Use of movement

Manual techniques are amongst the principle means available to the physiotherapists in the treatment and management of the altered tone seen post neurological insult. The importance of afferent inputs and their effects on muscle tone and postural/biomechanical alignment have been well documented in the literature (Rothwell, 1994; Shumway-Cook & Woollacott, 2007). Changes in cortical representations have been shown to accompany functional gains after rehabilitation (Johansson, 2000; Richards et al., 2008). Such studies help to provide direct evidence that altering passive or active sensory input can drive motor output; therapeutic movement and handling is a means of altering afferent input to the patient. An understanding of the basic principles that affect neural plasticity is key to enhancing motor recovery after neurological insult (Kleim & Jones, 2008).

The main aims of physical interventions are:

Weight-bearing

Therapeutic standing is a way of maintaining length in the soft tissues, modulating tone and encouraging extensor activity. To be most effective it should be dynamic to promote tonal changes (Massion, 1994), activating the extensor muscles whilst reciprocally inhibiting the flexors via the vestibuar system (Markham, 1987; Brown, 1994). Standing can be effective in modulating tone and reducing the frequency of spasms, whilst maintaining joint range (Bohannon, 1993). A pilot study looking at the efficacy and feasibility of a therapeutic standing programme for people with multiple sclerosis showed increased range of movement in wheelchair-dependent subjects and a downward trend in spasticity and spasms was noted (Baker et al., 2007). A decrease in motor neuron excitability in patients with spastic hemiparesis was also noted after a single session of standing on a tilt table for 30 minutes (Tsai et al., 2001). Tilt tables can be used to stand medically stable patients in the early stages of rehabilitation, even if they are still unconscious; wedges under the feet can be used as required to increase the stretch on the calf musculature. Alternatively, in the more awake patient, backslabs (Carter & Edwards, 2002) or electrical standing frames may be used (Figure 14.2). With the current emphasis on risk management it is recommended that, where possible and practicable, equipment should be used to minimize the manual handling risk (Chartered Society of Physiotherapy (CSP), 2008). The use of standing hoists can allow patients to weight-bear regularly in a normal functional task and so should be encouraged (Figure 14.3).

Figure 14.2 Electric standing frames can enable patients to stand for long periods, providing weight-bearing, stretching and promoting activity in the trunk.

Figure 14.3 A patient progressing from sit to stand in a standing hoist (A–C). Physiotherapists should encourage the use of a standing hoist for suitable patients, as they provide weight-bearing in a functional activity.

Weight-bearing with specific alignment can also be achieved through the upper limbs to maintain length and influence tone, but must be performed with extreme care. Normal biomechanical alignment is maintained by external rotation at the shoulder and the wrist joint should not be overstretched (Champion & Barber, 2009).

Key points

♦ Movement dysfunction arises from a combination of positive, negative and adaptive features.

♦ Interventions aimed solely at the reduction of positive features do not necessaily lead to improvements in activity and participation.

♦ Weight-bearing should be dynamic and involve movement whenever possible.

♦ Alignment of limbs must be maintained.

Positioning and seating

Therapeutic positioning and seating is underpinned by the premise of providing sufficient external support to enable a person to cope better with the effects of gravity, and to maintain postural alignment without using undue muscular activity; the reader is referred to Pope (2007) for a detailed review of posture and seating.

The relationship between positioning and outcome is still the subject of debate, with research evidence, whilst not conclusive, showing limited effectiveness (de Jong et al., 2006; Fox et al., 2000; Gustafsson & McKenna, 2006). However, there remains a consensus view in the literature advocating the importance of positioning and the need for multidisciplinary team involvement (Pope, 2007; Intercollegiate Stroke Working Party (ISWP), 2008). Where possible, positioning should be integrated into functional activities in a normal daily routine (Figure 14.4) and appropriate manual handling equipment and techniques always considered (CSP, 2008). Standard positioning charts are useful to promote consistency across the team and can be personalized, for example drawing on additional pillows to illustrate adjustment for specific postural needs; alternatively, photographs obtained with informed consent can be used.

Figure 14.4 This patient uses a perching chair to sit and eat his breakfast, which encourages development of trunk stability and weight-bearing through his lower limbs, whilst carrying out a functional activity.

Positioning in bed

Optimal positioning of a patient in supine can present a variety of challenges for the therapist. For example, patients with predominantly negative impairments may all too readily accept the supportive surface and be at risk of loss of range, whereas those with positive or indeed adaptive impairments may not be able to adapt their posture to the base provided. The use of pillows, wedges and T-rolls can assist in altering limb and body postures and help provide appropriate support (Figure 14.5). Profiling electrical beds can also be utilized to help maintain different postural alignment, likewise side-lying can be used for introducing change and breaking up any predominant tonal patterns or preferred postures. Positioning a patient in prone can be beneficial for some but its use must be considered carefully, for instance those with tracheotomies or severe contractures may be unable to achieve this position. As the head, shoulders, thighs and knees are the main load-bearing areas in prone, the introduction of a wedge can facilitate function by moving the fulcrum of movement to the pelvis (Pope,2007) or a commercially produced beanbag can also be tried to encourage head extension and shoulder protraction (Figure 14.6).

Figure 14.5 The use of a T-roll to prevent lower-limb extension and adduction.

Figure 14.6 The use of a bean bag to induce a comfortable prone position.

Mattresses

All patients should have a mattress that matches his or her pressure and positoning needs; a recent Cochrane Review by McInnes et al. (2008) provides comprehensive evaluation of the different support surfaces for pressure ulcer prevention. Physiotherapists should collaborate with nursing staff to facilitate optimal prescription for function. For example, the use of overlays on a standard mattress may be sufficient for pressure care yet affect transfers, as it increases the overall bed height so only a standing hoist can be used with taller patients. A replacement mattress that is the same height as a standard mattress but has higher pressure relieving properties may be preferable in terms of rehabilitation, although it is more costly. Overhead hoists may have to be used for air-filled mattresses. Findings from the PRESSURE Trial Group (Nixon et al., 2006) indicated that more than one-third of patients reported difficulties associated with movement in bed, and getting in and out of bed with overlays.

For acute head injuries where intracranial pressure (ICP) is a concern, electronic pressure beds can offer an effective way to achieve weight transference and positive effects on respiratory function. For patients with uncontrolled movements (e.g. Huntington’s disease, see Ch. 7), reduced sensation, or cognitive or perceptual deficits, the use of cot sides, or placing the mattress on the floor, should be considered to reduce the risk of injury to the patient from falling out of bed.

Electric and self-propelled wheelchairs

Appropriate wheelchair provision can promote independence and improve quality of life (Devitt et al., 2004). However, debate remains in clinical practice over encouraging self-propulsion in the early stages of rehabilitation with Cornall (1991) stating it increases spasticity, whereas more recent studies have shown no adverse effects (Barrett et al., 2001; Pomeroy et al., 2003). A wide variety of manual or electric wheelchairs, including indoor/outdoor electrically powered chairs (EPIOC) are available through either the NHS or privately and the introduction of a voucher scheme has helped to increase choice (www.direct.gov.uk). However, findings from a qualitative study of people with severe disability from multiple sclerosis found that whilst tilt-in-space wheelchairs were more comfortable than standard wheelchairs, reducing spasms and improving posture, they had negative aspects such as their bulky size and lack of manoeuvrability (Dewey et al., 2004).

Whilst electric wheelchairs provide an alternative to manual chairs, cognitive and perceptual difficulties can limit a person’s ability to use one, but it should nonetheless not be ruled out automatically before the individual is assessed (Dawson & Thornton, 2003). Some wheelchairs offer the facility of helping the person into a near-standing position, which is helpful for maintaining range of movement in joints and for pressure care (O’Connor & Smith, 2008).

