Interventions for clients with movement limitations

DARCY A. UMPHRED, PT, PhD, FAPTA, NANCY N. BYL, PT, MPH, PhD, FAPTA, ROLANDO T. LAZARO, PT, PhD, DPT, GCS and MARGARET L. ROLLER, PT, MS, DPT

Objectives

After reading this chapter the student or therapist will be able to:

1. Appreciate the complexity of motor responses, and discuss methods used to influence body systems and their effects on functional behaviors.

2. Outline the differences in recovery related to healing, compensation, substitution, habituation, and adaptation.

3. Analyze the similarities and differences among impairment training of specific body systems, functional training, augmented feedback training, and learning-based sensorimotor retraining.

4. Select appropriate intervention strategies to optimize desired outcomes.

5. Analyze variables that may both positively and negatively affect complex motor responses and a patient’s ability to participate in functional activities.

6. Identify procedures and sequences required to attain the most successful therapeutic outcome that best meets the needs and goals of the client and the family.

7. Consider the contribution of the client, the client’s support systems, research evidence, neurophysiology, and the best practice standards available to optimize outcomes.

Key terms

augmented intervention

evidence-based practice

functional training

impairment training

neuromuscular retraining

Before discussing therapeutic intervention procedures, the therapist must identify the learning environment within which the client will perform. As discussed in Chapter 1, that environment is made up of the therapist and the client, all internal body control mechanisms of the client, and the external restraints and demands of the world. Although this text focuses on relearning functional movement, the reader must always consider all aspects of the client including how other organs or body systems will be affected by or will affect the therapeutic outcome both during rehabilitation and in relation to long-term quality of life. An examination and evaluation (see Chapter 8) are performed before intervention to establish movement diagnoses. These examinations lead to movement diagnoses that must link to functional limitations or restrictions in activities and their causations (body system problems). Movement diagnoses and the degree and extent of the system or subsystem dysfunction or impairments determine prognosis of the outcomes on the basis of the client’s potential for functional improvement. Factors such as motivation, family support, financial support, and cultural biases must be considered as part of the prognosis.¹ This process guides the selection of intervention strategies. Although it could be assumed that some of these impairments would be directly correlated to the central nervous system (CNS) trauma experienced by the client, it must also be determined whether some or most of these impairments have developed over a lifetime as a result of small traumas and adjustments to life. This insidious cause of impairments needs to be differentiated from acute causation of activity limitations because goal setting and expectations related to prognosis and recovery can be different.

Both the American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) have developed guides to practice that help to direct therapists entering the professions and should help to guide practice throughout their working lives.²^,³ APTA, through the initiation of the California Physical Therapy Association, has been collecting and classifying evidence-based articles through the Hooked on Evidence project.⁴ Through the use of current evidence-based practice; sensorimotor processing, motor control, motor learning, and neuroplasticity theories (see Chapter 4); and body systems models, the therapist must determine the flexibility or inherent motor control the client demonstrates while executing functional activities and participating in life. This chapter or other chapters in the book cannot establish for the reader the exact treatment sequence that should be used for every patient, but an example of a decision-making pathway has been given in Box 9-1. Functional goals must be established that lead to the client’s ability to participate in life within his or her environment and whenever possible lead to or maintain the quality of life desired by the client. Similarly, the therapist must differentiate whether the observed motor problems are based on acute or longstanding impairments before establishing timelines for prognosis.

BOX 9-1 TREATMENT STRATEGY CATEGORIES

Compensation training

Use of an assistive device or orthotic to compensate for a permanent impairment or lost body system function.

Substitution training

Teaching the client to use a different sensory system or muscle(s) group to substitute for lost function of another system. An example of sensory substitution might be teaching the client to use vision to substitute for an impaired vestibular system or somatosensory system for balance function. Substitution within the motor system might be teaching hip hiking to substitute for lack of dorsiflexion of the ankle during swing phase of gait.

Habituation training

Activity-based provocation of symptoms with the goal of symptom reduction with repetitive practice. An example would be teaching head movement to a patient who has a chronic labyrinthitis and severe nausea with any head movement.

Neural adaptation

Driving changes in structure and function of the central or peripheral nervous system with repetitive, attended practice. This category would be considered neural plasticity. This category of treatment strategy takes the greatest repetition of practice and requires a strong desire by the individual to gain the functional ability and realize the potential of the central nervous system to change.

