Exercise- a prescription for all or not? Susan Edwards FCSP SRP

Historical perspective no possibility of neuronal recovery orthopaedic approach clinical practice - change was possible review of neurophysiological rationale impaired reciprocal innervation skill acquisition and training FUNCTION

UMN lesion Abnormal muscular contractionWeakness Dynamic spasms co-contraction clonus associated reactions flexor withdrawal Static spasticity spastic dystonia Immobilisation at short muscle length Biomechanical changes reduced compliance contracture Hypertonia + Reduced ROM Abnormal postures Impaired function Sheean 2001

Nervous and musculo-skeletal system cannot be separated Balanced view of neural control of movement, biomechanical requirements for the task and limitations of CNS damage on both of these systems

Which therapy approach? Physiotherapy is of value in the treatment of stroke but does it matter what type? (Kwakkel et al 1999) Lack of relevant literature 88% of UK physiotherapists use Bobath (Davidson and Waters 2000) What is it?

Bobath (1990) suggested that excessive co- contraction of agonists and antagonists resulted in stiffness and slow, difficult movement. More likely to contribute to limb stiffness in children with CP but in adults with stroke, the primary problem seems to be in the inability to produce adequate force in the agonist (Davies et al 1996)

Biomechanical Model Over-emphasis on the neural control of movement has led to a neglect of the importance of muscle strength, force production and movement velocity

Muscle Stretch 6 hours for CP child (Tardieu et al 1988) half hour for neurologically intact mouse ! (Williams 1990) biomechanical properties of muscle – optimal force at mid range (Rothwell 1994)

Task-specific training or practice approach is showing enhanced evidence over impairment-focussed approaches (National Clinical Guidelines for Stroke 2002)

Repetition Variety of movement patterns How often can a therapist carry out movements? Need for regular exercise / stretching programme

Task-specific training Programmes using CIMT focus attention towards the weaker limb and use repeated and extensive practice for up to 6 hours a day. (Liepert et al 2000) Treadmill training with supported body weight - incomplete spinal cord injury (Deitz 2003) - stroke (Hesse 1995, 1999)

Muscle Strength and Aerobic Fitness Potential health benefits from regular exercise: - improved fitness and muscle strength - improved mood and sense of well-being - weight control - improved bone density - improved co-ordination

Muscle Strength and Aerobic Fitness “Individuals with physical impairments will need a great deal of encouragement to engage in regular intensive exercise. This encouragement may not always be forthcoming from therapists who have been led to believe that effortful activity is harmful to their patients and must be avoided. However, recent evidence shows that this is not the case and that exercise should be an integral part of an overall rehabilitation programme.” (Haas and Jones 2004)

Muscle Strength and Aerobic Fitness “There is a consensus that muscle weakness is a feature in many neurological pathologies. The notion that increased co-activation of antagonistic muscles rather than muscular weakness is responsible for motor control problems has not been confirmed by scientific evidence.” (Haas and Jones 2004)

American College of Sports Medicine Guidelines Strengthening programme, 8-10 separate exercises for major muscle groups 8-10 repetitions At least twice a week Concentric as well as eccentric exercise Normal breathing should be maintained during the exercises Most patients will require supervision Exercises through as full a range as possible

Aerobic Training General health check Gradually build up time from 10 minutes to 30 minutes Patients have reduced exercise capacity Physiological burnout Walking has greatest potential for increasing overall activity levels

Summary Therapists need to encourage perseverance with tasks which are meaningful and at a level sufficient to induce changes in strength and fitness. This should include on-going management / exercise outside of the ‘neurogym’ with more active collaboration with agencies providing leisure and social pursuits.