Splinting/casting*

The best approach to contractures remains prevention yet in some patients, despite proactive intervention, adaptive impairments still occur. Altered tone has long been implicated in the development of contractures and without intervention affected areas are at risk of losing range from soft-tissue changes (Goldspink & Williams, 1990). Results from a recent study showed for the first time that spasticity can cause contracture in the first 4 months post stroke, but authors noted that thereafter muscle weakness became the main reason for limitations in activities (Ada et al., 2006b). Patients who show no functional recovery in muscle activity 2 to 4 weeks after stroke have been shown to be at high risk of developing contractures (Pandyan et al., 2003).

If positioning and regular movement are ineffective in preventing loss in range of motion, then splinting the affected body part may be undertaken as part of therapy.

Whilst the mechanism behind this intervention remains not fully understood it is thought to have a neurophysiological and biomechanical basis (Lannin et al., 2007b; Mortenson & Eng, 2003; Moseley et al., 2008).

Taking the decision to cast a limb requires careful clinical reasoning and discussion with colleagues in the MDT. Splinting may be precluded if the condition of the patient’s skin or vascular system is poor as there is a risk of pressure sores and tissue damage. If the patient is demonstrating challenging behaviour the splint may present a danger to the patient or others. Incontinence will need to be managed in conjunction with the nursing staff; if the cast becomes wet or soiled it will require removal and replacing. The use of a synthetic/fibreglass-based material instead of plaster is preferable in these types of situations as it is more durable, lighter and dries more rapidly. The development of new materials has given rise to more techniques, e.g. the ability to combine ‘soft and hard’ sections means that areas can be selectively reinforced as required. Details about application procedures are outside the scope of this text and the reader are referred to Edwards and Charlton (2002), although, as pointed out by Lannin et al. (2007b) in a recent systematic review, there is little consensus in practice for casting protocols.

Targeted strength training

Targeted strength training is an important aspect of neurological rehabilitation (Ch. 18). Previous concerns that such intervention would lead to an increase of positive features has not been bourne out by the research evidence (Flansbjer et al., 2008; ISWP, 2008). Indeed, the increasing recognition of negative impairments such as muscle weakness, which is a cardinal feature post stroke (Cramp et al., 2006), has translated to changes in clinical practice, with therapists incorporating task-specific muscle strengthening exercises into treatment programmes (Ada et al., 2006a; Bale & Strand, 2008). However, the wider effects of strengthening on improving participation in societal roles remain unknown (Morris et al., 2004). Chapter 18 discusses the role of muscle strengthening in different neurological disorders and outlines the need for further clinical research.

Exercise

Evidence suggests that exercise does not result in increased positive features and indeed can help to address negative and adaptive changes (see Ch. 18). Nevertheless, neurological impairments can bring challenges to maintaining an active lifestyle in keeping with health-related fitness, but exercise programmes can be designed to increase cardiovascular conditioning (Kilbreath & Davis, 2005; Pang et al., 2005; White & Dressendorfer, 2004). For example, people with moderate disability post stroke have been involved in fitness programmes including aerobic and strength components lasting from 30 to 90 minutes (Duncan et al., 2003). Dawes et al. (2000) found that high-intensity cycling did not lead to any increase in tone. This finding was further supported by Lee et al. (2008) who looked at the effects of aerobic cycle training and progressive resistance training on walking ability post stroke, and found that both musculoskeletal and cardiovascular impairments were still modifiable some years after stroke with selected robust exercise. The use of partial-body-weight support treadmill training has likewise produced positive outcomes on functional mobility (Hesse, 2008) and aerobic treadmill training has been noted for its potential to reduce effort and fatigue in people with multiple sclerosis (Newman et al., 2007).

