Chapter 74: Physical Therapy and Rehabilitation of Neurologic Patients

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Physical Therapy and Rehabilitation of Neurologic Patients



Physical rehabilitation is an important part of therapy for patients with neurologic conditions. Rehabilitation may be used in a variety of situations, including medical and postsurgical neurologic conditions, peripheral nerve conditions, and neuromuscular disorders. Both upper and lower motor neuron conditions may benefit from rehabilitation. It is important to realize that physical rehabilitation should be used in conjunction with other standard treatments such as decompressive surgery of an intervertebral disk herniation rather than as the primary treatment. The specific rehabilitation plan should be based on the type and severity of the neurologic condition and the specific needs of the patient. In general, maintaining joint function and range of motion, improving balance and proprioception, preserving or increasing muscle strength, and improving overall function are goals for the neurologic patient. Rehabilitation may increase the rate of recovery in patients that are expected to recover eventually from their neurologic condition. In patients with progressive neurologic conditions such as degenerative myelopathy, rehabilitation may retard deterioration of the patient.



Joint Function and Passive Range of Motion


Placing each joint through a normal range of motion helps to maintain joint health in patients with neurologic deficits. Reduced or unopposed muscle tone of either the flexor or the extensor muscles may result in contracture of the joints if a complete range of motion is not achieved at least daily. Passive range of motion (PROM) should be performed with the patient lying in lateral recumbency on a well-padded area. The upper limb joints are moved through gentle flexion and extension within the patient’s comfortable range of motion. Each joint should be moved through 15 to 20 cycles. As the patient improves, the entire limb may be put through an exaggerated gait movement, called range of motion through functional patterns or bicycling. These movements should be performed for 15 to 20 repetitions. The patient is then repositioned with the other side up, and the exercises are repeated on the other limbs. These exercises should be performed one to four times per day until the patient is able to ambulate or has reached a recovery plateau.


PROM may be combined with stretching in joints that have already lost some range of motion. The affected joint and adjacent muscles should be prewarmed with a warm pack to enhance extensibility of tissues. Massage of tense muscles may also cause relaxation and more effective stretching. PROM should be applied to the joint, and on reaching the respective end point of flexion and extension the therapist should exert a gentle stretch for 15 seconds to maintain the joint at the upper limits of flexion or extension, being careful not to induce unnecessary discomfort.


In patients with limited voluntary movement, eliciting a flexor reflex of the forelimb or hind limb results in some muscle contraction, joint motion, and sensory input to the limb and spinal cord. As the limb retracts, additional strengthening may be achieved by providing resistance to limb motion. In patients with poor-to-absent pain perception, caution must be used in eliciting the flexor reflex to avoid damage to the skin and other soft tissues of the toes.



Initial Strength, Balance, and Proprioception Exercises for the Neurologic Patient


A variety of exercises help to improve strength, balance, and coordination. These exercises are especially useful in patients that have voluntary movement with varying degrees of weakness and proprioceptive deficits.




Standing Exercises


The most basic strength and coordination exercise is the standing exercise. It entails having the patient in a standing position with all four limbs placed in a square, symmetric position on the ground with support of the body provided by a sling or other assistive device. As the patient begins to weaken and collapse to the ground, the therapist lifts the dog back into a square standing position. Initially standing exercises are performed for 1 to 3 minutes, with the goal of standing unassisted for 5 minutes. At this point the patient likely has adequate strength and stamina to begin other exercises. Standing in water is also an excellent exercise because the buoyancy of the water helps to support the body while the dog actively tries to stand and move the limbs. Exercise in water must always be attended. When an animal is able to stand (independently or with some mild assistance), activities to improve balance may begin. These exercises should be conducted on a nonslip surface to reduce the risk of falling.



Weight Shifting


While the animal is standing, a treat or ball may be used to encourage weight shifting. The therapist should move the treat or ball, allowing the dog to move its head and follow the treat up and down and side to side. He or she should start with small movements and progress to larger, more challenging movements. The movement of the head causes the dog’s center of gravity to shift, and the dog must shift its weight to maintain its balance. Standing on an inflatable disk provides support, yet challenges proprioceptive awareness.


The handler may also disturb the animal’s balance by gently pushing it at the hips or shoulder. The goal is to disturb its balance just enough so the animal can recover, being careful not to push too hard. Some dogs become conditioned to this activity and shift their weight toward the therapist to prevent being pushed toward the affected side. In this case a rebound weight shift may be effective, with the therapist gently pushing the animal toward the affected side. When the animal shifts its weight to resist, the therapist suddenly releases pressure. This results in a sudden unbalancing; the animal initially shifts its weight toward the unaffected side, but to keep from falling it shifts its weight back to the affected side. Additional challenges may be added by slowly moving a supporting towel back and forth to force the dog to shift its weight. A limb may also be lifted off the ground. This requires the patient to adjust and redistribute its weight to the remaining three limbs. This exercise may be performed on each limb on an alternating basis. Weight shifts may also be performed during walking. As the animal is walked, the handler gently bumps or pushes the animal to one side. Caution should be exercised to avoid falls and injury.



Assisted Ambulation/Gait Training


If a dog is unable to walk independently, a sling, towel, harness, or canine cart may be used to provide support as needed. Encourage the dog to move slowly, allowing time for it to advance the limbs as independently as possible. It may be necessary to manually assist the dog in the sequencing and placement of the limbs. The emphasis is on weight bearing with each and every step, encouraging a slow gait so that neuromuscular coordination and muscle strengthening may occur. Walking in water is beneficial because the animal’s weight is partially supported and the limbs typically move at a slower speed than land-based walking. Supported swimming can also provide benefits in patients with severe neurologic conditions; in some cases animals generate some limb movement, even if in an uncoordinated fashion, allowing strengthening and neuromuscular reeducation.



