Neurofunctional Intervention Approaches

Abstract

Neurofunctional approaches play the paramount functions in management of neurological disorders to improve the functional capability after impairments and activity limitations. These interventional approaches aligned with the neuroplasticity theories and all rely on repetition matters to build up engrams for the change of the brain function and activity performance. Affolter approach guides cognitive perceptual interaction through tactile-kinesthetic inputs. Neuromuscular facilitation relays the periphery information to the central nervous system by joint and muscle stimulus by using different techniques such stretching, irradiation, traction and approximation. Neurodevelopmental therapy manages the abnormal movement and postures through hands on facilitation of normal movement and inhibiting abnormal patterns movement. Roods approaches focus on the primitive reflexes through sensory stimuli to the targeted sensory receptors to initiate the appropriate motor pattern development. Brunnstrom approaches build on the synergies to provoke the engagement of the affected limbs. Task-oriented approaches are based on motor learning and involve repeat training with task-oriented activities. It is effective for improvement of the functional performance. It is a training method for encouraging functional movement with an interesting task. And also it improved the dexterity when applied using mixed interventions in hemiplegic.

1. Introduction

In 1980s, neurofunctional approaches (NFA) were presented as one of the few intercessions made fundamentally for clients with extreme shortfalls taking after traumatic brain injury (TBI) [1, 2]. Particularly, NFA is intended for clients who were restricted in their capacity to unravel novel issues or generalize abilities from one setting to another [3], and whose lack of insight constrained their capacity to engage within the rehabilitative process [3, 4]. This unit will summarize different approaches utilized as an interventional program for individuals enduring from distinctive neurological disorders.

2. Affolter approach

The Affolter approach is an innovative perceptual-cognitive approach developed in Switzerland by Felicie Affolter in 1981. Affolter holds the degrees in child psychology, education of normal, deaf, and language disordered children; audiology; and language pathology and speech sciences [5]. She studied with Jean Piaget and uses his interaction model of development as a foundation for her theory. Affolter and Walter Biscofberger have conducted research specifically involving development based on tactile-kinesthetic (T-K) interaction. Affolter theory and treatment approach is designed to give the student food for thought about the process of cognitive-perceptual development and the relationship that exists between T-K input and problem-solving skills in daily life [6]. This practical technique emphasizes evaluation and treatment in realistic situations using functional and age-appropriate activities. It has been successfully used in the treatment of coma recovery; cerebral vascular accident (CVA), TBI, and other neurological deficits including Alzheimer’s disease and aging issues, pervasive developmental disorder and autism, and learning disabilities [5]. The Affolter concept challenges the clinician to take a hands-on functional approach in the treatment of T-K perceptual deficits in addition to using the standard evaluations and assessment for visual and auditory perceptual processing. Affolter has developed the treatment technique of nonverbal guiding to facilitate perceptual-cognitive interaction. Therapy is geared toward emphasizing appropriate input through a problem-solving process rather than focusing on the output and successful completion of a product. In using this treatment technique, specific guideline should be carefully followed and continually practiced.

2.1 Assumptions about the treatment framework

2.1.1 Treating patients in real situations

A fundamental assumption of treatment is that children with Pervasive Developmental Disorder (PDD) do have the ability to learn, and adults with acquired brain damage can relearn, but they require offer of assistance in doing so [7, 8]. To provide them with the assistance, we must help them organize in the way they search information in a better way, so that interaction improves, and the root can grow [9]. Organizing the seek for data requires identifying sources of data and isolating significant [10], from unessential sources when interacting and participate in activities with a therapist’s hand to guide the patient makes a significant change [10, 11]. To achieve this goal, patients need intervention in actual daily life situations, not in artificial environments.

2.1.2 Targeting change in the underlying system

The work of this therapy does not intend the specific skills as a separate skill or isolated goals of treatment that are separated from the interaction of tasks solving problems in everyday life [12]. If the child cannot eat or participate in play properly, treatment does not pay attention on the same principles [13], that is, enabling nonverbal interactions to occur by enabling the patient to pick up adequate information for interacting with the environment around them [13, 14]. Visual or auditory inputs are not presumed to be of adequate information, rather a tactile perception [15]. The input that is viewed as essential and primary is tactile input [16]. In the absence of tactile information, to help patients, treatment must be designed to get this information [17]. However, to get these inputs are not from the outside environment for participating in everyday life [15, 17]. The kind and quantity of the data available for interaction are regarded as context dependent [18]; the situation demands changes from time to time and specifically with the required information for interaction [18]. Therefore, interacting in the activity is seen in the way of problem-solving event in all its aspects [19], including evaluating the processes, testing and creating in everyday life (for-example; eating spaghetti from the plate, getting toys from bathtub, putting on shoes, and getting a package through the door [20]. The problem to be solved or not will depend on the situation and available information in that situation [21].

