K. McGivern
NM Final Study Guide
See review questions on TBI
TBI Review- Lecture 10
 Often the result of falls, MVA, or Violence. Most commonly affect kids 0-4, 15-19 with males being
1.5x more likely
 Impairments are from UMN lesion and are dependent on area injured. We must understand their
location, type of head injury, and extent of primary and secondary brain damage
 Can be open head injury- skull is fx’ed, or closed head injury- where skull is intact. The sequelae
of secondary conditions are different for open and closed injuries
 Primary brain damage- occur at the moment of inpact, only at site of impact or contrecoup.
Anterior poles of the temporal and frontal lobes are susceptible to injury- polar brain damage,
while the occipital lobe is less likely to be injured in a traumatic event. The skull is sharp and can
have shearing forces= frontal and temporal lesions. Rapid movement of the brain causes
widespread tearing or stretching of neuronal axons in myelin sheath= diffuse axonal injury,
results from acceleration-deceleration injury
 Secondary brain damage- occurs within minutes  hours of injury. The airway can be
obstructed by blood, foreign bodies, tongue, or aspiration. Reducing circulating oxygen results in
arterial hypoxemia and causes widespread 2º brain damage
 Bleeding from skull or brain can result in intracranial hematoma. Blood can accumulate above
(epidural) or below the dura (subdural hematoma. It can also accumulate in the brainintracerebral hematoma. As it accumulates- ICP increases, brain is compressed and shifted and
herniation may occur.
 Other common causes of 2º brain damage include arterial hypotension, post traumatic
epilepsy/seizures, or intracranial infection.
Examination of Cognitive findings
 Examination of pts with UMN lesions= assessment of congition, perception, behavior, and
communication, also motor learning or relearning. Pts should observe the following behaviors and
cognitive functions
o LOC/Alertness, orientation, short/long term memory, attention span, level of agitation and
anxiety, ability to problem-solve, ability to sequence and organize events
 The rancho los amigos levels of cognitive functioning scale- describe behavior of individuals with
head injury.
1. Level 1- No response (comatose state)
 Treatment: Sensory stimulation techniques to arouse patient (music, smells, tastes,
pictures). Be careful with sensory stimulation and watch for adverse responses. Sensory
bombardment can lead to an increase in reflex responses or an avoidance reaction.
Positioning is important to prevent contractures
2. Level 2- Generalized response: reflex response to painful stimuli, no purposeful reactions/may
be the same for different stimuli. Responses may be significantly delayed
 Treatment: Sensory stimulation techniques (music, smells, tastes, pictures). Same as above,
also see level 3 too
 Treatment: Simple 1-step directions, gross motor activities
3. Level 3- Local response: withdrawal/vocal to painful stimuli, purposeful reactions to different
stimuli (turn away from pain, blink with bright light), response inconsistently, turns toward or
away from auditory stimuli
 Treatment: Simple 1-step directions, gross motor activities, allow pt time to respond, talk
to the person at eye level. Remove external sources of agitation, provide short sessions
throughout the day, begin sitting, exercises to improve ROM, tone, kinesthetic stimulation
4. Level 4- Confused Agitated: Alert and heightened state, tries to remove stimuli (perceived as
noxious), absent short term memory, may cry out or scream out of proportion to stimulus even
after removal, aggressive, mood swings from euphoric to hostile. Constantly moving, just starting
to emerge from coma
 Treatment: Calm, soothing atmosphere, simple and repetitive tasks, functional training,
Don’t remove restraints if being used, limit distractions, try simple self-care tasks. Avoid
questioning, use automatic and familiar gross motor activities without demand for follow
through, functional training
5. Level 5- Confused, Inappropriate: Alert, not agitated, may wander randomly. Not oriented,
unable to learn new information. Are a walking danger to themselves
 Treatment: Calm, soothing atmosphere, simple and repetitive tasks, functional training, see
above
6. Level 6- Confused, Appropriate: Inconsistently oriented, vague recognition and memory,
unaware of impairments. Can attend to highly familiar tasks in non-distracting environment,
remote memory has more depth and detail than recent memory
 Treatment: daily routine, decrease help and increase strength and coordination,
orientation activities, keep a calendar for upcoming events, gradually decrease amount of
help for specific activities, talk to them in a normal fashion, functional training
7. Level 7- Automatic, Appropriate: Consistently oriented, Unaware of others needs/feelings and
unable to think about consequences, superficial awareness of impairments. Able to attend to
highly familiar tasks in non-distracting environment for at least 30 minutes with minA to complete
tasks, minimal supervision for new learning, has carryover of new learning, unrealistic planning
for the future, overestimates abilities, self-centered
 Treatment: Increase patients insight/ability to recognize tasks and therapy, increase
endurance and independence, limit humor, sarcasm, usually don’t understand abilities.