Before beginning any intervention, the therapist must determine the treatment strategies that will be used to help the client attain the desired functional outcomes. The specific environment used by the therapist to optimize patient performance will depend on the functional level and amount of motor control exhibited by the patient. The following classifications can be used to document the specific role of the therapist within the training session (refer to Chapter 4 for additional detail):

Functional training: Practice of a functional skill that is meaningful, goal directed, and task oriented. Patient will experience errors and self-correct as the program becomes more automatic and integrated. An example would be gait training on a tile surface, rugs, inclined surfaces, compliant surfaces such as grass, and so on to practice ambulation.

Body system or impairment training: Treatment focus is on correcting a body system problem during an activity (e.g., pure muscle strengthening, stretching, sensory training, endurance training).

Augmented feedback training: Patient needs external feedback (auditory, visual, kinesthetic) and control over the motor program running the target task. This will limit the response patterns (e.g., reducing degrees of freedom, reduction or enhancement of tone) for successful performance of the desired movement (e.g., handling techniques, body-supported treadmill training, constraint-induced training).

Learning-based sensorimotor retraining: Treatment focus is placed on improving sensory discrimination dysfunction as a consequence of somatosensory, premotor, and motor cortical disorganization resulting from trauma, degeneration, or overuse.

Clients with CNS damage often benefit from combining interventions from the above categories. An example of this might be the early phase of partial body-weight supported treadmill training. In the early phases, a therapist or assistant is guiding the client’s leg during swing and stance phases while the body harness supports a proportion of the client’s total weight (augmented feedback) to assist the postural system in running appropriate programs to maintain balance and decrease the power needed to generate a more normal gait pattern. This augmented intervention is being done in a functional pattern within an environment that perturbs the client’s base of support under the normal center of gravity. Thus, this perturbation moves each foot reciprocally backwards and the body forward, triggering a stepping reaction. In the case of an individual after a cerebrovascular accident (CVA), one leg will still respond normally, thus helping to trigger a between-limb reciprocal stepping action of the involved leg. In the case of bilateral involvement, both legs may need placement, requiring two people to assist. The activity may be classified as impairment training, with the focus on appropriate power production or cardiovascular fitness, leading to functional training to trigger normal motor programs necessary for gait. Simultaneously, augmented training done by a therapist includes manual assistance in the direction, rate, and placement of the involved leg throughout the gait cycle. In this previous example, therapists need to make sure they are aware of the patient’s center of gravity and do not move the foot before it should be at “push off” during the gait cycle. This activity would not be considered functional training until the client could reciprocally move both legs during the gait pattern without the need of the harnass for postural support and the therapist to guide the movement.

When selecting from a variety of treatment interventions (neuromuscular retraining, functional training, impairment training, and augmented feedback training), it is important for the therapist to consider that each one is based on different strategies and rationales that contribute to the expected outcome. All interventions should address the needs of the patient and must consider any emotional and cognitive restraints. Although these intervention methods can be used simultaneously or in various combinations, the clinician needs to consider which aspect of the intervention falls into which treatment classification. Although various treatment outcomes can be measured, if classification of each treatment variable is not identified, the determination of how and why the outcomes were influenced by the intervention becomes confusing and difficult to distinguish. Without understanding the interactions of intervention methods and the outcome, treatment effectiveness and future clinical decision making remain unpredictable, and unique practice patterns and pathways are hard to identify with consistency. A master clinician who is effective with all patients but does not know how and why the decisions are made along the intervention pathway cannot leave a legacy of effectiveness that will ever lead to efficacy. Although not all graduates or inexperienced clinicians may have the innate aptitude or potential to become master clinicians, if professionals understand the verbal, spatial, cognitive, fine and gross motor, and emotional sensitivity variables that play a role in the evolution toward mastery, educational experiences might be able to nurture future colleagues along this pathway and help those with mastership potential reach that level of function earlier in their professional careers.