3. Proprioceptive neuro-muscular facilitation

What we know nowadays as proprioceptive neuromuscular help (PNF) started as “proprioceptive assistance” a term created by Dr. Herman Kabat in the early 1940s. In 1954, Dorothy Voss included the word “neuromuscular” to deliver us the presently familiar proprioceptive neuromuscular facilitation, (PNF) [22]. Dr. Kabat’s conceptual system for PNF came from his encounter as a neurophysiologist and doctor [23]. The work of Elizabeth Kenney, an Australian nurse who treated polio patients with particular stretching and strengthening exercises, was an early impact on Kabat [24]. Kenny’s work was seen as a flight from the typical treatment at the time but needed the establishing of the sound neurophysiological method of reasoning Kabat coordinates Sister Kenney’s manual method with Sherrington’s disclosure of progressive acceptance, corresponding innervation, and restraint, and the marvel of irradiation [22]. They conclusively stated that PNF is a neurophysiological approach in which impulses from the periphery are facilitated to the central nervous system (CNS) through the stimulation of sensory receptors present in muscles and around the joints by stretch, resistance, traction, approximation, and audiovisual. Many therapists use PNF to help people regain their range of motion after injury or surgery [25]. However, it can also be used by athletes and dancers to improve their flexibility [26].

3.1 Principles of proprioceptive neuromuscular facilitation

The effectiveness of the PNF principles and procedures based on the integration of the appropriate use of joint and soft tissues mobilization [25]. The core PNF science can be universally utilized in any treatment approach [26], since the foundation is the evaluation and treatment of posture and movement [27]. The utilization of PNF for spinal dysfunction is enhanced by different working knowledge such as arthrokinematics, neurophysiology, and possible pathomechanics of the spine [27].

1. All Human beings have potentials that are not fully developed: Motor activity is restricted to the individual’s physical capacity and characteristic and already learned neuromuscular reactions [28]. In any case, the typical individual incorporates a tremendous and undiscovered neuromuscular potential, which may be created through natural impacts and deliberate choices or tapped amid upsetting scenes [29, 30]. Through the use of client’s strengths; the patient is motivated to achieve high level of function to minimize his or her weaknesses according to this philosophy [31].

2. Cephalocaudal and proximal distal is a normal motor development direction: Head, and neck develops first and then the trunk and lastly, in the extremities [32]. Proximal to distal points is a way of motor development [32]. Amid therapy, the neck and head are considered first during treatment since they affect the design of the motion in the body [26]. As well the next motor development is the trunk, which has central role of the body alignment [27]. Fine motor skills and extremities are developed following optimal function of the head and neck [26].

3. Reflex activity is dominant factor in early motor behavior [33]. Mature motor behavior is supported by postural reflex mechanisms; in therapy, weak muscles are supported through the facilitation of reflexes and by choosing developmental posture [33], functional activity initiation, or entailing trunk and head with extremity patterns [34].

4. Shifts between flexors and extensors dominance, are the cyclic trends evidenced during the growth of motor behavior [34]. Amid the useful action, movement flexion and extension changes [34]. This relationship is a complement that results to balance of postures and steadiness [34]. Facilitating reciprocal relationship of flexors and extensors reestablishes balance and stability during treatment [35].

5. Reversed actions make up activities that are regarded as goal-directed: rhythmic and reversing actions referred to as normal [36]. To establish balance among activities reversing movements are necessary and this brings balance and interaction between antagonists [36]. To enhance functioning, therapy must encourage movement in both directions [36].

6. Both balanced interaction of antagonists, normal posture, and movement depend on “Synergism” [34]; the balance of flexor dominance, movement reversal, and balance of reflex activity provide functional movement [34, 36]. During therapy sessions, in-equilibrium in these factors, to restore normal patterns of motion and posture responses are corrected [35]. Achieving these motor functions is through transitions between postures; such functions are doing reciprocal tasks, rolling, prone to supine or from sitting [37].

7. Total patterns of movement and posture are developed in a sequence to develop motor behavior [30]; specific sequence is followed during the development of motor behavior [30]. During development, complex functions are developed by early developmental milestones [30, 37]. The progress of motor behavior is in an orderly manner from mobility to stability to controlled mobility and into function [24], and developed an adverse repertoire of motor behavior [24]. Combined movements of the neck, trunk, and extremities also progress in a specified sequence [38].

4. Rood approach

Rood’s approach is one of the neurophysiological and traditional approach based on hierarchical theories of CNS development [39]. This approach was developed by Margaret Rood in 1940 [40]. The essential concepts of this approach involves the motor patterns development through the sensory stimuli based on primitive reflexes and normal motor development patterns to progress motor performance skills [41, 42]. Rood’s approach theories support the activation and de-activation of the receptors by sensory stimulation through facilitation and inhibition techniques [41]. Which of them concerned with the interaction of different factors such somatic, psychic and motor behaviors regulations [42]. The roods approach used by different health professionals in handling the motor control problems of patients, resulted from neurological insults [43]. The interventions process of the approach is based on development of the CNS, whereby the motor pattern development facilitated or inhibited for rehabilitation purposes [44, 45, 46]. Rood’s philosophy focused on establishing typical motor development through building up required motor engrams [47].

4.1 Rood’s approach techniques

The key principles of the Rood approach includes: normalizing tone, sequential developmental of autogenic motor patterns, repetition and purposeful-directed movement [48]. Though Rood’s theories started in the 1940s, todays there are few corrections experienced some time recently she passed on, the modification handle has proceeded till presently based on current neuroscientific evidence [41]. Margret Rood during the discovery of this approach, Rood developed stages of motor control: Mobility, stability, controlled mobility, and skill [49]. She further worked on the sequence of motor development during the development of a child under each stage; reciprocal inhibition, [50] innervation/mobility, a reflex governed by spinal and supraspinal centers, subserves a protective function [50], phasic and reciprocal type of movement [50], contraction of agonist and antagonist, co-contraction, [50] c0-innervation/stability, simultaneous agonist and antagonist contraction with antagonist supreme [50], heavy work/controlled mobility [50], Stockmeyer “mobility superimposed on stability”, and Creeping [50]. Skill, crawling, walking, reaching, activities requiring the coordinated use of hands [49, 50]. Rood’s approach is one of several of the neurophysiological approaches created at that time and is centered upon four fundamental concepts to consider amid treatment: duality, the ontogenetic sequence, manipulation of the autonomic nervous system, and the level of sensitivity of the front horn cell [51, 52]. Following proprioceptive facilitatory techniques are used: heavy joint compression, stretch, intrinsic stretch, secondary ending stretch, stretch pressure, resistance, tapping, vestibular stimulation, inversion, therapeutic vibration and osteo-pressure [45, 53]. Finally, she developed following spasticity; inhibitory technique: gentle shaking or rocking, slow stroking, slow rolling, light joint compression, tendinous pressure, maintained stretch and rocking in developmental stages [53].

5. Brunnstrom approach

In 1951, Dr. Thomas Twitchell, a neurologist, published a seminal paper in which he described the longitudinal progression of motor recovery in 121 patients [54]. Twitchell observed that, early in recovery, these people tended to demonstrate stereotypical movement patterns. In addition, he observed that they tended to progress in their motor recovery through a consistent series of stages [54]. Twitchell did not hypothesize why some patients recovered further than others and did not present any recommendations for therapeutic interventions that might influence motor recovery [55]. Signe Brunnstrom, a physical therapist, combined Twitchell’s findings with her own clinical observations to develop a treatment approach that was designed to facilitate the progression through the stages of recovery that Twitchell had reported. Brunnstrom’s major contributions were:

• Her detailed description of reflexes and associated reactions exhibited by patients with post-stroke hemiplegia

• The concept of flexor and extensor synergy patterns in the paretic arm and leg

• A postulated sequence of treatment, designed to move patents through seven stages of recovery for the arm and hand

Many of Brunnstrom’s contributions remain influential today. The associated reactions and reflexes she described are still recognized as characteristic features of motor behavior in stroke survivors with limited recovery [56]. A major difference is that Brunnstrom advised therapists to use techniques to elicit these pathological responses in an effort to stimulate movement. Today, however, rehabilitation professionals seek to prevent eliciting these responses [46]. The current understanding is that reflexive movements are not precursors to active, functional motor performance. Currently, rehabilitation professionals disagree on whether to consider the limb synergies as primary sequelae of the neurological damage (as Brunnstrom and Twitchell stipulated) that patients develop when they attempt to move in spite of underlying mechanical obstacles, such as immobility at the pelvis or scapular [57]. Those who view the flexor and extensor synergies of the upper limb as maladaptive strategies organize therapeutic interventions to prevent or remove specified “obstacles to movement” that may lead the person to develop inefficient motor strategies. Those who view the synergies as unavoidable motor deficits that precede full recovery of motor function are not concerned when patients move in these stereotypical patterns of movement [57]. There is no controversy, however, about the efficacy of following a therapeutic sequence in which the therapist guides the patient in moving through the six postulated stages of recovery. This paradigm for structuring motor therapy is not supported by current understanding of neuroplasticity and recovery of motor function after stroke.

5.1 Brunnstrom stages of recovery for the affected arm

According to [58], in their study on a neurophysiological and clinical study of Brunnstrom recovery stages in the upper limb following stroke, outlined the following stages of motor recovery:

1. Stage I Flaccidity: no voluntary movement, muscle tone, or reflexive responses

2. Stage II Synergies can be elicited reflexively; spasticity is developing

3. Stage III Beginning voluntary movement but only in synergy; spasticity may be significant

4. Stage IV Spasticity begins to decrease; ability to voluntarily perform movements that deviate slightly from synergy patterns

5. Stage V Increased control of isolated voluntary movements, independent of synergy patterns

6. Stage VI Isolated motor control; spasticity is minimal

7. Stage VII Normal speed and coordination of motor function

5.2 Principles of the Brunnstrom approach

The Brunnstrom approach is based on two key principles: Principle both normal movement which signifies how a healthy individual moves, [59] it requires muscles to work together, following damage to the CNS the muscles will not work as well together [59, 60, 61]. During recovery, muscles will start working together better and following damage to the CNS, movement recovery follows a specific sequence [59, 61]. The sequence is:

• There may be no “voluntary” movement after immediate onset of the injury.

• Spasticity appears, and basic movement reflexes occur.

• Patient begins to get voluntary control over their reflexes. This may leads to an increase in tone.

• Basic motor movement patterns are developed. This leads to a reduction in increase in tone (spasticity). Thus the complex motor movement patterns are learned and there's a remarkable decreasing in tone.

• Spasticity vanishes and individual movements mastered and coordination skills advanced approximately normal and then normal function restored.

6. Neurodevelopmental therapy/Bobath approach

Bobath approach which is also known as neurodevelopmental treatment (NDT) [62], is named after a physiotherapist Berta Bobath, and her husband Karl, a neuropsychiatrist proposed it for management of neurological injury impairments [62]. The Bobath approach is defined as client-centered hands on and a problem-solving approach [63]. It is used in management of individuals with abnormal movement and postures resulted from neurological injuries [63, 64]. This approach was first developed for effective management of patients with cerebral palsy manifested by neuro-motor dysfunctions [65, 66, 67]. The Bobath concept provided a reference that viewed children with Cerebral Palsy (CP) as having difficulty with postural control and movement against gravity [50]. The Bobath concept provided a reference that viewed children with CP as having difficulty with postural control and movement against gravity [50]. Bobath approach is used in all age group of persons with CNS lesion which resulted into functional dysfunction either movement of postural control. It is referred as both problem-solving approach to the assessment and treatment [68]. This approach underpinned the neurophysiological theories of motor control, motor learning and neural plasticity. This relied on new normal movement patterns and postures learned as a result mastered, and forms cortical representation of repetitive motor patterns. According to [69], the functional movement needs motor, sensory, cognitive, perceptual and biomechanical to be well efficiently produced in individuals with neurological injury. The task learning is influenced by the environmental condition, performance components needed to perform an activity and the evidence showed that neurofacilitation techniques of handling increases sensorimotor in initiation and performing the activity [70].

6.1 Clinical approach of Bobath concept

6.1.1 Motor control

Bobath approach concerns with personal factors such as sensory, perception, adaptive behavior and motor control skills of patient [71]. Bobath approach which is task-specific and goal-directed approach, [72] facilitates the optimal motor functions of the individual through the organization of proprioceptive and exteroceptive environments [72]. This client-centered approach focuses on neurological impairments resulted from either UMNL or LMNL to change motor performance [73], through selective activation of cutaneous and muscle receptors [63]. The muscle activation and sensory input to specific task facilitates complete accomplishment of the task in different contexts and environments, [74] taking into account the perceptual and cognitive demands [74]. It is recommended to be practiced in different real-life situation other than clinical milieu [23].

6.2 Basic principles of Bobath approach/neurodevelopmental treatment

According to [75], there are six principles of NDT management:

• Individualize functional outcomes: Interventions should consist of activities and strategies specific to the patient’s needs, based on both the patient’s unique limitations and his/her functional goals.

• Emphasis on motor control: Choose the therapeutic activities that encourage the client’s active participation in order to promote both problem-solving and active use of muscles. This means getting past the redundant use of omni-cycle or a Nu-step. The activities should be meaningful to the patient as well as give them a chance to learn a novel movement [76].

• Increase active use of the affected or involved side: Find opportunities to involve the affected side in intervention activities, even if this means filing in the movement gaps with physical handling techniques.

• Provide practice: Allow the patient to practice and repeat activities in order to refine and recover movement.

• Teach 24-hour management: As mentioned previously, provide education in order to carry over learned tasks during therapy to other parts of the patient’s day.

• Use and interdisciplinary approach: Involve all relevant rehabilitation disciplines (OT, PT and SLP) and ensure the carryover of NDT techniques.