Facilitate an increase in insight and judgment, facilitate ability to organize and carry out
own therapy program, increase physical endurance
8. Level 8- Purposeful, Appropriate: Independently attends to needs and tasks, thinks about
consequences, depressed, aware of deficits. Can independently attend to familiar tasks for 1 hour
in distracting environments, able to recall and integrate past and recent events, depressed,
irritable, low frustration tolerance, over + underestimate ability, argumentative, self-centered,
able to acknowledge inappropriate social behavior with minA
 Treatment: Encourage memory and details, evaluate self, evaluate general work skills,
ability to do things they did before, and encourage the patient to remember as much as
possible
Lecture 11 TBI Con’t
Level of Consciousness
 LOC is continuum of awake, lethargic, obtunded, stupor, and coma.
o Lethargic: drowsy, easily falls asleep if not stimulated. Slow and communication difficult
o Obtunded: sleeping and difficult to arouse. When awake they will likely be confused
o Stupor: an individual who is semiconscious, unresponsive but may respond briefly with
gross movements to a strong stimulus, such as sharp pain. Won’t be able to follow any
commands.
o Coma: totally unconscious, unresponsive, unaware, and unarousable. Don’t respond to any
stimulus, regardless of strength. Widespread and diffuse damage to both cerebral
hemispheres and/or brainstem (reticular activating system). Usually, short duration- few
days few weeks
o Vegetative state: unconscious and unaware of surroundings. They do not speak or
respond to verbal commands. They have sleep-wake cycles and funlike an individual in
coma, may have their eyes open and track objects. May also have generalized nonspecific
movements, groan, or show reflex responses (i.e. withdrawals from pain). No evidence
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of cerebral cortical function. No damage to the brainstem is found (major cortical damage),
if it continues longer than a year it’s a persistent vegetative state.
o Minimally Conscious state (MCS): an individual with MCS has limited but definite
evidence of self awareness or environmental awareness. Can localize pain or reach for
objects.
Glasgow Coma Scale (KNOW)
o Used to assess LOC after TBI. Performed in first 24 hours post injury- 3 measures
 Eye opening, best motor response, best verbal response.
o Add the scores, range from 3-15.
 Severe brain injury- 3-8 (coma if eye opening is absent)
 Moderate brain inj- 9-12
 Minor brain inj-13-15
o Eye opening
 4- spontaneous eye opening, 3-to speech (not necessarily @ request of opening
eyes), 2- to pain, 1- no response
o Motor Response
 6- follows commands (verbal request), 5-localizes pain, 4-withdrawals from pain
(flexion withdrawal), 3- abnormal flexion (Decorticate posturing) 2- abnormal
extension (decerebrate posturing), 1- no response
o Verbal Response
 5- Oriented (knows name and age, speaks coherently), confused conversation, 4disoriented (still speaks coherently), 3- inappropriate words or incoherent (makes
no sense), 2- incomprehensible sounds (grunts/groans no words), 1- no response
Impairments following TBI
o TBI causes a wide variety of direct, indirect, and composite impairments.
o Direct- result of neurologic damage and can include the following
 Motor impairments- weakness, abnormal synergistic movement, abnormal muscle
tone, coordination problems, involuntary movements
 Sensory impairments- loss of somatosensation, visual deficits, perceptual deficits,
vestibular deficits
 Cognitive impairments: orientation deficits, memory loss, alterations in arousal
and LOC
 Speech and language impairments: aphasia, dysarthria
 CN Impairments: impairments in the functions controlled by the 12 CN
 Behavioral impairments: sexual disinhibition, emotional, personality changes,
frustration, aggression
o Following a TBI there are indirect impairments too
 Increased ICP, atrophy, contractures, fx, alterations of skin integrity, seizures,
weakness, heel cord tightness
o Other injuries- peripheral nerve injury, SC injury, fx, and soft tissue trauma
PT role is to collaborate with other team members to reduce the impact of impairments and guide
individual to function. TBI can result in cognitive, motor, and sensory changes tthat are
unique to this diagnosis.
