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Box 7.3 The physical benefits of movement

Sensorimotor appreciation.

Posture and balance control.

Maintenance of joint and soft tissue range of movement.

Maximization of functional independence.

Minimization of tonal changes such as spasticity (Hawkins et al. 1999).

Cardiorespiratory fitness (Convertino et al. 1997).

Effective management of patients with neurological impairment requires holistic assessment including consideration of altered tone, abnormal patterns of movement, abnormal reflex activity and joint protection.

Abnormal reflex activity

For the patient with neurological deficit moving and positioning can help to manage the positional influences of unwanted reflex activity for those with altered tone (Davies 1985, Edwards 2002a, Jackson 1998, Stokes 2004). Positions suggested relate to the desire to avoid the development of abnormal patterns of movement associated with altered tone through minimizing the influence of primitive developmental reflexes (Bobath 1990). The three reflexes whose ‘release’ can be influenced are: (i) the tonic labyrinthine reflex; (ii) the symmetrical tonic neck reflex; and (iii) the asymmetrical tonic neck reflex (Davies 1985, Davies 2000, Jackson 1998). Davies (2000) describes these primitive reflexes as follows.

The tonic labyrinthine reflex is evoked by changes in the position of the head in space, originating at otolithic organs of the labyrinths and believed to be integrated at brainstem levels. In supine, extensor tone* increases throughout the body with resultant extension of head, spine and limb extension and shoulder retraction. In prone, flexor tone* increases throughout the body. This may only be seen as a reduction in extensor tone* in a patient with severe spasticity. The influence of head position relative to the body will also be noticed in sitting or standing and may affect functional movement or position.

The symmetrical tonic neck reflex is a proprioceptive reflex, elicited by stretching of the muscles and joints of the neck. When the head extends, extensor tone in the arms and flexor tone in the legs increase. When the head is flexed, the extensor tone in the lower limbs increases, with more flexor tone in the arms. This position can be seen where the patient sits unsupported or is half lying in bed with their head flexed; their affected leg extends and affected arm flexes more. This can also be seen when a patient is sitting unsupported in a chair or wheelchair.

The asymmetrical tonic neck reflex is elicited as a proprioceptive response from the muscles of the joints and neck. Extensor tone increases in the limbs on the same side to which the head is turned. The limbs on the occipital side show an increase in flexor tone. Patients who have poor mobility dependent on a wheelchair may have an increase in lower limb flexor tone on their weak side as well as affecting their arm. Here, a flexion contracture of the knee may develop, requiring effective management strategies recommended by therapists following individual patient assessment.

Professionals agree that positioning is a key element of rehabilitation and management of patients with neurological deficit (Bobath 1990, Davies 1985, Edwards and Carter 2002, Hawkins et al. 1999, Lynch and Grisogono 1991, Raine et al. 2009). An optimal position is not always possible due to variables such as the patient’s medical condition and presence of contractures (Edwards 1998). There appears to be an overall lack of consensus in clinicians’ actual practice regarding the key components of the positions necessary to limit the onset of spasticity and unwanted patterns of movement (Chatterton et al. 2001, Jackson 1998, Mee and Bee 2007). Prevention of complications is an important aim (Bobath 1990, Davies 1985, Edwards and Carter 2002, Lynch and Grisogono 1991, Mee and Bee 2007, Raine et al. 2009). Davies ((1985), 2000) describes positioning for stroke patients and urges the avoidance of flat supine positioning due to its influence on the tonic neck and labyrinthine reflexes