Hydrotherapy and swimming

Hydrotherapy and swimming can provide freedom and challenge of movement to people with neurological impairments that are often not available to them on land (Cook, 2007). During hydrotherapy the water has a dual role, providing support and warmth, and has a global effect on muscle activity; it can be utilized to alter tone and joint range prior to treatment on dry land. Cook (2007) provides a comprehensive overview of the muscular, cardiovascular, haematological, renal and respiratory effects of immersion. Although the published evidence for hydrotherapy in neurological conditions is sparse, beneficial effects have been noted in people with spasticity following spinal injury (Kesiktas et al., 2004), stroke (Taylor et al., 1993) and multiple sclerosis (Peterson, 2001). The Halliwick concept is one well recognized approach for people of all ages which emphasizes ability rather than disability (Skinner & Thomson, 2008).

Electrical stimulation

Electrical stimulation is used in a number of different formats by physiotherapists in the treatment of positive and negative impairments with mixed results. A systematic review of electrical stimulation for shoulder pain found no significant effect on upper limb spasticity, but some improved range of passive lateral rotation noted (Price & Pandyan, 2001), whereas electrical stimulation combined with Bobath therapy in a randomized controlled trial (RCT; n=40) helped reduce plantarflexor spasticity in a cohort of stroke patients (Bakhtiary & Fatemy, 2008). Another study using a home programme of neuromuscular and sensory amplitude electrical stimulation on 10 people with chronic stroke had mixed results; four showed a reduction in spasticity yet others had an increase in tone that Sullivan and Headman (2007) attributed to subjects having to travel to the testing site in extreme cold weather. Krause et al. (2008) found that functional electrical stimulation along with cycling interventions in five people with spinal cord injury led to a reduction in spastic muscle tone. Results from a randomized single blind crossover trial of 32 people with multiple sclerosis that looked at the effect of transcutaneous electrical nerve stimulation (TENS) on spasticity suggest it does not appear to be effective with spasticity, but that longer applications (8 hours per day) may be useful with pain and muscle spasm (Miller et al., 2007).

Electrical stimulation has also been recommended by the National Institute for Health and Clinical Excellence (NICE) (2009) for use with drop foot, a negative impairment of central neurological origin. EMG triggered FES has been studied in the rehabilitation of wrist and finger extensors in later stage stroke and has shown positive changes in the ability to grasp small objects and maintain muscle activity (Hara et al., 2006).

Biofeedback

Evidence regarding the use of biofeedback in neurological rehabilitation is mixed. Hiraoka (2001) reported an increased functional ability in the hemiplegic upper limb following the use of EMG biofeedback, whereas a Cochrane Review by Woodford and Price (2007) on standard physiotherapy plus EMG feedback only indicated possible positive effects at the shoulder. Moreland et al. (1998) found it had a beneficial effect on improving the strength of ankle dorsiflexors. Van Peppen et al. (2006) reported no significant difference with the use of visual feedback in balance or walking ability, yet an earlier study by Sackley and Lincoln (1997) found visual feedback seemed linked to recovery of balance. Cheng et al. (2004) described improved weight transference with biofeedback.

Medication

The therapist needs a basic understanding of the pharmacological means of controlling altered tone (see chapters on specific neurological conditions). Physiotherapists’ skills in assessing tone, over time, can also play a valid role in evaluating the effectiveness of drugs and when they should be administered. Medication may be appropriate where physical means are inadequate, but consideration needs to be given to their use (Thompson et al., 2005). Pain increases spasticity and so the use of analgesia should be considered; however, not all patients can communicate effectively to request analgesia.

It is essential to establish if the presentation of spasticity is generalized, regional or focal. The treatment options are then clearer. For generalized spasticity, oral medication may be a first approach. For focal spasticity, injections of botulinum toxin may be a useful adjunct to therapy or, where more permanent paralysis is required, phenol nerve blocks can be used. Guidelines for the use of botulinum toxin have been produced and emphasize the need for a multidisciplinary team approach (Royal College of Physicians, 2009). Intrathecal baclofen may be used where spasticity is a major problem; functional benefit may be gained if it unmasks underlying motor control previously hidden by the positive impairment or alleviates pain from muscle spasms (Kofler et al., 2009).

Continuous passive movement

Whilst continuous passive movement (CPM) machines are common in orthopaedics they can also be beneficial in neurological physiotherapy. For example, CPM can be used to help improve range of movement in head-injured patients with contractures (Macfarlane & Thornton, 1997); it is thought to assist in the breakdown of abnormal cross-bridge attachments, which have been shown to contribute to abnormal stiffness during lengthening (Carey & Burghardt, 1993). However, unless combined with active movement, it is likely to require repeated use to prevent the reformation of anomalous attachments (Singer et al., 2001). Furthermore, Lynch et al. (2005) compared the use of CPM with self-range motion exercise in 32 stroke patients and found a positive trend for CPM towards improved shoulder joint stability but no differences in motor impairment, disability, pain or tone.

Thermal treatments

Ice can have a temporary effect in reducing tone, although it is usually applied as an adjunct and only in a specific area. The application of ice to spastic quadriceps muscle has been demonstrated to lead to an objectively measured reduction in spasticity (Brown et al., 1993). Cooling has also been shown to have some benefits to patients with an essential tremor (Cooper et al., 2000). Two studies (Feys et al., 2005; Quintern et al., 1999) reported significant reductions in tremor following cooling of the upper limb in people with MS that could have important functional implications when performing discrete functional activities such as intermittent self-catheterization or taking a meal. However, the effect of cold in people with MS can be variable, exacerbating symptoms in some people (see Ch. 5).

The application of heat packs can help to increase range of motion (Funk et al., 2001) by altering the properties of connective tissue that can be affected in movement dysfunction (Hardy & Woodall, 1998).

Acupuncture

The use of acupuncture in the treatment of neurological conditions remains the subject of debate. The National Clinical Guideline for Stroke (ISWP, 2008), in drawing upon key evidence from two Cochrane Systematic Reviews (SR) by Wu et al. (2006) and Zhang et al. (2005), recommends acupuncture should only be used in the context of ongoing clinical trials. Results of these SRs show acupuncture to be safe in the stroke population post 30 days, but evidence of benefit remains lacking, requiring more methodologically sound research to be carried out. Yet in a small RCT (n=7) conducted by Mukherjee et al. (2007), a significant decrease in spasticity in wrist flexors was noted when using electroacupuncture combined with strengthening exercises. Sonde et al. (2000) likewise reported a decrease in spasticity in the lower limb following the use of high-frequency TENS to stimulate acupuncture points. Donnellan and Shanley (2008) examined the use of acupuncture in people with secondary progressive multiple sclerosis and raised the possibility it may provoke lower limb muscle spasms in those with spasticity. Overall, they concluded that there was preliminary evidence to suggest acupuncture is safe in this population, but advised that the risk of increasing spasms should be raised with individuals.

Education of patients and carers

Management of altered tone requires a 24-hour approach and education is an essential component. Education needs to be tailored to the patient’s abilities and desire to know and must be given in a way that is understandable. Allison et al. (2008) found that health professionals’ use of language was often a barrier to patient and carer understanding. The physiotherapist must try to judge what information to provide and when to provide it, but it is the patient who decides when or if he/she uses this information. Research indicates that information is best delivered in a way that actively involves patients and carers and allows them to have repeated opportunities to ask questions and to feel empowered about making decisions (Reynolds, 2005a; Smith et al, 2008; also see Ch. 11).

Patients need education to be able to identify possible triggers of increased spasms. Nociceptive stimuli, such as those from skin, bladder and bowel (even tight clothing and wrinkled seat cushions), can exacerbate spasticity through stimulating flexor reflex afferent (FRA) activity (Sheean, 2008). With patients who have difficulty communicating or who are in a comatose state, increasing spasticity can be a sign that there is another problem, such as infection or constipation.