General recommendations for working with TBI pts and family
o Don’t say- “you’ll soon be well”, have a daily routine, treat patient at age-appropriate level,
respect patient’s likes and dislikes etc
Supporting the family
o Keep in mind the family is also greatly affected. They have also been traumatized by the
event.
o Stages of grieving
Denial, shock, & disbelief: family may feel that, “this couldn’t have happened to us”
Anger, frustration, and guilt: Family member may feel anger toward anyone who
could be seen as the cause of the injury, or anger toward the hospital staff. Feelings
of being victimized may arise
 Depression, withdrawal: family members may withdraw from friends and social
contacts. They may lack motivation to take care of own needs and relationships, may
not be eating properly, not get enough sleep, and be ineffective at their jobs
 Acceptance: With time, famiflfy members will accept the changes and after this they
can attend to their own recovery, beginning to make the necessary lifestyle changes
o Each family member must take care of him or herself to continue to be of value to
themselves and the patient.
o Recommendations to assist family members- resume a family routine, get enough rest,
don’t neglect others, accept and ask for help, express feelings, evaluate your situation
Specific recommendations for interacting and treating TBI pts
o See above Rancho levels on tx
Behavior Disorders
o Persons with TBI often exhibit changes in behavior and may demonstrate an inability to
control their behavior. Behavior disorders are common post TBI and must be addressed.
 The brain: global confusion or specific cognitive deficits resulting from brain injury
itself or 2º complictions that provoke disorders such as agitation, aggression, or
other dangerous activity.
 The body: restlessness, agitation, screaming, may indicate discomfort- bowel,
bladder
 The person: knowing pre-injury behavior is helpful to understand current behavior
 The environment: Examine circumstances which precede a disordered behavior
and examine what others did or didn’t do before/after the behavior
o 2 main phases to consider when assessing behavior- initial recovery phase followed by
formal rehabilitation. Behavior and management during these phases are described…
 Behavior disorders in initial recovery phase
 Non-goal directed body movements and agitation, inappropriate goaldirected behaviors (remove tubes), screaming, moaning, incoherent
disorganized or bizarre verbalizations, disinhibited behavior (uncontrolled
laughter, inappropriate sexual behavior) accusations of neglect or abuse by
staff
o Caused by post traumatic confusion- inability to process
information accurately. The aim of management is to ensure
continuation of necessary medical tx and protect pt
o Management accomplished by: normalizing and manipulating the
environment, appropriate physical management, use of drugs,
applications of behavior management principles and techniques, ed.
Support and counseling
 After initial- formal rehabilitation begins with resolution of post-traumatic
confusion. 2 classes of behavior may be apparent at this time
 Positive behavioral disorders- actively affect others. Interfere with active
therapies and present management challenges to staff- aggressive, impulsive,
uninhibited, childish, antisocial, manipulative
 Negative behavioral disorders- lack of behavior- reduced behavioral
output and impede the acquisition of adaptive responses (insightless,
driveless, amotivational, slow)
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Aim of management is to eliminate socially unacceptable behavior- TEAM
APPROACH.
 Specific management
o Reward all instances of adaptive behavior (positive reinforcement)
o Withdraw rewards that are currently maintaining the maladaptive
behavior (extinction)- withdrawl attention and ignore behavior
o Withhold sources of positive reinforcement for brief periods after
each instance of maladaptive behavior (timeout from positive
reinforcement)- remove from activity they enjoy
o Apply a pre-declared penalty following adaptive behavior (Responsecost)- have a cost if engage in bad behavior
o Apply an adverse consequences following extremely severe or
resistant maladaptive behavior (adverse conditioning)
 When applying management principles, be consistent and follow through. Pt
must know what to expect and KNOW the consequences. Prevent or avoid
need for physical intervention, avoid situations that provoke adverse
behavior.
Look at Pt Case Scenario- Karen
Lecture 12: Neural Plasticity
 Before the 1970s the brain was thought to be static and incapable of alteration.
 Neural plasticity is a term that describes the adaptive capabilities of the CNS. Neural
reorganization occurs ALL the time. Neural plasticity may be both positive and/or
negative. Consider the effects of therapy and training and how intensive interventions may
promote positive neural changes and facilitate recovery of function. When an individual
experiences a prolonged decrease in activity levels, the brain will respond to this disuse
and negative neural changes will occur.
 Recovery of neurological function after brain injury
o Direct mechanisms (restorative): resolution of temporary changes (cerebral shock
etc), recovery of injured neuron, intact neurons nearby take on identical function
o Indirect mechanisms (compensation): completely different neural circuits
reorganize and take on function of damaged circuits (cortical remapping
 Plastic and adaptable Brain and SCo Short term function plasticity- increased sensitivity to release of NTM then reverses
o Long Term structural plasticity- changes in organizations and numbers of
connections among neurons
 Intercellular (at synapse level) Plasticity following brain injury
o Denervation supersensitivity- post synaptic neuron forms more receptors in
response to less presynaptic input (ex. PD)
o Unmasking of silent or unused neural pathways- redundant pathways exist and
some remain silent, after injury silent pathways are unmasked to restore
neurological function, occurs immediately and quickly
o Neural regeneration (regenerative synaptogenesis)- injured axons begin sprouting
or regenerating, limited research that this exists in the brain and SC of humans
(more common in PNS), axons have difficulty regrowing over long distances and
when they do they do not show normal function, occurs slowly
o Collateral sprouting of undamaged neurons (reactive synaptogenesis)- healthy
neurons that live near the damaged neurons sprout new connections to neurons
that were previously innervated by the damaged neurons
 Cortical Re-mapping
o Peripheral injury: after amputation of the arm, the face area of the somatosensory
cortex enlarges and shifts into the area represented by the arm. Researchers have
found that touching an arm amputees face evokes a phantom limb response
o Brain injury: using neuroimaging it has been found that the facial cortex is
activated in individuals with stroke who move their formally paretic hand. Thus the
hand representation shifted over the face region which was undamaged
o Secondary sensory & motor areas take over for damaged primary areas
o Uncrossed motor pathways- from the undamaged hemisphere may also contribute
to motor recovery after brain damage
 Recovery and neural plasticity may be influenced by a # of factors
o Age: persons of all ages have the capacity for neural plastic change- potential is
greater in younger persons
o Characteristics of the neurologic lesions (size, growth, or rate of change):
change of recovery from a small lesion may be greater, assuming the functional area
has not been entirely removed. Slow developing lesions appear to cause less
functional loss than lesions that occur rapidly
o Effect of experience: enriched subjects, or those with experience in enriched
environments may have developed neural circuitry that is more varied than that of
restricted subjects. This could provide them with a greater ability to reorganize the
NS after a lesion, or use alternate pathways to perform a skill
o Training: training must be of skilled activities with intense practice
Lecture 13: Applications of motor learning-relearning principles within a task-oriented approach: the
physical therapy patient as an active problem solver
 Motor control theories: attempt to explain how the brain controls and generates movement
 Today most clinicians use contemporary systems theory of motor control and use a taskoriented approach
 Motor control tx relies on the overlap of the environment, individual, and task.
 Hx of motor learning- psychology and kinesiology, best way to train and refine motor skills with
pts.
 Application of motor learning principles for pts
o Apply the principles of motor learning to rehab= active problem-solving approach to
learning and re-learning of functional motor tasks. It represents a shift away from
emphasizing tx of impairments to education that emphasizes task specific function training.
Thus it is a task-oriented approach.
o Kelly scenario about motor learning- look it up
 Motor learning and motor performance are not the same!
 Motor performance: short term, it is temporary change in motor performance and occurs at an
instance in time. It is directly observable during a practice session. Defined by variable such as
duration to complete a task, the quality of movement, and the efficiency in completing the task. An
improvement in motor performance may be temporary
 Motor learning: long term, relatively permanent change in motor performance and occurs in
response to repeated practice. Motor learning is not directly observable during a practice session.
