Neuromuscular rehabilitation:summary

• Neuromuscular rehabilitation aims to help theindividual to recover their movement control andoptimize their functional capacity.

• It is an inclusive approach that encompasses thecognitive, behavioural and neurophysiologicaldimensions of the individual.

• The rehabilitation promoted in this book hasthree basic recurring concepts:

� It aims to be functional

� It involves skill/ability-level rehabilitation

� It uses the learning/adaptation code tooptimize motor control changes.

Functional rehabilitation

• Functional movement is the movement repertoireof an individual.

• Movement which is out of the individual’sexperience is termed extra-functional.

• Functional rehabilitation utilizes the patient’s ownmovement repertoire to help them to recover theirmovement losses. It uses actions the patient isalready familiar with but can’t carry out.

• Extra-functional movement requires a period oflearning/training and is, therefore, not ideal forindividuals who are in pain or recovering from aninjury.

Skill/ability-level rehabilitation

• Neuromuscular rehabilitation can be within askill and/or ability level.

• Skill is how proficient a person is in performing aparticular task.

• Skill depends on practice and a mixture of thesensory-motor and cognitive abilities of theindividual.

• Motor abilities are the various control factors thatunderlie movement.

• At skill-level rehabilitation the patient simplyaims to carry out the movements they arecurrently unable to complete.

• Ability-level rehabilitation (re-abilitation) focuseson specific underlying motor losses whichprevent the person from attaining theirmovement goals.

• Cognition about injury and pain, persistent painand fear of it, and behavioural factors, are allmanageable within skill-level rehabilitation.

The code for neuromuscularadaptation

• Learning, retraining, motor organization to injuryand return to functionality depend on thecapacity of the motor system to adapt.

• These adaptive processes can be optimizedby introducing five principal elements:cognition, activity, feedback, repetition andsimilarity.

• Cognition involves thinking, rationalizing,memorizing, focusing, being attentive, decidingon actions and understanding the aims and goalsof the rehabilitation process.

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• Being physically active is important forneuromuscular adaptation. Passive movementapproaches are unlikely to be effective inpromoting lasting and functional motor controlchanges.

• Feedback can be intrinsic from proprioception orextrinsic as guidance from the therapist.

• Repetition, repetition, repetition – practice isvery important for long-term memory.

• Rehabilitation should use movement patternsthat are similar to, and within the context of, themovement being recovered.

• Experiences that possess a higher content ofadaptive code elements have a greater potentialfor promoting long-term changes.

Motor abilities

• Motor abilities can be classified according to theirlevel of motor complexity: parametric, synergeticand composite abilities.

• Parametric abilities are: force, velocity/speed/rate, length, endurance.

• There are two identifiable synergistic controlpatterns: reciprocal activation and co-contraction.

• Composite abilities are: coordination (fine,single- and multi-limb, and body coordination),balance/postural stability, transition time andmotor relaxation.

• Motor ability changes can be observed inmusculoskeletal injuries and pain conditions andin patients suffering from central nervous system(CNS) damage.

• There is evidence that motor abilities can benormalized by activities that challenge themspecifically.

Sensory ability

• The sensory-motor system is a functional unit.

• Proprioceptive acuity can be affected due toperipheral and/or central causes.

• Musculoskeletal injury can affect the peripheralproprioceptive apparatus while CNS damage willaffect the central processing of proprioception.

• Recovery of proprioception comprises bothreparative and adaptive processes. As such, it

may have its own inherent recovery period thatmay take several weeks or months to complete.

• Promoting normal functional movement will helpproprioception by facilitating positive sensory-motor reorganization/adaptation. There is noneed to specifically target proprioception.

• All exercises are proprioceptive exercises.

The motor system inmusculoskeletal injury

• The motor reorganization following injury is amulti-dimensional strategy culminating inpostural and movement reorganization aimed atreducing the mechanical stresses imposed on thedamaged tissues – in this text it is referred to asthe injury response.

• The injury response is a positive healthy responseand not a motor dysfunction or pathology.

• Acute musculoskeletal injuries should be leftalone – the body knows best. The patient shouldbe encouraged to keep active.

• Neuromuscular rehabilitation is useful when theinjury response serves no obvious protectivefunction. It includes:

� Conditions where the injury response hasbecome an adaptive state, such as in chronicrecovery from injury or surgery, or conditionswhere there were movement constraints orimmobilization

� Sensitization conditions where tissue damagehas resolved but the patient still experiencespain

� Injury-related psychological distress that leadsto “psychomotor” control losses.

• In the neurological dimension there is no injuryspecific rehabilitation. A body area isrehabilitated according to its function rather thanto the underlying pathology.

Cognition and behaviour

• Cognition, behaviour and movement control areinseparable.

• Helping individuals to modify their injurybehaviour and challenging beliefs and attitudesabout their condition can facilitate motorrecovery.

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• Some injuries and pain conditions can beacquired by the way the person uses their body inrelation to the physical environment (taskbehaviour), or by the way in which the personorganizes and schedules their physical activities(organizational behaviour, often overuse injuries).

• Guiding individuals in how to modify their taskand organizational behaviour could help toprevent musculoskeletal injury and pain.

• Movement control can change solely by cognitivemeans.

Non-traumatic pain conditions

• Individuals may acquire painful musculoskeletalconditions without traumatic injury.

• Often these conditions develop in low-load,repetitive physical activities (computer use) or inresponse to psychological distress.

• These conditions oftenmanifest as pain and tenderpoints around the head (tension headache),suboccipital area, neck and neck-scapular muscles(trapezius myalgia) and jaw (bruxism).

• All these conditions share similar processes –inability of the individual to relax, transmission oftension via the neuromuscular system to specificmuscles.

• Intervention should be all-inclusive – acombination of cognitive, psychosocial,behavioural, organizational and neuromuscularapproaches.

• Focused motor relaxation should be used to trainthe individual how to relax their painful muscles.

• Transferring the relaxation to functional dailyactivities is important. Promote relaxation-in-movement.

• The patient’s own coping strategies are veryimportant for reducing stress and chronic statesof arousal.

• Neuromucular rehabilitation is also about motorrelaxation.

Damaged central nervoussystem

• Many of the principles of neuromuscularrehabilitation can be applied to managingindividuals who suffered CNS damage.

• The rehabilitation plan should contain the motoradaptation elements – cognition, activity,feedback, repetition and similarity.

• Keep the training as close as possible to dailyfunctional movement.

• Avoid complex movements that are not within thenormal movement repertoire of the individual –train them in something they already know (butcan’t do).

Further thoughts on motorrecovery

• Recovery of motor control is an intrinsic person/nervous-system process.

• This recovery is dependent on psychological,behavioural, neurophysiological and tissue-relatedfactors. Often many of these factors areinterrelated.

• The role of neuromuscular rehabilitation is tooptimize the recovery of movement control,working with all these factors.

• Rehabilitation is more about facilitatingcognitive-sensory-motor processes by providing astimulating and variations-rich environment. It isnot just exercising.

• The movement challenges should be introducedat a level that matches or is above the patient’smovement capacity.

Finally

• The only clinical certainty is uncertainty – don’tfight it, learn to work with it. You will neverknow all the answers but you will be expected toprovide expert care.

• Complexity rules! Don’t become lost in thelabyrinth of the neuromuscular system; look atthe whole, not at minute details.

• Neuromuscular rehabilitation is a creativeprocess; it is not protocol-based. Every patient isdifferent and presents with new challenges. Youwill forever have to problem-solve on your feet.

• Think movement not muscles.

• There is nothing like one brain to stimulateanother.

• Make it fun, interesting and continuouslychallenging.

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