The reader must also remember that intervention encompasses multiple interactive environments where intervention decisions are often made moment by moment during any treatment period. The challenge to the educated clinical professional is to determine what is being done, why it is working, how to continue its effectiveness, and how to determine the progress of the successful intervention. The clinician must also determine how to empower the client (emotionally, cognitively, and motorically) to take over the intervention with inherent, automatic mechanisms that lead to fluid, flexible, functional outcomes independent of both the therapist and the environment within which the activity is occurring. It is not until clinicians can determine effective treatment outcomes from various interventions that efficacy within a research laboratory can be studied without speculation and hypothesis formation based on speculation.¹ Effectiveness is the first way to determine evidence-based practice. Once effectiveness has been established through case studies and larger controlled studies within the clinical environment, researchers can begin to tease out separate variables and establish efficacy as part of evidence to justify clinical decision making.

History of development of interventions for neurological disabilities

In the mid 1900s the interventions by physical therapists (PTs) and occupational therapists (OTs) were separate. Generally, PTs worked on gross motor activities with specific emphasis on the lower extremities and the trunk, whereas OTs worked on the upper extremities and fine motor activities. Both professions focused on daily living skills, with those involving the arms falling within the domain of the OT and those involving the legs falling within the domain of the PT. Activities that required gross motor skills such as sitting, coming to stand, walking, walking with assistive devices, and running fell within the purview of the PT, whereas grooming, hygiene, and eating were the responsibility of the OT. Today, this approach is considered ridiculous owing to our understanding of motor learning, neuroplasticity, and motor programming and control. In the past it was also accepted that the PT worked on specific system problems such as weakness, inflexibility, lack of coordination, and voluntary control, whereas the OT worked on functional activities integrated within the environment (such as dressing) and the patient’s emotional needs and desires (occupational expectations). According to the terminology of the mid to late twentieth century, PTs were trained to identify and correct impairments that caused functional limitations, whereas OTs were trained in activity analysis and treatment that identified and optimized the functional activities that resulted from the impairments. Few clinicians seemed to focus on the sequential or interactive aspect of lack of function with specific impairments. Thus after the onset of a stroke the PT would strengthen and evaluate range of motion (ROM) of the leg and trunk, whereas the OT would encourage the patient to try to functionally use the arm. The PT would be preparing the patient to transfer out of bed and get into and out of a chair and then helping the patient walk, whereas the OT would be preparing the patient to use the arm in functional activities such as grooming or eating. Both therapists hoped the patient would accept responsibility for continued improvement through practice. What both professions discovered was that the patient generally did not regain normal motor control. He or she might be able to walk and might be able to move the shoulder, but the movement strategies were generally stereotypical, were abnormal in patterns, and took tremendous effort by and energy from the patient to perform. Over time, clients lost the motivation to even try, and thus what had been gained through therapy may have been lost from lack of practice once they got home. There was also minimal recovery of functional hand use, often because of the tremendous effort a patient had to use to move the shoulder to place the hand somewhere. Once that effort had been used the tightness and increased tone in the hand prevented functional use. Although functionally independent skills as measured on the Functional Independence Measure were achieved, normal movement patterns and normal motor control were rarely restored, and quality of life was clearly affected for the patient and family.

During the decade or two before the 1960s, some talented and intelligent clinicians began to question the traditional intervention strategies used by the OT and PT. These pioneers 5–29 in neurological rehabilitation set the stage for the development of new concepts that allowed basic science to infiltrate the clinical arena. The intervention strategies of Jean Ayers, Berta Bobath, Signe Brunnstrom, Margaret Johnstone, Susanne Klein-Vogelbach, Margaret Knott, Dorothy Voss, Margaret Rood, and others became popular. Colleagues observed these master clinicians and could easily see that the “new” interventions were much more effective and provided better outcomes than previous interventions. Each approach focused on multisensory inputs introduced to the client in controlled and identified sequences. These sequences were based on the inherent nature of synergistic patterns⁵^,²¹^,³⁰^,³¹ and motor patterns observed in humans⁵^,⁷^,³² and lower-order animals³³ or a combination of the two.¹⁹^,²¹ Each method focused on the individual client, the specific clinical problems, and the availability of alternative treatment approaches within an established framework. Some of these approaches focused on specific neurological medical diagnoses. The treatment emphasis was then on specific patients and their related movement disorders. Children with cerebral palsy and head injuries⁷^,²³^,²⁸ and adults with hemiplegia⁸^,⁹^,²¹^,³² were the three most frequently identified medical diagnostic categories. In 1968 at Northwestern University a large conference was held and laid the foundation for the first STEP conference (Northwest University Special Therapeutic Exercise Project [NUSTEP]). Most of these master clinicians, along with research scientists of the day, came together to try to (1) identify the commonalities and differences between these approaches, and (2) integrate and use the neuroscience of the day to explain why these approaches worked.³⁴ Since the 1970s, substantial clinical attention has also been paid to children with learning and language difficulties.⁵^,¹³^,³⁵ Now these concepts and treatment procedures have been applied across the age spectrum for all types of medically diagnosed neurological problems seen in the clinical setting (refer to Section II of this text). This expansion of the use of any of the methods for any pathological condition manifested by insults from disease, injury, or degeneration of the brain seems to be a natural evolution given the structure and function of the CNS and commonalities in system problems and activity limitations that take the individual away from participating in life.

Fortunately, most dogmatism no longer persists with respect to territorial boundaries identified by clinicians using some specific intervention methods. A conference in 1990 ³⁶ played a significant role in challenging the relevance of these territorial boundaries and stressed the adoption of a systems model when looking at impairments, activity limitations, and participation in life interactions.³⁷ As the boundaries for interventions began blurring, intervention approaches such as proprioceptive neuromuscular facilitation (PNF) were then integrated into the care of clients with orthopedic problems and patients with neurological impairments. Today, few universities within the United States teach separate sections or units on specific approaches, but rather teach students to identify problems, when they are occurring in functional programs, and what bodily systems might be the cause of those activity limitations.

For example, assume that a client with hemiplegia exhibited signs of a hypertonic upper-extremity pattern of shoulder adduction, internal rotation, elbow flexion, and forearm pronation with wrist and finger flexion. Brunnstrom ⁸ would have identified that pattern as the stronger of her two upper-extremity synergies. Michels,²¹ although using an explanation similar to Brunnstrom’s to describe the pattern, would have elaborated and described additional upper-extremity synergy patterns. Bobath would have asserted that the client was stuck in a mass-movement pattern resulting from abnormal postural reflex activity.³⁰ Although the conceptualization of the problem certainly determined treatment protocols, the pattern all three clinicians would have worked toward was shoulder abduction, external rotation, elbow extension, forearm supination, and wrist and finger extension. The rationale for the use of this pattern within an intervention period would vary according to the philosophical approach. One clinician might describe the pattern as a reflex-inhibiting position (Bobath).³¹ Another would describe the pattern as the weakest component of the various synergies (Brunnstrom),⁸ whereas still another might identify the pattern as producing an extreme stretch and rotational element that inhibited the spastic pattern (Rood).²⁵ How those master clinicians sequenced treatment from the original hypertonic pattern to the opposite pattern and then to the goal-directed functional pattern would vary. Some would facilitate push-pull patterns in the supine and side-lying positions and rolling. Others would look at propping patterns in sitting clients or at weight-bearing patterns of clients in the prone position, over a ball or bolster, or in partial kneeling. All have the potential of improving the functional pattern of the upper extremity and modifying the hypertonic pattern. One method may have been better than the others given a particular patient, but in truth improved patient performance may have stemmed not from the method itself, but rather from the preferential CNS biases of the client and the variability of application skills among the clinicians themselves. That is, when a therapist intentionally uses specific augmented feedback to modulate the motor system’s response to an environment but does not identify the other external feedback present within that environment (e.g., lighting, sound, touch, environmental constraints), therapeutic results will vary. Because of variance, efficacy of intervention is often questionable, although the effectiveness of that therapist may be easily recognized.