It is inferred based on improvemed motor performance and assessed indirectly via
o Retention Test: a reassessment of individuals’ performance at a later date and after a
period of no practice (performace may deteriorate slightly but return to original
performance levels after relatively few practice trials)
o Transfer of learning: testing the ability of an individual to successfully perform the
learned skill under a variety of different environments
o Generalizability: testing the individuals’ ability to apply the learned skills from one task to
other new but very similar tasks
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Motor learning and neuroplastic changes:
o Brain is continuously remodeling through life. fMRI and PET allow objectivity in visualizing
motor learning in the form of neoplastic changes. The repetive active training and
continued practice required for motor learning occurs and drives cortical plasticity. This
form of positive plasticity is often referred to as “use-dependent” cortical reorganization,
unfortunately “injury-induced” cortical reorganization also occurs wherby the brain
reduces the size of cortical motor representation of the injured limb
o Use-dependent cortical plasticity
 The sensorimotor cortical representation of the braille reading finger is expanded in
the blind. Individuals with stroke who receive constraint induced movement
therapy show increased motor map sizes of the paretic finger muscles after tx.
o Injury induced cortical plasticity
 Cortical motor representation of any immobilized, paretic, or amputated limb will
shrink within 4-6 weeks post injury related to the decreased use of the neural
connections controlling the affected limb. Don’t use it you loose it
o Neuroplasticity influenced by- age, characteristics of lesion (fast vs. slow), effect of
experience (PLOF), training
Stages of motor learning
o Early-Cognitive stage:
 Self problem solving occurs (figure out how to approximate the task)
 Trial and error practice= variable/clumsy performance
 Heavy reliance on visual input to guide movement (watches to learn)
 Frequent verbal and non-verbal communication is provided by clinician to describe,
demonstrate, or manually guide the desired movement, thus establishing a
reference of correctness/cognitive map for learner
o Intermediate- Associative stage
 Proprioception input (intrinsic feedback) important while dependence on visual
input decreases (proprioceptive feedback is less consciously accessible than visual
feedback)
 Performance is refined with less variability and fewer errors. Clinician decreases
manual guidance and verbal feedback
 Appropriate to begin practice in different environments to facilitate transfer of
learning
 More about motor performance- are they retaining the new skill
o Late- Automatic/Autonomous stage
 Movements consistent and largely error-free
 Minimal cognitive involvement (low attention) is required as the tasks becomes
automatic to perform. Environmental distractions do not impair performance.
 Attention can be devoted to other things such as scanning the environment for
obstacles, talking etc
 Tx should be aimed at refinement of skills under a variety of environments
o A clinical note: not all patients achieve final stage of motor learning.
Principles of motor learning- Practical applications.
o Principle 1: Practice amount, massed vs distributed, variable vs. constant, blocked vs.
random, part vs. whole
o Amount of practice (repetition)
 Amount of practice is the most important and most intuitive principle of motor
learning.
 Constraint-induced movement therapy (CIMT): takes principle of practice and
repetition to the extreme. It is an example of massed practice (amount of practice
time is greater than the amount of rest time). Mainly used for those with stroke to
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increase functional use of the paretic arm. Tx involves restraining the nonparetic
hand with a mitt 90% of walking hours for 14 days in a row. Theses functional
improvements were retained for two years after tx.
Massed vs. distributed practice
 Massed practice: amount of practice time is greater than the amoung of rest time
(i.e. CIMT)
 Distributed practice: amount of rest time between trials Is equal to or greater than
the amount of practice time.
 we don’t have research that says which is better, massed looks beneficial but fatigue
and injury are likely to occur.
Variable vs. constant practice
 Variable practice: practicing the task under a variety of environmental conditions
and practicing tasks with similar biomechanics and speed to enhance transfer of
learning and generalizability respectively. Ex- practicing sit-to-stand from a
plinth, hard chair, sofa, toilet etc.
 Constant practice: repeated practice of the same task under the same
environmental conditions. Not a lot of new learning
 To enhance motor learning, variable practice is preferred. Alz- constant is better
Blocked vs. Random practice
 Blocked practice: all repetitions of task A are practiced before moving onto task B
 C (AAA, BBB, CCC)
 Random Practice: no task is repeated two times in a row and the sequence of
practice is randomly selected (ABC, BAC, CBA etc)
 Question: pt would learn the desired function task best when he/she 
intersperses practice on all tasks (i.e. random practice). Ideal for motor learning
 Blocked practice improves short-term performance but not long-term retention.
 Random practice retards initial performance but enhances long-term motor
learning through trial-to-trial forgetting and resolving of motor action plan. This is
contextual interference as it requires more active cognitive thought processes
 Clinical note: initially a short period of blocked practice should occur so that the
new skill is roughly approximated and then random practice should predominate. It
is important to educate your patients on the motor learning problem-solving
approach you are using. Educate them that motor learning is poor at first.
