Rethinking the Tools in the Toolbox? Evidence-Based Strategies to "Move

Forward" in Neurological Rehabilitation

T. George Hornby, PT, PhD, Indiana University, Indianapolis, IN

Lindsay H. Shoger, PT, Rehabilitation Hospital of Indiana

Jennifer K. Lotter, PT, Rehabilitation Hospital of Indiana

Neuropt list-serve - when to integrate traditional techniques/derivatives (Neuro-IFRAH) into PT neurologic education

2009 – JNPT President’s Perspective

Initial translation of early scientific work was important in development of neurological PT (NDT, PNF, Brunstromm)

Evolution of neurologic PT influenced by scientific advances –STEP conferences - how current science influences practice??

Continued use of traditional theories without considering more recent findings would not be exemplar of evidence-based practice

… time to let go . . .

III Step Roadmap - Apply neuroplastic

principles - Define dosage

parameters- Use relevant

outcomes- Translate science to

practice

“Why do we need to change our approaches? . . . current approaches are not adequate. . . assumptions do not fit current knowledge”

“Therapist are dissatisfied with traditional models …. . . looking for new models based on more recent

discoveries/new understandings of motor control”

1990’s - Challenging traditional models of neurologic physical therapy

“Why do we need to change our approaches? . . . current approaches are not adequate. . . assumptions do not fit current knowledge”

“Therapist are dissatisfied with traditional models …. . . looking for new models based on more recent

discoveries/new understandings of motor control”

1990’s - Challenging traditional models of neurologic physical therapy

We can facilitate normal movement by applying specific

sensory stimulation.

Common assumptions?

Need to inhibit abnormal movement/abnormal reflexes

Recovery follows predictable sequence . . . mimics normal

development

“Why do we need to change our approaches? . . . current approaches are not adequate. . . assumptions do not fit current knowledge”

“Therapist are dissatisfied with traditional models …. . . looking for new models based on more recent

discoveries/new understandings of motor control”

1990’s - Challenging traditional models of neurologic physical therapy

Increasing importance of neurologic rehabilitation

Why change? Why the dissatisfaction?

Advances in science

Lack of functional carry-over of facilitation approaches

Normal science

2000-2001 - How does or can physical therapy practice evolve?

Research based on past achievements . . . agreement about basic foundations for practical application

Research accumulates to validate specific theoretical foundations/paradigms

Characterized by adherent supporters for prevailing views/against competing alternative views

“The history and philosophy of science offers lesions of about the development and maturation of any profession”

Normal science Anomaly

2000-2001 - How does or can physical therapy practice evolve?

Discovery of violations to accepted paradigms, testing/violating prevailing views

Encounters significant resistance from adherents to existing paradigms

“The history and philosophy of science offers lesions of about the development and maturation of any profession”

CrisisNormal science Anomaly

Repeated occurrence of anomalous observations

Professional insecurity/failure of existing paradigms prelude to search for new ones

Proliferation of versions of theories

Crisis

2000-2001 - How does or can physical therapy practice evolve?

“The history and philosophy of science offers lesions of about the development and maturation of any profession”

Crisis

Resolution of crisis with revolutionary changes in accepted views . . paradigm shift

Adherents to traditional paradigms struggle against emerging theories

New form of “normal science” develops

2000-2001 - How does or can physical therapy practice evolve?

“The history and philosophy of science offers lesions of about the development and maturation of any profession”

RevolutionCrisisNormal science Anomaly

Revolution

Neurologic PT will be very different in 5-10 years

. . .good news . . .practice based on new science will be more effective, standardized. . this is the promise of revolution

. . . well-founded rehabilitation paradigms will result in strengthened PT practice . . as long as PT sticks to being based in science

When?

2000-2001 - How does or can physical therapy practice evolve?

“The history and philosophy of science offers lesions of about the development and maturation of any profession”

In 5-10 years . . .

Response?

Discussion of when to integrate various traditional courses used in neurologic rehabilitation into PT education

Uncertain what changed with Sullivan 2009 perspective

July 2020 – Neuropt list-serve

Education? Selected programs integrate new science,

but how many? Traditional theories often remained

Practice? Lang 2009, Moore 2010, Kimberly 2010, Kuys 2006 -

limited practice, limited intensityZbogar 2016, 2017, Henderson 2021 – limited practice,

limited intensity

Research?