Because of the overlap of treatment methods and the infiltration of therapeutic management into all avenues of neurological dysfunction, various multisensory models were developed during the early 1980s.¹³^,^38–41 These have continued to evolve into acceptable methods in today’s clinical arena. Although these models attempted to integrate existing techniques, in reality they have created a new set of holistic treatment approaches. In July 2005 the III STEP conference⁴² was held in Utah to again bring current theories and evidence-based practice into today’s clinical environment. The history of the three STEP conferences demonstrates the evolution of evidence-based practice from the first conference, where basic science was the only evidence to justify treatment, to the second conference, where evidence in motor learning and motor control began to bring efficacy to intervention. By the time the third conference was held, the research in neuro/movement science regarding true efficacy within practice and the reliability and validity of our examination tools set the stage for standards in practice.⁴³ Where the next conference will take the professions and how soon that will occur is up to colleagues in the future. No proceedings from that third conference were published, but over the preceding years articles covering most of the presentations had been published in the Journal of Physical Therapy. The ultimate goal would be to develop one all-encompassing methodology that allows the clinician the freedom to use any method that is appropriate for the needs and individual learning styles of the client as well as to tap the unique individual differences of the clinician. Although intervention today is based on an integrated model, the influence of third-party payers, the need for efficacy of practice, and time constraints often factor into the therapist’s choice of intervention. Visionary and entrepreneurial practice ideas that have the potential to be effective will always be a challenge to future therapists. Those ideas generally originate within the clinical environment and not the research laboratory. For that reason, clinicians need to communicate ideas to the researcher, and then those researchers can develop research studies that test the established efficacy or refute that effectiveness. Few researchers are master clinicians, and few clinicians are master researchers; thus collaboration is needed as the professions move forward in establishing evidence-based practice.

Today’s therapists have replaced many of the existing philosophical approaches with patient-centered therapeutic intervention. Patient performance, available evidence, and the expertise of the clinician often play a key role in the specific decision regarding an intervention. When confronted with an abnormal upper-extremity pattern, today’s therapist may choose to work on improving the movement pattern using a functional activity. Control of the combination of movement responses and modulation over specific central pattern generators or learned behavior programs will allow the patient opportunities to experience functional movement that is task oriented and environmentally specific. With goal-directed practice of the functional activity, neuroplastic changes, motor learning, and carryover can be achieved.⁴⁴ With a better scientific basis for understanding the function of the human nervous system, how the motor system learns and is controlled, and how other body systems, both internal and external to the CNS, modulate response patterns, today’s clinicians have many additional options for selection of intervention strategies.^45–54 Whether a patient would initially benefit best from neuromuscular retraining, functional retraining, or a more traditional augmented or contrived treatment environment is up to the clinician and is based on the specific needs identified during the examination and evaluation process.

No matter what treatment method is selected by a clinician, all intervention should focus on the active learning process of the client. The client should never be a passive participant, even if the level of consciousness is considered vegetative, nor should the client be asked to perform an activity when the system problems only create distortion or demonstrate total lack of control of the desired movement. With all interventions requiring an active motor response, whether to change a body system impairment such as by increasing or reducing the rate of a motor response, modulate the tonal state of the central pattern generators and learned motor behaviors, or influence a functional response during an activity, the client’s CNS is being asked to process and respond to the external world. That response needs to become procedural and controlled by the patient without any augmentation to be measured as functionally independent. In time, the ultimate goal is for the client to self-regulate and orchestrate modulation over this adaptable and dynamic integrated sensorimotor system in all functional activities and in all external environments.

A problem-oriented approach to the treatment of any impairment or activity limitation implies that flexibility and neural adaptation are key elements in recovery. However, adaptation should not be random, disjointed, or non–goal oriented. It should be based on methods that provide the best combination of available treatment alternatives to meet the specific needs of the individual. Development of a clinical knowledge bank enables the therapist to match treatment alternatives with the patient’s impairments, activity limitations, objectives for improved function, and desired quality of life. A professionally educated therapist no longer bases treatment on identified approaches, although specific aspects of those approaches may be treatment tools that will meet the client’s needs and assist him or her in regaining functional control of movement. Treatment is based on an interaction among basic science, applied science, the therapist’s skills, and the client’s desired outcomes.49–52^,⁵⁵^,⁵⁶ In most cases, multiple intervention strategies must be included, but the therapist needs to be able to identify why those selected treatments will lead to system improvement as well as documenting those findings using reliable standardized and acceptable clinical methods and terminology. These intervention strategies must be dynamic yet also understandable and repeatable. As new scientific theories are discovered, new information must be integrated to continue to modify treatment approaches.