A case scenario of application of Bobath approach in training sitting and standing. They are both main motor function to achieve independent locomotion, to use upper limb and hand [77]. In daily life of individuals these activities of sitting and standing acts as the major in performing other activities including normal movement, locomotion, reaching and grasping [78]. They are a number of different factors which influence the training of sit to stand including seat height, foot positon and upper limb. Seat height, the research evidence considered the length of levers in individuals but the modification and adaption is important respectively the capacity of the patient to optimize progressively the performance of the patients and also grading down or up is considered as the patient is improving the performance capacity [79, 80, 81]. Foot position has the impact in sitting to standing positons. During the initiation of the propulsion the heels should be either up or down, even it has limited number of researches and need more discussion [82]. The several studies support the position of the upper limb should be folded across the body. The position facilitated lower limb propulsion [83]. Interlimb neural coupling support the body alignment and proper activity activation as the major the concept of Bobath approach. In addition it releases the workloads of the lower limb [79]. According to [83] the restriction of upper limb in involvement of the body postural transition from sitting to standing remarkably changes the nature of the task. The study conducted [84] mentioned four core stages of sitting to stand namely flexion momentum, momentum transfer, extension, and stabilization. Flexion momentum begins with initiation of the movement and ends just before the buttocks lift from the chair (seat off). Momentum transfer begins at seat off and ends at maximal ankle dorsiflexion. Extension phase just after maximal ankle dorsiflexion until cessation of hip extension. Stabilization from when hip extension ceases until all movement has stopped.

As described in Table 1 there are many factors which have to be taken into consideration when implementing this approach and evaluating its outcome and effectiveness. The mentioned aspect can have an influence in achieving the goal with the patient. Thus when choosing the task, the therapist need to think of multiple varieties in terms of task nature, person capacity and environmental contexts.

Task/goal	individual	Environment
Sit to walk	Physical appearance	Clutters, unfriendly equipment, small space
Dressing	Ability of maintaining dynamic and static balance
Transfer between seats	Perceptual and spatial awareness ability	For instance differences in height of seat, depth stability, arm supports, comparison with other materials such as a table or desk.
Stand to reach	Ability of flexibility
STS while using upper	Age
limb functionally	Pain

Table 1.

Different aspects of the task, person and environment.

Source: Schenkman et al. [84]^.

During interventions the nature of therapy based on task demands, impairments and environmental contexts as shown in Table 2.

Task	Specific impairments	Environment
Task	Reduced ROM in the ankle for appropriate foot placement	Contextual practice
Practice		Adaptability of the environment to facilitate the task
Repetition	Reduced trunk alignment for weight transfer
Variation
Timing	Postural activity in low toned upper limb
Speed and range
Grade up and down
The demands and performance of the task
Challenging the use of cognition
Dual tasking
Contexts

Table 2.

Components of therapy setting to be considered.

Source: Schenkman et al. [84].

7. Constrained induced movement therapy

Constrained Induced Movement Therapy (CIMT) showed the effective improvement in post-stroke patient improving the motor function of the affected arm [85]. This approach forced the affected arm to involve in task-oriented activities such as Activities of Daily Living (ADLs) [85]. Transcranial magnetic stimulation showed the increase in electrical stimulation on lesioned area from pre-to post Constrained Induced (CI) therapy to patient with stroke. There is expansion of the motor cortex representation of the affected arm. The cortical reorganization remarkably increased in mental imaging of the motor functional activities being repeated by the affected arm [86, 87]. In acute post-stroke patients there was a high significance improvement in all scores of Barthel index and functional independence measure (FIM) measures (eating, bathing, grooming and dressing) [88]. The intervention provided is the application of padded mitten on unaffected arm and training an affected arm with UE motor function and ADLs for at least 6 hours/day during 14 days [88]. This is the similar protocol that was first developed by Taub [86, 89] in investigation of the effects of CIMT on humans. However the protocol different from Taub referred to as modified CIMT (mCIMT). CIMT has high effects on affected upper limb of the stroke patients compared to other alternatives treatment or no treatment. This approach of CIMT work in more neurological conditions including spinal cord injury [90], where the study conducted on effects to Unilateral cortical Spinal Tract Injury in adults rat prove that there was growth and synapse formation of CST fibers from the intact side into the denervated spinal cord, synapse formation in the denervated cervical gray matter [90]. Growth and arborization of CST fibers was accompanied by marked behavioral improvements. But not limited to other conditions such as Multiple Sclerosis and cerebral palsy [90, 91, 92, 93, 94].

