課件案例教案講稿neurological physiotherapy a problem solving appr2nd edwards churchill livingstone2002ww

1、Neurological PhysiotherapyFor Churchill Livingstone:Editorial Director (Health Professions): Mary Law Project Development Manager: Dinah Thorn Project Manager: Derek RobertsonDesign Direction: George AjayiNeurological PhysiotherapyA problem-solving approachEdited bySusan Edwards FCSP Consult n Neuro

2、logical Physiotherapy, London, UKSECOND EDITIONCHURCHIL L LIVINGSTON EEDINBURGH LONDON NEW YORK PHILADELPHIA ST LOUIS SYDNEY TORONTO 2002CHURCHILL LIVINGSTONEAn imprint of Harcourt Publishers Limited© Harcourt Publishers Limited 2002 is a registered trademark of Harcourt Publishers LimitedThe r

3、ight of Susan Edwards to be identified as editor of this work has been asserted by her in accordance with the Copyright, Designs and Patent 1988. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopy

4、ing, recording or otherwise, without either the prior permission of the publishers (Harcourt Publishers Limited, Robert Stevenson House, 1-3 Baxter's Place, Leith Walk, Edinburgh EH1 3AF), or nce permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tot

5、tenham Court Road, London W1 P OLP.First edition 1996Second edition 2002ISBN 0 443 06440 7British Library Cataloguing in Publication DataA catalogue record for this book is available from the British LibraryLibrary of Congress Cataloging in Publication DataA catalog record for this book is available

6、 from the Library of CongressNoteMedical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary. The editor, contributors and the publishers have taken care to ensure that the information given in this

7、 text is accurate and up to date. However, ers are strongly advised to confirm that the information, especially with regard to drug usage, complies with the latest legislation and standards of practice.Printed The publisher'spolicy is to usepaper manufactured from sustainable forestsContentsCont

8、ributors ixPreface xiIntroduction1Susan Edwards1. Problem solving in neurological physiotherapy - setting the scene3 Margaret J. Mayston2. Assessment, outcome measurement and goal setting in physiotherapy practice 21Jennifer A. man3. An analysis of normal movement as the basis for the development of

9、 treatment techniques 35Susan Edwards4. Neuropsychological problems and solutions 69Dawn Wendy Langdon5. Abnormal tone and movement as a result of neurological impairment: considerations for treatment 89Susan Edwards6. General principles of treatment 121Philippa Carter, Susan Edwards7. Drug treatmen

10、t of neurological disability 155Alan J. Thompson8. Case histories 169Susan Edwards9. Posture management and special seating 189Pauline M. Pope10. Splinting and the use of orthoses in the management of patients with neurological disorders 219Susan Edwards, Paul T. Charlton11. Longer-term management f

11、or patients with residual or progressive disability 255 Susan Edwards12. The way forward 275Cecily PartridgeIndex 285viiContributorsPhilippa Carter MCSP Superintendent Physiotherapist, King's College Hospital, London, UKPaul T. Charlton DipOrthotics DipOTC Senior Orthotist specialising in Neurol

12、ogy,J.C. Peacock & Son , Orthotic Services, Newcastle upon TyneSusan Edwards FCSPConsult n Neurological Physiotherapy, London, UKJennifer A. man PhD BAppSc MCSP Research Fellow, Institute of Neurology, London, UK; Lecturer, University of Plymouth, Plymouth, UKDawn Wendy Langdon MA MPhil PhD CCli

13、nPsych BSDepartment of Psychology, Royal Holloway, University of London, Egham, UKMargaret J. Mayston PhD MSc BAppSc MCSP Director, The Bobath Centre for Children with Cerebral Palsy and Adults with Neurological Disability; Lecturer, Department of Physiology, University College London, London, UKCec

14、ily Partridge PhD BA(Hons) FCSP er in Physiotherapy,Centre for Health Services Studies,The University of Kent, Canterbury, UKPauline M. Pope MSc BA FCSP Consult n Disability Therapy, Mary Marlborough Centre,Nuffield Orthopae entre NHS Trust, Oxford, UKAlan J. Thompson MD FRCP FRCPI Garfield Weston P

15、rofessor of Clinical Neurology and Neuro abilitation, Institute of Neurology, London, UKixPrefaceThis book aims to provide both undergraduate and qualified therapists with an improved understanding of problems commonly encoun- tered in their work with people with neurological disability. It is a dau

16、nting process, particularly in the light of the ever-increasing availability of knowledge and information related to the control of human movement.It must be emphasised that the perspective of this book is clinical and arises from clinical experi- ence. This approach to management is based on using

17、the analysis of movement as a means to eval- uate disability resulting from a wide variety of neurological conditions. The need for evidence- based practice is recognised and, wherever possi- ble, references are given to support the text. However, I have not been constrained by lack of publications

18、in making assertions about treatment approaches. There is a continuing challenge to sub- st ate the constructive and functional changes demonstrated by patients treated in this manner.There are many people who have provided invaluable support and assistance to me in com- piling this second edition.