Intervention strategies

Functional training

Functional training is a method of retraining the motor system using repetitive practice of functional tasks in an attempt to reestablish the client’s ability to perform activities of daily living (ADLs) and participate in specific life activities such as golfing, fly-fishing, basketball, or bridge. This method of training is a common and popular intervention strategy used by clinicians owing to the fact that it is a relatively simple and straightforward approach to improving deficits in function. A system problem such as weakness in the quadriceps muscle of the leg can be treated by muscle strengthening in a functional pattern that can be easily measured. Because of its inherent simplicity, functional training is sometimes misused or abused by clinicians. Most patients with neurological deficits have multiple subsystem problems within multiple areas, which forces the CNS to use alternative movement patterns in order to try to accomplish the functional task presented. If the therapist accesses a motor plan such as transfers but allows the patient to use programs that are inefficient, inappropriate, or stereotypical, then the activity itself is often beyond the patient’s ability. The patient may learn something, but it will not be the normal program for transfers. This activity often leads to additional problems for the client.

In Chapter 8 the steps involved in the examination process are explained in detail. The intricate relationship of body system problems, impairments, and functional limitations that decrease participation in the rehabilitation process are discussed. Functional training can be implemented once the clinician has identified the client’s activity limitations. The clinician must first answer the questions “What can the client do?” “What limitations does the client have when engaging in functional activities?” “Are there motor programs that are being used to substitute for normal motor function?” and “Can the therapist use functional training to improve body system problems within the context of the functional skill?” Once the therapist has an understanding of the reasons for any activity limitation and can alleviate substitution and compensation for the deficit, functional tasks should be identified and practiced.

The effect of functional training on task performance and participation

The main focus of functional training is the correction of activity limitations that prevent an individual from participating in life. However, through repetitive practice of functional tasks and gross motor patterns, many of the client’s impairments can also be affected. For example, if a therapist practices sit-to-stand transfers with a client in a variety of environments and performs multiple repetitions of each type of transfer, not only can learning be reinforced, but the client can also gain strength in the synergistic patterns of the lower extremities that work against gravity to concentrically lift the client off of the support surface and eccentrically lower him or her down. Weight bearing through the feet in a variety of degrees of ankle dorsiflexion during transfer training will effectively place the ankles in functional positions. The act of standing also helps the trunk and neck extensors to engage in postural control. Varying the speed of the activity during the treatment can stimulate cerebellar adaptation to the movement task. Moving from one position to another with the head in a variety of positions stimulates the vestibular apparatus and may assist in habituating a hypersensitive vestibular system, allowing the client to change body positions without symptoms of dizziness, resulting in a higher quality of life. Repetitive practice also affects the vasomotor system and may assist in habituating postural hypotensive responses.

A good example of the misuse of functional training is the “nag-and-drag” method of gait training in the parallel bars. This method finds the therapist literally dragging the client through the length of the parallel bars in an attempt to elicit some sort of movement response from the client. The therapist then labels this procedure “gait training.” Clearly, this approach will result in the client eventually learning dysfunctional, inefficient motor programs. Before long, as the client learns to run these dysfunctional programs procedurally, the clinician will realize that he or she has created a bigger problem, and a considerable amount of time and resources may be required to undo the damage that was created by limiting the available movement strategies, limiting the variability within practice, and ultimately restricting the plasticity of the nervous system. Similarly, forcing the axial trunk musculature to compensate for lack of motor control within the elbow and wrist will result in dysfunctional upper-extremity movement patterns.

Functional training is the best method of intervention when the client can run normal programs that have some limitation such as poor ROM or inadequate muscle power from disuse. In that way, functional training will run normal programming until fatigue sets in, which may be after only one or two repetitions. Increasing the repetitions and/or the power necessary to run the programs will lead to functional improvement. In using functional training, accurate standardized measurement tools that clearly illustrate change will quickly tell the therapist whether the change is in the direction of more functional control or additional limitation.

An intervention approach in the early 1990s that evolved as an offshoot of functional training was labeled clinical pathways. These pathways were established by health care institutions to improve consistency of management of patients who met specific medical diagnostic criteria. It has been proven that the implementation of these pathways reduces variability in clinical practice and improves patient outcomes.⁶⁷ Health care practitioners also became aware that some individuals do not fall into these pathways and need to be treated according to the specific clinical problems that the patients were presenting.