Research in 2010s and prior ...

Abundance of research to test the validity of principles of neuroplasticity

Locomotor function?

Specificity, intensity, amount of practice tested and applied

Errors and variability can enhance/shape locomotor output

Balance/falls?

Very large errors may “inoculate” against falls

Still work on amount/intensity

III Step Roadmap - Apply neuroplastic

principles - Define dosage

parameters- Use relevant

outcomes- Translate science to

practiceArm function?

Some practice good, large amounts may not be needed

Outcome measures?

Core outcomes CPGClinical implementation of

outcomes

Knowledge Translation?

Early application to alter practice, clinical outcomes

Data on validity/utility of traditional techniques has not progressed . . .

Research in 2010s and prior ...

Neuro-IFRAH

-Will never have data to validate efficacy=“Results are self-evident”

Neurodevelopment Technique

-Systematic reviews indicate NDT no better than other treatments (Kollen 2009)

-Potentially worse than task-specific training (Scrivener 2000)

Proprioceptive Neuromuscular Facilitation

-5 studies incorporated in systematic review (Gunning 2019)

-Only one positive outcome comparing PNF to reasonable alternative

2021 – JNPT President’s Perspective

While the Academy recognizes the historical importance of traditional approaches . ..

To persist with approaches that are not supported by the best available evidence run

contract to the vision set forth by our predecessors and evidence-based medicine

. . . ANPT position is to emphasize the use of the best available evidence in the treatment of adults with CNS injury

. . . does not support the use of traditional strategies (NDT, PNF, Neuro-IFRAH) for

which high-quality research of comparative efficacy is weak or absent

2021 – JNPT President’s Perspective

. . . but with what?

RevolutionCrisis

We need to rethink the tools in our toolbox . . . .

Challenging assumptions of traditional models of neurologic rehabilitation

Recovery follows predictable sequence . . . mimics normal

development

Progression through development patterns unnecessary, may

minimize/slow recovery

Progression through development patterns can

reduce gains (Scrivener 2020, Kollen 2009, CPG JNPT 2020)

Walking training can allow recovery of unpracticed tasks (Horn 2005, Straube 2014, Hornby

2016)

VIEWS - High-intensity training improves

balance/strength/transfers -“Reverse Transfer” or “Leap-frog”

hypothesis

Challenging assumptions of traditional models of neurologic rehabilitation

We can facilitate normal movement by applying specific

sensory stimulation.

Exoskeletal-assisted training (Hornby Stroke 2008, Hidler NNR 2009, Lewek PTJ

2009, CPG JNPT 2020)

Therapist-assisted training (Dobkin Neurol 2006, Duncan JAMA

2011, CPG JNPT 2020)

Attention towards normalizing kinematics may result in limited gains in function or kinematics

Need to inhibit abnormal movement/abnormal reflexes

Challenging assumptions of traditional models of neurologic rehabilitation

Strength/balance, not spasticity, are primary determinants of activity limitations (Michael

2005, Patterson 2007, Saraf 2010)

Practice without normalizing kinematics can improve

kinematics/kinetics (Mahtani 2017, Ardestani 2019, 2020)

Substantial data indicate augmenting errors may shape motor patterns (Bastian 2006,

Leech 2021, Shadmehr 1995 )

Gait quality improves without focus on abnormal movement,

allowing errors

Need to inhibit abnormal movement/abnormal reflexes

Challenging assumptions of traditional models of neurologic rehabilitation

We can facilitate normal movement by applying specific

sensory stimulation

Inhibition of spastic reflexes known (1980-2000s) not to be a major component of movement dysfunction . . . attention to normalizing kinematics persisted

New findings in animal models and translation to humans added to this notion . . .

Need to inhibit abnormal movement/abnormal reflexes

Challenging assumptions of traditional models of neurologic rehabilitation

We can facilitate normal movement by applying specific

sensory stimulation

Inhibition of spastic reflexes known (1980-2000s) not to be a major component of movement dysfunction . . . attention to normalizing kinematics persisted

New findings in animal models and translation to humans added to this notion . . .