Advanced Strength, Balance, and Proprioception Exercises for the Neurologic Patient


A balance board may be used to rock the dog forward and backward and side to side. Commercial devices or a rectangular piece of plywood with a narrow rod running longitudinally or transversely along the bottom may be used. The board tips in a lateral or cranial-caudal direction, respectively, when the patient stands on it. A wobble board or human Biomechanical Ankle Platform System board with a half ball on the bottom of a platform may be used to help the animal practice proprioceptive positioning 360 degrees on just the forelimbs or the hind limbs. If the goal is to have the animal exercise using all four limbs, a specially made longer platform must be used that accommodates quadrupeds. It is important to provide support to allow the animal to shift its weight and exercise its proprioceptive mechanism. As proprioception improves, the motions may be made irregularly and faster to challenge the patient.


Other items may be used for additional proprioceptive training. Balance balls or rolls are large-diameter round or elongated exercise balls that the patient can be placed on and supported to improve balance, coordination, and strength. The forelimbs are placed on the ball and supported by the handler, requiring the dog to maintain static balance of the caudal trunk and rear limbs. Dynamic balance may also be challenged as the ball or roll is slowly moved forward, backward, and side to side, challenging the rear legs to maintain balance while movement occurs. To address the cranial trunk and forelimbs, the rear limbs are placed over the ball as the forelimbs are asked to balance the body weight during both stance and gentle movements. Further challenge is provided by having dogs stand on the roll with support.


Cavaletti rails are horizontal poles that are elevated such that the patient must pick its limbs up to step over the poles. As the patient improves, the rails may be placed at varying heights and distances. Having the patient walk across or stand on a foam mattress or trampoline and walk over surfaces with different textures may also be used to improve balance and coordination. Altering the texture of the ground surface challenges the animal’s functional walking proprioceptive ability. These exercises should be continued until the patient has a normal or very-near-normal gait.


In addition to walking over regular surfaces and surfaces of differing textures, dogs may be walked on a ground or underwater treadmill. Walking on a treadmill provides additional challenges to proprioception and is valuable in rehabilitation of human stroke patients. Sling support may be needed to prevent falls. A therapist positioned by the treadmill may help advance the limb during the appropriate phase of the gait cycle or correct knuckling over on the dorsum of the paw while walking. Walking on an underwater treadmill allows support of the patient’s body weight, and the water provides resistance to movement and muscle strengthening. Other strengthening activities include sit-to-stand exercises, walking with weights strapped on the limbs, or placing elastic bands around the distal limb with the therapist providing gentle resistance during motion.



Assistive Devices


Assistive devices provide increased independence for the pet, give support to a weak or nonfunctioning body part, and help the handler maintain proper body mechanics while performing therapy. These devices can also help to protect the feet during walking to prevent ulcers from forming. They are available in a variety of forms, including slings, two-wheeled and four-wheeled carts, boots, and splints.


Boots are an excellent way to protect the feet when an animal with neurologic deficits is knuckling or turning its feet over and walking on the dorsum of the foot. Animals with poor proprioception are unaware of the placement of their distal limbs and tend to walk on the dorsum of their paws or drag the nails when walking. Boots are placed over the foot and fastened by Velcro straps at the top. Most have a rubber sole to prevent slipping and are machine washable. Devices with straps are available to help prevent knuckling of the foot. It is important to remove the boots periodically (several times daily) to assess skin condition, especially in neurologically impaired patients, and if possible to increase weight bearing and proprioception through the bottom of the foot when performing therapeutic exercise. If not fitted properly, boots can interrupt circulation, impede gait patterns, and potentially cause more problems if the animal stumbles and falls. Proper fit is essential, and appropriate client education instructions for skin care and rehabilitative exercises must be communicated to the owner.


Slings come in a variety of shapes and sizes. Some products may be strapped around the abdomen or fitted for the forelimbs, hind limbs, or both. In most patients with thoracolumbar conditions, a sling fitting to the pelvis works better than simple abdominal slings. Slings should have long handheld straps attached to allow proper body mechanics to avoid personal injury to the handler when supporting the pet. These devices aid in transitioning a recumbent animal to a standing position and are especially useful for larger dogs. A sling can also assist with ambulation and prevent falls on slippery floors, especially after surgery, thereby avoiding further injury to the animal. Slings are available in a variety of sizes to provide the best fit. Slings used for the forelimbs should not obstruct respiration, and urine flow should not be compromised with hind limb slings in male dogs. A sling should have a soft lining against the animal’s skin to avoid irritation and sores, and the material should be washable. The sling must not be too narrow, especially around the groin and belly region, to avoid excessive pressure and development of sores. Slings are also useful during the later phases of rehabilitation for supporting standing during therapeutic exercises such as repeated sit to stands.


Carts, or canine wheelchairs, provide support, allow independence for the animal, and help prevent the deleterious effects of recumbency. Two- or four-wheeled carts are available for disabled paraplegic or quadriplegic patients. Carts should not be used too early in the course of rehabilitation because dogs may become too dependent on their support. They should be fitted properly according to manufacturers’ recommendations. Animals should be supervised at all times when in a cart so that they do not fall down stairs or tip over, and dogs should not be placed in the cart for long periods of time to prevent fatigue. Skin condition should be assessed daily to be certain that no areas of tissue breakdown occur.

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Jul 18, 2016 | Posted by in PHARMACOLOGY, TOXICOLOGY & THERAPEUTICS | Comments Off on Chapter 74: Physical Therapy and Rehabilitation of Neurologic Patients

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