Patients may be able to learn to exhale and breathe through spasms to help prevent further tensing and worsening the spasm (Livingstone, 1998). Some patients will be able to gain further cognitive control over their spasms. If clonus is a problem, patients can be taught to push down through the long axis of the lower leg via the knee, giving a prolonged stretch to inhibit overactivity in the affected muscles.

A home programme may be incorporated into the overall management of tone, and compliance may be increased if exercises are included as part of everyday life, e.g. standing up against a wall whilst brushing teeth. Even if the person is unable to carry out all the exercises or stretches independently, he or she should direct a carer and thus retain responsibility. In some cases the spouse or partner may not see this as part of his or her role and the wish to maintain the partner and not the carer role should be respected (Courts et al., 2005). All carers should have their needs assessed separately (ISWP, 2008). Relevant information about support groups or networks (see Appendix) can also be provided.

Diagnosis and prognosis

The approach to the management of tonal impairment will depend on the patient’s diagnosis. For the patient with a rapidly deteriorating condition, such as a primary brain tumour or motor neurone disease, the priorities would be aimed at increasing activities and participation, with an emphasis on management and monitoring. Importance would be placed on the provision of equipment, and timely advice to carers regarding transfers and positioning as appropriate. Impairment focused goals would only be appropriate to address problems such as pain.

Prediction of outcome is multifactorial and individual, although there are some common factors linked to a more positive prognosis (Counsell et al., 2004; Jiang et al., 2002). In acute head injury where the prognosis is difficult to predict and the patient is at particular risk of developing contractures, emphasis is often placed on respiratory problems and insufficient attention given to potential adaptive impairments. The physiotherapist should advocate on behalf of the patient and be proactive in their approach to rehabilitation until factors indicate otherwise.

The ability to learn

The response to physical rehabilitation cannot be seen in isolation from perception, cognition, motivation, premorbid ability, behavioural difficulties and communication dysfunction. Motor learning is described as a complex perception–cognition–action process (Shumway-Cook & Woollacott, 2007). This area is covered in more detail in Chapter 17 on psychological management. Motivation is described by the WHO as a global mental function that can be both a conscious or unconscious drive that leads to an incentive to act (WHO, 2001) and is key in rehabilitation.

Potential for physical change

When handling a patient, certain signs indicate a potentially favourable outcome for physical change. These include:

Altered tone may not be constant and the wider picture should be sought through a full assessment, preferably over at least two sessions at different times of the day. However, it is important to remember that, in the absence of movement, preventing deterioration is an extremely valid reason for active intervention, especially in the early stages of rehabilitation and for people with progressive conditions.

Carryover and teamwork

Carryover can be described as the extent to which treatment gains are maintained and used functionally between treatment sessions. Management of physical impairments requires a 24-hour approach for maximum effectiveness and it is essential the whole rehabilitation team works towards common goals and has the knowledge and skills necessary to provide a coordinated approach (Thompson et al., 2005). For example, the speech and language therapist could undertake treatment while the patient is in a standing frame, or a perching stool could be used to encourage a more extended posture during activities in other therapies. Regular communication between staff including joint goals and treatment sessions, meetings, multidisciplinary notes and training may assist professions to work together effectively (Kilbride et al., 2005; Reynolds, 2005b).

Other clinical measures

A paper walkway (Tyson & Thornton, 2001) can give useful information in the absence of a gait laboratory (i.e. stride length, step width and length). Painted footprints allow changes in weight distribution to be recorded and are a useful way of documenting the realignment of the foot complex. Similarly, periodic photographs allow comparison over time (Tyson & DeSouza, 2003). The procedure needs to be standardized to ensure that the same perspective and distance are used each time. Video recordings are an excellent means of documenting change in posture and movement (Wiles et al., 2003). It is possible to use frequency of events, e.g. spasms (Snow et al., 1990) to assess the outcome of intervention.