Selection of functional training strategies

What is the “ideal” procedure for effectively and efficiently using functional training as a treatment intervention? First, it is suggested that the clinician identify and select procedures that will use the client’s strengths to regain lost function and correct system limitations—“What can the client do?” The clinician is also advised to avoid activities that may be too difficult and elicit compensatory strategies that may result in the development of abnormal, stereotypical movement and potentially create additional impairments. An example of this is using transfer training when the patient is unable to keep the program within the limits that define it as a transfer. What instead happens is that the patient would begin to fall. Once in that situation, the patient is then working on approaches to prevent from falling, not activities that allow the patient to safely transfer. The therapist’s decision regarding what functional patterns or activities to practice, and in what order, will depend on several factors. The therapist must choose functional activities that are necessary for the client to perform independently or manage with less help before being discharged home. For PTs, safe transfers and ambulation are generally the focus of functional training. For OTs, independent bathing, dressing, and feeding are major foci. Yet both PTs and OTs also need to be sensitive to the activities that the patient or the patient’s family want to improve to enhance the quality of life for everyone involved in the person’s case. The ability to get in and out of a car might be the most important activity for the client to learn because he or she needs to make frequent trips to the physician’s office and the primary caregiver has cardiac problems and is unable to assist the patient in transferring without placing his or her own cardiac system at extreme risk.

The goal of therapy is to move toward functional training as quickly as the client’s motor system can control the movement. As learning and repetition assist the CNS in widening the response pattern during a functional activity, the client’s ability to respond to variance within the environment will enlarge and assist in gaining greater independence. An example of this application of functional training might be asking a client to perform a stand-to-sit transfer. The client is first guided down to sitting onto a large gym ball, a high-low table, or a stool that allows the client to sit only one fourth to one half of the way down before returning to stand. As the client develops increased strength and balance and improved control over abnormal limb synergies and tone in this pattern, then a smaller gym ball or a lower point on a high-low table can be used. Finally, the client is asked to sit down onto a ball/mat or chair that results in the patient sitting with the hips and knees at 90 degrees. Once the client can sit down and return to a vertical position, the next task will be to sit down, relax, and then stand up. Once that activity is done easily, the client will be functionally able to stand to sit and to reverse the movement pattern to sit to stand.

Although many clinicians understand the importance of running motor tasks within an appropriate biomechanical, musculoskeletal, and sensorimotor window in which the client has the ability to perform procedures functionally, it may be argued that in many cases this particular type of treatment strategy is simply not possible in a real-world situation. For example, given the current health care environment, if the client is given a limited number of visits to achieve the desired outcome, the clinician may conclude that there is no choice but to “allow as many degrees of freedom as possible” or, in other words, to “force the window open” no matter the abnormal movement patterns used or the limitations in independent functional control that they may produce.

In summary, the clinician should first identify and emphasize the client’s strengths (“What can the client do?”) and use those strengths to efficiently and effectively achieve functional change. Next, the clinician must prioritize what systems or activities the client truly needs to change. The choice of what activities to emphasize during therapeutic training always poses a dilemma to therapists. Although it may be ideal for the client to eventually be able to ambulate independently on all surfaces without any assistance or reach for any object in and from any spatial position, it may be more important initially for the client to be able to safely transfer from the bed to the wheelchair, sit independently while someone assists with dressing, or walk and transfer onto and off of the commode independently at home. One should keep in mind that although several skills may be learned by training them simultaneously, it may make more sense to concentrate on the safe performance of one or two necessary functional tasks rather than having the client end up being able to perform multiple tasks that require considerable outside assistance for safety. The need to work functionally on additional activities may also be an opportunity for the clinician to request additional therapy visits for the client, arguing that there is a reasonable expectation that more intervention would result in a greater increase in function and a greater decrease in the risk for potential injury than if the intervention were not continued. The use of valid and reliable functional outcome measures becomes critically important in case management. These tools objectively measure the effect of the intervention, help predict the potential risks if the therapy is not continued, and ultimately aid in the justification to continue therapeutic intervention.