Part-task practice vs whole-task practice
 Should functional tasks be broken down into parts and practice in components?
Maybe- depends on the task
 Part-task practice: practicing complex motor skills in discrete components prior to
practicing entire task. It is best for serial tasks (task that can be divided naturally
into units)
 Whole-task practice: practicing complex motor skill in entirety. Best for short
movement durations and for continuous motor skills that are cyclical and rhythmic
in nature
 Clinical note: whole-task training may not always be appropriate (low level pts)
but should be instituted ASAP. Locomotor training using body-weight support
treadmills- whole task practice for walking- allows upright posture and
uninterrupted repetitions of complete gait cycles. Over time as gait ability improves,
BW support is reduced for FWB. It is task specific and naturally continuous. It is a
whole task practice, includes repetition and task-specificity. Great for SCI, stroke,
PD, TBI, orthopedics. It enhances the rhythmic stepping movements via central
pattern generators (CPGs)
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Principle 2: Feedback- intrinsic FB, extrinsic FB (concurrent and terminal- knowledge of results
and performance)
o Intrinsic FB: generated from within the individual during the movement and includes
visual, auditory, and somatosensory FB. Intrinsic FB allows for error detection and
therefore foster independent problem solving. The process aids in establishing an internal
reference of correctness whereby a cognitive map or memory of the movement is created.
This memory is then used in future practice to detect and correct movement errors
o Extrinsic FB: Extrinsic FB is additional or augmented information about the movement
provided from an external source (i.e. the therapist or coach). Extrinsic FB can be delivered
verbally, visually (i.e. demonstration, videotape of performance), or manually.
 Extrinsic concurrent FB: given during the task
 Extrinsic terminal FB: given after the task is completed
o Knowledge of results (KR): KR is a type of extrinsic terminal FB. It is delivered verbally
and relates to outcome of movement and whether there was success in meeting the goal
(more bang for the $)
o Knowledge of performance (KP): type of extrinsic concurrent or terminal FB. It is also
delivered verbally but relates to the movement pattern (i.e. kinematic FB). It informs your
patient on how to perform the task better for the next practice trial. KP increases
motivation and alertness to the task at hand. (Movement pattern)
Question: How often should your patient receive extrinsic FB from you to enhance learning?
After a few practice trials
o high frequency extrinsic FB (both concurrent & terminal) improves immediate
performance but hinders long-term motor learning
Extrinsic feedback schedules
o Immediate post response FB- given immediately after each trial, improves performances
but degrades learning
o Summary FB*- FB is withheld until after a series of trial sand is given in summary form
o Faded FB*- FB is gradually withheld as practice progresses
o Bandwidth FB*- FB given online if the movement falls outside a predetermined band or
zone of correctness
o *- summary, faded, and bandwidth FB are all ways to withhold FB and have been shown to
enhance long-term motor learning but degrade entail performance
o Clinical note- when determining amnt of FB to deliver you must consider stage of learning.
Early cognitive stage more frequent FB bay help to give them a reference of correctness
Clinical notes on Extrinsic FB:
o Positive roles: provides information to the learner regarding how the movement should be
performed and corrected (reference of correctness), keeps the learner on target, motivates
the learner
o Negative roles: too much interferes with the learnes ability to self detect errors, too much
degrades permanent learning, too much creates performance dependency
Principle 3: task-specificity
o The closer you simulate the actual task and/or the environment the better the transfer of
learning
Principle 4: mental practice
o Rehearsal of a task without physical activity has been shown to have positive effects on
motor learning. It should not replace physical practice but be an adjunct. Mental practice is
used for pts in spinal or cerebral shock, they are limited by fatigue, can be part of HEP if
safety is a concern. May not be suitable for pts with cognitive impairment
Principle 5: guidance
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o Use of manual guidance during rehabilitation is often used to minimize error, prevent
injury, and reduce fear. Use of guidance is useful for improving performance of a new task
but if overused it hinders permanent changes. Too much reduces the learner’s active
problem solving and trial and error experiences
Principle 6: Motivation
o Pt should be involved in planning the tx session, and goals. The task should be meaningful
to the pt to enhance attention, motivation, and motor learning.
o Positive FB and reinforcement are important to increase patient motivation. Tx sessions
should have some easy and hard tasks and end with a successful performance to increase
motivation and compliance. We are motivators.