19、Jon Marsden, senior physiotherapist at the Human Movement and Balance Unit, Queen's Square, London provided a constant supply of articles and books that enabled me to produce the first edition. For this second edition, in spite of his PhD commitments, he again found time to provide constructive

20、comment and must take full credit for the revised section on ataxia in Chapter 5.Numerous colleagues have and critically appraised many of the chapters, for which I ammost grateful. I hesitate to name them all for fear of inadvertently omitting one from such a large number of individuals. My thanks

21、also go to the other authors in this book: Margaret Mayston for 'setting the scene' Jenny man for her chapter on assessment and outcome measures; Dawn Langdon and Pauline Pope for updating their previous contributions; Alan Thompson for his chapter on drug management; and Cecily Partridge fo

22、r proposing 'the way forward'.I would like to acknowledge the therapy staff in the Directorate of Neuroabilitation and Therapy Services at the National Hospital for their continued support, despite the fact that I no longer work there, and for taking part in the orig- inal, and some of the n

23、ew, photographic sessions. I also wish to thank George Kaim, head of the Audio-visual Department at the National Hospital who was responsible for many of the original photographs which, some ers may note, are unchanged from the first edition and David Waldman for the new photographs in the splinting

24、 section.And finally my thanks to family and friends who, in spite of questioning my reasoning for embarking on a second edition, have continued to provide invaluable support and appropriate distraction. The regular bridge and sports events have gone some way to preserving some degree of sa in an ot

25、herwise frenzied 2 years of my life.Susan EdwardsxiIntroductionSusan EdwardsThe purpose of this book is to describe aspects of posture and movement and difficulties which may arise as a result of neurological damage. The emphasis is on the analysis of the abnormal pathology which prevails and determ

26、ining appropriate treatment interventions.The ability to solve problems has been described as an integral part of physiotherapy practice ( Henry 1985). 'Problem solving' is a term often used in the management and treatment of patients with a variety of disabilities and particularly for those

27、 with neurological dys- function. Patients with neurological disability may present with complex and extensive move- ment disorders in addition to cognitive and sensory impairments. Analysing these deficits and determining the most appropriate course of treatment is the aim of all staff working in t

28、his field.Problem solving may be considered in the context of both the physiotherapist identifying the patient's problems and adopting an appro- priate treatment approach and the patient himself learning to contend with the movement deficit through compensatory strategies. Much has been written

29、with respect to the former, the terms 'clinical reasoning' and 'problem solving' often being used synonymously (Higgs 1992). The concept of the patient being a problem solver is perhaps less well recognised.The physiotherapist as a problem solver is dependent upon an accurate and ext

30、ensive knowledge of movement, taking into considera- tion all aspects of the impairment which may contribute to the movement deficit. The patient,12NEUROLOGICAL PHYSIOTHERAPYunable to function in the same way as before the onset of his neurological deficit, must determine the most efficient way to c

31、ontend with his dis- ability. Function is the ultimate goal for both parties but the means by which this is attained raises several issues.The current clinical environment requires that the therapist makes judgements that weigh the advantages and disadvantages of each inter- vention (Shewchuk &

32、Fr s 1988). While quality of movement is imperative for optimal function, itmust be recognised that, for the majority of patients with neurological disability, restoration of normal movement is often an unattainable goal. There must be a balance between re-education of more normal movement patterns

33、and acceptance, and promotion, of necessary and desirable compensation. Patients, therefore, must be involved in the decision-making process. 'In essence, they have a PhD in their own uniqueness that is very powerful in solving complex problems' (Weed & Zimny 1989).REFERENCE SHiggs J 199

34、2 Develo clinical reasoning competencies.Physiotherapy 78: 575-581 Henry J 1985 Identifying problems in clinical problem solving. Perceptions and interventions with nonproblem-solving behaviors. Physical Therapy 65(7): 1071-1074Shewchuk R M, Fr s K T 1988 Principles of clinical decision making - an

35、introduction to decision analysis. Physical Therapy 68(3): 357-359Weed L L, Zimny N J 1989 The problem-orientated system, problem knowledge coupling and clinical decision making. Physical Therapy 69(7): 565-568Problem solving in neurological physiotherapy - setting the sceneMargaret J. MaystonHISTOR

36、YA therapist using a problem-solving approach to the management of neurological patients prior to the 1940s may have asked: How can I train the to use their unaffected body parts to com- pensate for the affected parts, and how can I prevent deformity? The result was a strong emphasis on orthopaedic

37、intervention with various types of splints, strengthening exercises and surgical intervention. However, in the 1940s several other ideas emerged, the most popular being the Bobath approach. Bobath (1985) with others, such as Peto (Forrai 1999), Kabat & Knott (1954), Voss (1967) and Rood (1954),