CASE STUDY 9-1 FUNCTIONAL TRAINING: AMBULATION

Teaching a client to ambulate can be approached in many ways. Assume that the objective for a particular session is ambulation. First, the client may be asked to ambulate in the parallel bars using the upper extremities to assist in forward progression of the movement to decrease fear and to assist in maintaining balance. Once the patient can perform this ambulatory activity, the therapist might decide to progress the patient’s ambulation by introducing a walker, which has four points of support. Ambulating with the walker will again increase power production in the legs and create an environment of safety for the client. Once walking with the walker can be performed at various speeds and distances, the therapist may advance the activity to using two canes, then one cane depending on the client’s balance, coordination, and need. While the patient is practicing ambulating with cane(s), he may also be walking on a treadmill to increase endurance, velocity of gait, and power. Once the patient can ambulate safely with a cane, the therapist may decide to transition to walking without any assistive devices. Again the patient may first be asked to walk on a treadmill while holding on with his arms until he feels safe walking and no longer needs an assistive device. The therapist could transition to ramps, obstacles, uneven ground, and so on. All these activities would require the individual to begin with functional control over the program for ambulation. All the activities are focused on regaining independence in the functional activity of walking, using repetitive practice. These therapeutic devices assist the patient in successfully practicing the entire gait cycle on both legs. In time, the patient is asked to continue walking without the need of the assistive devices and will continue to practice that activity as functional movement or is considered functionally independent with the use of an assistive device. The therapist must also remember that when introducing an assistive device, that device itself will usually limit the environments within which a patient can ambulate independently.

Conclusion

One important variable that has clearly been identified with respect to functional training is “task specificity.”⁴⁷^,^68–76 Although it is important that a patient be independent in as many ADLs as possible, often the therapist, the patient, and the family need to prioritize which activities are most important to the quality of life of the patient. If walking into the mountains to do “birdwatching” is one important goal to the patient, then creating an environment that would closely resemble the environment of that activity is crucial. Similarly, practice within that environment is a key to successful carryover (see Chapter 4). If the patient wants to walk into the mountains and the family expects the patient to walk into his or her old job, a therapist must accept that motivation will drive behavior and task specificity will drive learning. Carryover into any other functional activity such as walking into the office building in order to go back to work may not be the motivating factor that will guide that individual’s desire to perform that motor task. Whether the patient ever goes back to work is not the variable that should be used as part of the motivational environment for task-specific gait training geared to walking in the mountains and is not a decision for which the therapist is responsible. Therapists need to allow the patient to tell them what will be the most important task and the specificity of that task to optimize motor learning and functional recovery.

Body system and impairment training

As mentioned in Chapter 8, the therapeutic examination results in the identification of activity limitations and possible body system and subsystem impairments that are causing the functional movement disorders. Impairment training is another intervention strategy that involves the correction of impairments with the expectation that improving these impairments will result in a corresponding improvement in function. For example, when a client has the inability to stand up without assistance (activity limitation) and the clinician determines the cause to be lower-extremity weakness, an appropriate approach may be to strengthen the lower extremities (impairment training). Numerous studies have shown the effectiveness of impairment training in improving the functional performance of individuals with neurological conditions such as cerebral palsy,⁷⁷^,⁷⁸ stroke,^79–87 multiple sclerosis,^88–93 Parkinson disease,^94–98 and other neuromuscular diagnoses.^99–110 The strengthening intervention selected should reflect the task and the environment within which the impairment was identified. The clinician should attempt to create a training situation so that the client may be able to run the necessary motor programs with all the required subsystems in place. For example, training sit to stand with weakness in the hip and knee extensors is much less likely to automatically result in the improvement of sit-to-stand function if the therapist begins the activity in sitting where generation of extension is most difficult, than if the strengthening training was performed with repetition of practice starting in standing and going to sit and back again to stand. By decreasing the degrees of freedom of the eccentric control of the hips and knees when going from stand to sit, the functional training activity has turned into specific impairment training. The therapist can ask the patient to eccentrically lengthen the extensors only in a limited range and then concentrically contract back to standing. As the power increases, the degrees of freedom can also be enlarged until the patient is able to complete the task of stand to sit while simultaneously regaining the sit to stand pattern. In pure impairment training a patient might also be asked to straighten the knee when sitting or to extend the hip when prone. These three exercises have the potential of training impaired strength, but only the first example forces the training within a functional pattern. Similarly, the therapist could train the sit-to-stand pattern using various seat heights that encompass many of the components that force the use of normal movement synergies and postural control, using the environment in which that activity is typically performed, versus performance of strengthening exercises against resistance in an open chain exercise program.