8. Task-oriented approach

Task-oriented approach found as an important approach in improving the functional outcomes in post-neurological injured persons. There was proved that balance, ADLs, and self-efficacy improved in hemiplegic patients [95, 96]. The provided interventions done in five times a week for four weeks, the session has 30 min, each task is performed three times for 10 min, with a 2-min break between each task [97]. The evaluation tools were modified Barthel index, Berg balance scale, and self-efficacy scale. The results of the Mann-Whitney U test also revealed significant differences in the BBS, MBI, and SES scores before and after training (p < 0.01). This approach showed also a remarkable impact in improving the balance and upper body skills in children with cerebral palsy as the study conducted [98, 99, 100] proved that all subjects had positive changes in gaining stability of standing and walking. The interventions program provided in two times/week, 40 min/session during 15 weeks. The outcome of the intervention program is associated with the intelligence of the subjects that should be positive or negative respectively the level of the capacity to follow instructions and cognitive learning ability. The above client-centered task-oriented approach program was used as it is based on motor learning and involves repeat training with task-oriented activities [98].

The client-centered task-oriented approach program in Table 3 was used, [98] and it is based on motor learning and involves repeat training with task-oriented activities [98]. It is effective for improvement of the functional performance of a child with CP [98]. In addition, it is a training method for encouraging functional movement while providing children with an interesting task [98]. And also it improved the dexterity when applied using mixed interventions in hemiplegic Cerebral palsy patient both bilateral manipulation and unilateral task-oriented activities [101, 102]. This approach preliminary study concluded that it should also be feasible and safe to be applied in persons with multiple sclerosis with moderate mobility impairments [103, 104]. The rigorous systematic review concluded that there is a little significance in improving the upper limb function and hand dexterity in patients with spinal cord injury thus the primary research was recommended for further re-evaluation of the effectiveness of the approach [105].

Active region		Program
Vestibular set	Hammock	Turning away side to side hammock activities
	Swing	Lying on sway board turning away side to side
		Quoits game activity
	Roll	Roll side to side on roll
Therapy ball		Lying on therapy ball and roll
		sit on ball and bounce
Sway board activities		Lying down to keep balance
Standing activities		Sway board activities of standing and sitting
		Weight bearing
		walking with a bar support
		Walk while holding balance beam supports
		Spinning activity
Mat based activities		Movement (pushing a ball) standing up
Proprioceptive input activities		Standing, walking
		Joint movement
		Muscular strength

Table 3.

Task-oriented activities in children with cerebral palsy.

Source: Kim and Lee [98].

9. Mirror therapy

Mirror therapy is a motor imagery process that modulates central mechanisms of motor recovery and neural plasticity. Mirror Therapy (MT) might have an effect on premotor and somatosensory cortex to activate the neurons in facilitating motor functions [106, 107]. MT is implemented by asking the patient to sit in front of the table with mirror and putting the arms both affected and unaffected on different sides of the mirror and during the performing the activities with unaffected arm the patient looks at the mirror to form motor image. With a case scenario which provided a session of 20 min/day, 5 days/week for 4 weeks showed significance in improving motor function of upper extremity [108].

The findings of the clinical stated the good outcome in reducing motor impairments, motor functions and ADLs as they were examined by FIM, Brunnstrom stages of recovery and Fugl-Meyer assessment (FMA) [109, 110, 111]. The study combined MT and electronic-mesh-glove found higher significance in normalizing muscle tone, improving hand skills, transfer as they were examined by MAS, box and block test (BBT), Action Research Arm Test (ARAT), and FIM [112]. Both involves in use of sensory stimulation such as kinesthetic inputs and visual illusion. As mentioned before MT activates premotor and somatosensory cortex and MG influence the activation of the sensory motor cortex [113, 114, 115]. Thus there is an increase in stimulation of somatosensory inputs which is likely to have remarkable effect of MT on movement control recovery.

10. Interaction of person, occupation, and environment in activity participation after neurological disorder

10.1 Introduction

As neurological disorders occur to persons from different professions, the Neuro-rehabilitation team encounters the challenge of helping clients in returning to a vast variety of occupations. These occupations include the different fields such as business, law, maintenance, office work, terrain work, medicine, housekeeping, accounting, police work, and as well as self-care occupations. Those challenges are grouped into three main aspects; which are person, occupation, and environmental. The quality of a person’s experience, with regards to their level of satisfaction and functioning, is the outcome of the fit between the person-environment-occupation transactions [116].

10.2 Changes at person level after neurological disorder

After neurological disorder occurs to person level; there are changes in sensory and motor function, cognitive components, volition (interest and values), and financial; those changes interfere activity participation in many ways.

1. Sensory and motor function: It involves two types of symptoms: “negative” and “positive” sensory phenomena [117]. A phenomenon in which there are deficits in sensation such as hyperalgesia, is called negative symptoms [117]. However, a positive sensory phenomenon means the abnormal increase of functional sensation such paresthesia or neuropathic pain [117].

2. Cognitive components: Cognitive impairment and memory loss are common after a stroke. Stroke affects the cognitive domain, which includes attention, memory, language, and orientation [117]. The most affected domains are attention and executive functions; at the time of stroke diagnosis, memory problems are often prominent, the presence of well-functioning cognitive skills is the cornerstone of occupational engagement.

3. Volition: It includes the thoughts and feelings about personal capacity and effectiveness and how a person perceives the importance of what they do as well as what bring them enjoyment and satisfaction [118]. Neurological disorders disrupt participation in some interests that require the use of body structure, body function, and social engagement at home and outside of the home. A sudden inability to act on one’s volition is likely to lead to a decreased quality of life [119]. Not being able to participate in challenging and enjoyable work tasks or leisure activities will erode one’s feelings of self-efficacy and sense of personal capacity.

10.3 Environment: impact of occupational, social, and physical environment

Neurological disorders do not only affect person internally but also environment, therefore creating a need to modify environment to support their interests and roles. The MOHO classifies environment into three components: Physical, social, and occupational environment [120]. The physical environment includes both natural and built space where people do their day-to-day activities, changes due to neurological disorders. People who work at home or from home are required to find a supportive space at home or outdoor for participating in day-to-day activities. Occupational environment: According to Black [121], Occupational environment may be defined as the workplace surroundings that encompass the physical and social environment. The social environment can be seen as social relationships, immediate physical surroundings and cultural settings in which people function and interact. The patient with neurological disorders experiences a number of environment barriers, limiting their participation and re-integration after being discharged from hospital. Social environment: The social attitudes define the big part in participation of different areas of engagement such as education, employment, health care and public realm [122]. Negative attitudes towards the persons with disability hinder them from exploring their potentialities like other persons without disability. However, the positive social attitudes enhance the participation in more than one area [122]. Among of them includes home and community based engagement and inclusion, which in turn strengthen self-esteem through sense of belonging [122].

10.4 Applying person-environment-occupation model interventions post neurological disorders

Figure 1 shows the extent of congruence in the person-environment-occupation (PEO) relationships is represented by the degree of overlap between the three spheres; the closer the spheres overlap, the greater the degree of harmony or fit [123]. According to PEO, the environment influences both person and occupation but, more importantly it can be easily modified more than person [116]. Thus the fitting between person, occupation and environment depends on the adaptability between those three components respectively the achieving goal of person [116]. Activity, task and occupation are all interrelated as they are the intervention tools used to gain occupational performance.

Figure 1.

Person-Environment-Occupation(PEO) relationship.

11. Neuro-functional disorders assessment

11.1 Introduction

Functional neurological disorders (FND) are among the most common causes of neurological disability [124]. There is no single factor to consider the cause of FND, but rather a combination of factors interacting together [125]. The etiology of FND is still specifically not known [126]. FND is caused by a complex combination of biological, psychological and social factors on the brain [127]. Referring to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [128], the term functional was adopted as the primary definition in the functional neurological symptom disorder [128]. This provides causative neutrality and may also increase patient understanding and acceptance [128]. The first decision in management of FND is the proper diagnosis followed by the explanation of the condition to the patients and care givers. After establishment of the disabling condition, rehabilitation team intervenes for long-term management [129]. Prior to individual follow up, every rehab personnel conduct a thorough assessment to highlight challenges to function and plan accordingly. The intervention plan should also include patient or caregiver involvement. Comorbidities, such as pain or fatigue and psychiatric comorbidities (anxiety, depression, dissociation etc.) should be carefully evaluated, as they need an individualized treatment plan [129].

11.2 Features of functional neurologic disorders

Motor FND, Suggestive clinical features include sudden onset, disappearance with distraction, increase with attention, and excessive fatigue or demonstration of effort [128]. With motor deficit, the presenting feature of the patients includes but not limited to dysfunctions of body structures in engagement of voluntary and purposeful task [130]. This includes inability to walk and to move the arm [125]. Sensation: sensory impairments in persons with neurological disorders include sensory loss, pain and abnormal sensation such as light touch and vibration [126]. The proprioceptive sensation mighty be also affected whereby the person losses the ability to sense the body part position [130]. Proprioception is tested by asking the patient to close eyes, and position the joint in space and let the patient identify the joint position [131]. A patient with functional proprioception will be able to correctly identify the exact placement of body part. Axial FND, Functional axial disturbances include disorders of gait and posture such as excessive gait slowness, astasia-abasia and knee buckling [128]. Speech FND, the patients with speech difficulties experiences challenges in verbal response to the incoming request (Broca’s aphasia) and understanding instruction (expressive aphasia)[132].

11.3 Areas of assessment for neuro-functional deficits patients

This is where now practice makes good performance, neurological exam sounds intimidating in the first occasions but the more ones enroll into examination, the more proficient becomes [129]. This is a hands-on patient stage and should not be escaped whenever neurological disorder is suspected.

The neurological exam can be organized into seven categories:

1. mental status,

2. cranial nerves,

3. motor system,

4. reflexes

5. sensory system

6. coordination

7. station and gait.

8. simulated functional activities

The practitioner approach neurological exam systematically and make sure that there is no area left unevaluated so as to mark the proper prognosis [129]. The preference of assessment approach should be followed to compare the affected part vs normal, distal vs proximal and let vs right mores especially the sensory impairments [129]. Mental Status: The mental status defines the reliability of the rest of neuro-exam. The patient keeps the appropriate eye contact and does not need things repeated, it signifies that he/she can converse. Thus you proceed with medical history and recent event in consistent manner [129]. The mental screening examinations include seven areas, which are attention, orientation, speech fluency, comprehension, verbal response, high cognitive involvement and memory [132]. But the therapist needs to test the status of mood to screening out the presence of psychiatric conditions [132]. This acts screening examination before deciding to proceed with high mental functions. Cranial Nerves: The cranial nerves consist of nerves that exit through foramina in the skull, not necessarily nerves that originate in the brain [131]. Neurologic impaired patients impose difficulties to the prognosis and recovery of the victim [133]. Therefore, cranial nerve screening should be set mandatory [133]. Thus a thorough evaluation should be included in evaluation process. Motor Exam: When assessing motor function among FND patients, it is of the utmost valuable to first distinguish the whether the case is of the upper motor neuron lesion or lower motor neuron lesion [131]. Depending on the strength of the patient, motor evaluation may incorporate mobility [131]. During motor examination the practitioner is recommended to conduct motor exam to measure fall risk prior to evaluation to minimize the falling incidence [131]. Furthermore, during motor assessments the practitioners observes different aspects of person such as muscle build ups, muscle tone, endurance and movement [134]. As well both equilibrium and non-equilibrium tests should be considered whilst evaluating coordination deficits. In addition, the practitioner has to keep a limb in Position in such a way that there is risk of recruiting other muscles with similar function are kept minimal [135]. Reflexes: Tendon Reflex test is the most objective part of the neurological exam and is the least dependent on cooperation [131]. When test reflexes, the muscle for which tendon to be tested should be put to tension [131] and stress then quickly tap or use the standardized reflex or knee hammer to the tendon to be tested and observe the reaction [131]. The intensity and extent of briskness response has to be analyzed [131]. This should be repeated to the other side and compare against the normal range. Sensation: Both superficial and deep sensation should be tested in all four limbs. Superficial sensation (pain and temperature) this is channeled by unmyelinated and small myelinated nerve fibers through the ascending tract of spinothalamic [136]. Pain sensation can be tested with a safety pin or the broken end of a cotton swab [136]; temperature sensation can be tested with a hot or cold fluid filled test tubes [136], however cool metal object like a tuning fork maybe used as an alternative [136]. Deep sensation which combines pressure, proprioception, and vibration is mediated by large fibers through the dorsal and lateral aspects of the ascending tract [124]. Coordination and Gait Assessment: Incoordination should be noted when patient sits and stands upright, or getting onto the examination table [126]. Gait assessment should not be separated far from coordination among functional neurologic disorder patients [129]. Position of body in space, posture and extremity placement [137] and, speed, steadiness, arm swinging, heel strikes, stance, and heel to toe walking have to be considered in evaluation of gait [137]. While neurologists and other physicians play an important role early on, the treatment of FND, it is typically the purview of allied health professionals, including physical therapist, occupational therapist, speech and language pathologist, art, and recreational therapists to conduct assessment prior to intervention [130].

12. Conclusions

The neurofunctional interventional approaches imply the significant impact in changing the activity participation of persons with neurological disorder and injury in terms of treating impairments and improving the ability of activity performance after injury. These approaches have been approved by many clinical based evidences and they are mostly contextualized according to the nature of setting, nature of patient and therapist’s own experience. Furthermore, among of all those traditional sensorimotor approaches have no remarkable significant difference in effectiveness and efficiency. Thus the therapist chooses the approach according to his/her experience in certain approach, clients conditions and practicing milieu. Besides to that all approaches favor the theories of neuroplasticity and building up required engrams needs repetitions. Apart from that the status of person, task and nature of real working environment have important influence in achieving the goal with the clients with neurological disorder or injury as long as brain insults result in many different areas of impairments such as motor, sensory, cognition and psychosocial issues.

Acknowledgments

NJ: Involved in reviewing articles and wrote about the literature of neurofunctional interventional approaches, involved in organizing and preparing the book chapter and followed up the progress of book chapter. UP: Involved in reviewing the articles and wrote about the literature of neurofunctional interventional approaches. NT: Involved in reviewing the articles and wrote about the literature of interaction of person, occupation, and environment in activity participation after neurological disorder. MJ: Involved in reviewing the articles and wrote about the literature of neurofunctional disorders assessment.

Conflict of interest

None declared.