38、pioneered the neurological approach to these disorders, recognising that patients with neurological impairment, in particular stroke patients, had potential for functional recovery of their affected body parts. For the child with a neurodevelop- mental disorder, the approach was based on the idea th

39、at each child's development could be guided by the therapist, to ise their poten- tial for functional independence and minimise contractures and deformities. While the Bobath approach is one of the most used and accepted in the UK, little has been written about it in recent years, and there is n

40、o robust evidence for its efficacy (Davidson & Waters 2000).In the last few years the as been a further progression in the neuro abilitation field, with increasing interest in different ms of central nervous system (CNS) function, skill acquisition and training. For example, for some therapists,

41、 the emphasis for retraining of the neurologically34NEUROLOGICAL PHYSIOTHERAPYimpaired now is on the biomechanical requirements of a task (Carr & Shepherd 1998), accepting that the patient has to compensate for their damaged nervous system. Carr and Shepherd are to be applauded for their well- r

42、esearched approach; however, it should be recognised that their actual ideas for manage- ment largely arose from the work of Bobath. The emphasis on patient participation and practice is helpful for the cognitively and physically able , but it is unclear how the approach can be used with people who

43、have significant neurological impairments.It must be realised that the nervous and mus- culoskeletal systems cannot be separated; they interact with each other to meet the demands of both the internal and external environment. Thus it is important to approach the with movement disorder with a balanc

44、ed view of the neural control of movement, the biomechanical requirements for a task and the limitations of CNS damage on both of these systems.In order to use a problem-solving approach for the treatment of people with neurological dis- ability, it is necessary to have an understanding of the contr

45、ol of movement, the result of damage to different areas of the CNS, neuroplasticity and ways to promote skill learning.CONTROL OF MOVEMENTThere are many m s of motor control. Some examples are neurophysiological, systems/dis- tributed m , neurobehavioural, engineering m , information processing and

46、biomechani- cal. All have value, but individually do not provide the therapist with complete information on which to base their practice. Therefore an understanding of different approaches is help- ful for the therapist working in the neuro- abilitation field. The most relevant of these are discusse

47、d below.Neurophysiological/information processingIt is recognised that there is an interaction between central and peripheral components ofthe CNS (see Dietz 1992 for a review). Dietz (1992) points out that neuronal mechanisms are a part of biomechanical strategies but are them- selves constrained b

48、y biomechanics. This view is supported by Martenuik et al (1987) who make the following comment: 'While there are biome- chanical factors which constrain movement control processes, there are also brain mechan- isms which are potentially complementary to the biomechanical factors that take part

49、in the plan- ning and control processes. We cannot neglect one at the expense of the other .'. What then do we need to know about the neurophysiological control of movement?Early ideas suggested that the CNS controlled movement primarily by reacting to sensory input (Foster 1985, Sherrington 190

50、6). Roland et al (1980) demonstrated the presence of brain activ- ity when simply imagining a movement by studying changes in regional cerebral blood flow. This work alongside other studies of CN iv- ity during function (Deecke et al 1969, Shibasaki & Nagae 1984, Kristeva et al 1994) has demon-

51、strated activity of the brain before a movement begins, and has shown that the nervous system is largely proactive and not simply reactive, in response to sensory feedback. Central (feedfor- ward) mechanisms are based on innate and ongoing experiences of the individual and can take place in the abse

52、nce of any kind of sensory feedback. Keele (1968) suggested that the CNS organises a general plan in advance of the task to be executed, referred to as the motor programme, on the basis of prior experience. Schmidt (1991) has taken up this idea of programme-based motor control, describing the compar

53、ative nature of how the brain organises the preparation and execution of movements. Much debate has taken place about the role of the motor programme and sensory feedback from the periphery in motor control (Morris et al 1994). However, it is clear that both central and peripheral factors are import

54、 n the efficient execution of motor tasks.Central program requires the integration of many neural structures, both supraspinal and in the periphery, to produce the required output to achieve the task goal. It is helpful to considerPROBLEM SOLVING IN NEUROLOGICAL PHYSIOTHERAPY5Figure 1.1Knowledge of

55、how different parts of the CNS connected to each other can be helpful in understanding the control of movement. (From Kandel et al 1991, p. 539.)the wiring-type diagram which gives an idea of how different parts of the CNS interact (Fig. 1.1), but this gives little insight into the contribution of d

56、ifferent systems to the control of movement. The advent of imaging techniques such as positron emission tomography (PET) and func- tional magnetic resonance imaging (fMRI) have enabled a window into the CNS to provide greater insight into how tasks are organised. For example, a recent PET study by Jueptner & Weiller (1998) shows that the cerebellum is mostly concerned with processing of sensory information during an ongoing task whereas the basal ganglia are more concerned with organisa- tion of well-learned tasks. Neurophysiologists suggest that the