Goal setting and goal attainment scaling

Goal setting is the key to good practice in rehabilitation and should actively involve patients in the process wherever possible; if the patient is not able to participate, appropriate family members or a patient advocate should be included (ISWP, 2008). However, in practice, goal setting varies and a recent postal survey found that patients need to be given more opportunities to be engaged in the process but ‘the shift from the patient role to one of partnership in care is developing slowly’ (Holliday et al., 2005, p.231).

The goal attainment scale (GAS), a mathematical way to quantify achievement of goals, was first described in the 1960s (Kiresuk & Sherman, 1968); Turner-Stokes (2009) provides up to date practical guidance for its use in rehabilitation. For patients with severe and complex disabilities, goals may be divided into passive or active function, where passive is related to ease of caring for the individual and active represents a gain in independent activity (Ashford & Turner-Stokes, 2006).

Parkinson’s disease

Physiotherapy is unlikely to influence the cardinal signs of Parkinson’s disease, therefore rehabilitation is primarily concerned with the treatment and management of the functional consequences of these primary impairments (Stack, 2009), see Chapter 6 and Table 14.6.

Table 14.6 Cardinal signs of Parkinson’s disease

Ataxia

Ataxia is a general term used to describe the decomposition of movement (Rothwell, 1994). Ataxia is characterized by errors in the rate, range, direction and force of movement (Ada & Canning, 2009) and, in general terms, movement is characterized as being uncoordinated. Ataxia is the principle symptom of cerebellar disorder, but is also noted in sensory ataxia (Lindsay & Bone, 2004). Ataxia presents with various movement disorders, see Table 14.7 and Chapter 5 on MS.

Table 14.7 Movement disorders seen in cerebellar ataxia

(From Carr J, Shepherd R. Neurological Rehabilitation: Optimising Motor Performance. Oxford, Butterworth Heinemann, 1998. Reprinted with permission of Elsevier Ltd.)

A systematic review of physiotherapy for people with cerebellar ataxia (Martin et al., 2009) concluded there is modest evidence for the effectiveness of physiotherapy to improve gait, trunk control and activity limitations. Further guidance by Cassidy et al. (2009) on physiotherapy interventions can be found at www.ataxia.org.uk. In vestibular ataxia, habituation exercises should be used, and can lead to a decrease in symptoms (Herdman & Whitney, 2000; see also Ch. 13). In sensory ataxia, the use of compensation strategies for function (Figure 14.7) and advice are essential to prevent injury or skin damage.

Figure 14.7 A supportive seating system allows this very ataxic young man to be able to drive a powered wheelchair.

Other movement disorders and alterations in muscle tone

This section describes and provides definitions for other movement disorders and alterations in muscle tone that the physiotherapist may see infrequently, but nonetheless will need to be aware of and be able to identify (Tables 14.8, 14.9). Physiotherapy will have no direct effect on these impairments, but interventions should focus on preventing secondary complications.

Table 14.8 Definitions of other movement disorders

Table 14.9 Definitions of tremor (Deuschl, et al., 1998)

Reprinted with permission of John Wiley & Sons.

Steve

Steve, a 24-year-old man, suffered a head injury from a climbing accident. Initially he was admitted to a neurosurgical unit at a specialist hospital where he underwent a craniotomy and removal of a haematoma from the frontoparietal region. Scanning revealed widespread contusions. He was intubated and ventilated for a week and bilateral prophylactic below knee casts were applied as he had considerable extensor activity and was at risk of losing full range of dorsiflexion in both lower limbs. He developed a flexion contracture of his right arm, which could not be splinted due to a large abrasion. Four weeks later he was transferred to a surgical ward in his local general hospital.

Jenny

Jenny, a 26-year-old single mother, had been diagnosed with multiple sclerosis resulting in a partial paraplegia. She was referred for outpatient physiotherapy by a neurologist, following a relapse. Jenny had been a wheelchair user for 3 years and presented in low mood and with social isolation. She had fears about losing her 4-year-old daughter if she approached social services for any help. Her wheelchair was small, the canvas sagged, and she found it difficult to propel for long distances.