Key Takeaways
- Neuroplasticity is the brain ability to reorganize neural pathways; it is the basis for neurological rehabilitation after stroke, TBI, and other CNS injuries
- Task-oriented (task-specific) training is the most evidence-based approach for motor recovery after stroke — practice of real-world functional tasks
- PNF techniques for neurological patients include rhythmic initiation, slow reversals, rhythmic stabilization, and hold-relax
- NDT/Bobath approach focuses on inhibiting abnormal tone and facilitating normal movement patterns through handling and positioning
- Constraint-induced movement therapy (CIMT) restrains the less-affected limb to force use of the hemiparetic limb; requires some residual hand function
- Body-weight supported treadmill training (BWSTT) facilitates gait training in patients who cannot support full weight, utilizing repetitive stepping to promote neuroplasticity
- Balance training for neurological patients progresses from static to dynamic balance, narrow to wide base of support, eyes open to eyes closed
- Visual cueing (floor lines, laser pointers) and auditory cueing (metronome) are effective strategies for overcoming freezing of gait in Parkinson disease
Neurological Interventions
Physical therapy interventions for neurological conditions are grounded in the principles of neuroplasticity — the nervous system's ability to reorganize and form new neural connections in response to experience, learning, and injury. The NPTE tests knowledge of evidence-based approaches to neurological rehabilitation.
Neuroplasticity Principles
Neuroplasticity is maximized when rehabilitation incorporates these key principles:
| Principle | Description | Application |
|---|---|---|
| Use it or lose it | Neural pathways not actively used will degrade | Encourage use of affected limb; avoid learned non-use |
| Use it and improve it | Training drives specific neural changes | Repetitive, progressive practice of functional tasks |
| Specificity | Training must be specific to the desired outcome | Practice the actual task you want to improve |
| Repetition | Sufficient repetition is needed for neural adaptation | High-volume practice (hundreds of repetitions) |
| Intensity | Training must be of sufficient intensity | Challenge the patient at an appropriate difficulty level |
| Salience | Training must be meaningful and important to the patient | Use patient-centered goals and real-world activities |
| Time | Neuroplasticity is time-sensitive | Earlier intervention yields better outcomes (but recovery continues for months/years) |
| Age | Younger brains have greater plasticity | Children recover faster, but adults also demonstrate significant neuroplasticity |
| Transference | Training in one context can improve related abilities | Generalization of skills to new environments and tasks |
Treatment Approaches
Task-Oriented Training (Most Evidence-Based)
Task-oriented training is considered the gold standard for motor recovery, particularly after stroke:
- Focuses on practicing real-world functional tasks (reaching, grasping, standing, walking)
- Tasks are broken down and practiced in parts or as a whole
- Progressive difficulty with environmental challenges
- High volume of repetition is essential (100-300+ repetitions per session)
- Research strongly supports task-specific practice over impairment-based exercises alone
Proprioceptive Neuromuscular Facilitation (PNF) Techniques
PNF techniques commonly used in neurological rehabilitation:
| Technique | Description | Purpose |
|---|---|---|
| Rhythmic initiation | Passive → active-assistive → active movement in a pattern | Improve initiation of movement (good for Parkinson) |
| Slow reversals | Alternating isotonic contractions in agonist/antagonist patterns | Improve active movement, endurance |
| Rhythmic stabilization | Alternating isometric contractions (no motion) | Improve stability, co-contraction |
| Hold-relax | Isometric contraction of tight muscle → relax → passive stretch | Increase ROM by inhibiting spasticity |
NDT/Bobath Approach
The Neurodevelopmental Treatment (NDT) or Bobath approach focuses on:
- Inhibiting abnormal tone and primitive reflexes
- Facilitating normal movement patterns through handling techniques
- Emphasis on postural control as the basis for movement
- Use of key points of control (proximal joints, pelvis, shoulder girdle) to influence tone and movement
- While widely used, evidence supporting NDT over task-oriented training is mixed
Constraint-Induced Movement Therapy (CIMT)
CIMT is an evidence-based approach for upper extremity recovery after stroke:
- The less-affected arm is restrained (mitt, sling) for 90% of waking hours
- Intensive training of the hemiparetic arm (6+ hours/day for 2 weeks in original protocol)
- Modified CIMT (mCIMT): Less intensive versions (3 hours/day) with similar benefits
- Requirements: Patient must have at least 20 degrees of wrist extension and 10 degrees of finger extension (residual motor function)
- Strong evidence for improving upper extremity function in chronic stroke
Gait Training Strategies
Body-Weight Supported Treadmill Training (BWSTT)
- Patient is suspended in a harness over a treadmill, with 20-40% body weight support
- Allows repetitive stepping practice even when the patient cannot fully weight-bear
- Promotes central pattern generators in the spinal cord
- Evidence supports use for improving gait speed and endurance after stroke and incomplete SCI
Cueing Strategies for Parkinson Disease
| Cue Type | Examples | Purpose |
|---|---|---|
| Visual cues | Floor lines/tape, laser pointer on walker, stepping over obstacles | Overcome freezing of gait, improve step length |
| Auditory cues | Metronome, rhythmic music, verbal counting | Regulate cadence, improve gait rhythm |
| Tactile cues | Tapping on the hip or shoulder | Initiate movement, overcome freezing |
| Cognitive strategies | Counting steps, focusing on heel strike | Bypass basal ganglia with cortical motor control |
Balance Training Progression
Balance training for neurological patients follows a systematic progression:
- Static sitting balance → Dynamic sitting balance
- Static standing balance (wide BOS) → Narrow BOS → Tandem → Single leg
- Stable surface → Unstable surface (foam, wobble board)
- Eyes open → Eyes closed (removing visual compensation)
- No dual task → Dual task (cognitive or motor distraction)
- Predictable perturbations → Unpredictable perturbations
A patient is 3 months post-stroke with some residual hand function (20 degrees wrist extension, 10 degrees finger extension). Which intervention has the STRONGEST evidence for improving upper extremity function?
A patient with Parkinson disease experiences freezing of gait when approaching doorways. The MOST effective PT strategy is:
Which neuroplasticity principle explains why practicing the actual functional task (e.g., reaching for a cup) produces better outcomes than performing isolated exercises?
Arrange the following balance training activities in order from LEAST to MOST challenging:
Arrange the items in the correct order
Body-weight supported treadmill training (BWSTT) promotes gait recovery primarily by activating:
The minimum motor requirement for a patient to be a candidate for constraint-induced movement therapy (CIMT) is:
The PNF technique of rhythmic stabilization is BEST used to improve: