The Use of Repetitive Facilitation Exercises for a Patient with Decreased Motor Control:
A Case Study
Hilari Pectol
Introduction
Motor control is the process by which humans use their brain to activate and coordinate
their muscles involved in the performance of a motor skill. There are several reasons
that a person might have decreased motor control. One cause of decreased motor
control is an anoxic brain injury. An anoxic brain injury is an injury to the brain due to a
lack of oxygen. An anoxic brain injury may occur due to respiratory arrest, drowning,
heart attack, brain tumors, or extreme low blood pressure. According to a study by Ute
E Heinz, early rehabilitation is indicated for a patient who has suffered an anoxic brain
injury.
Proprioceptive Neuromuscular Facilitation (PNF) is a method that can be used to
improve a patient’s motor control. PNF is one of the major therapeutic approaches
aimed at improving the important features necessary for the functional ambulation of
patients (2). This technique stimulates proprioceptors within the muscles and tendons,
thereby improving their functions and increasing muscle strength, flexibility, balance,
and coordination, effectively maximizing responses of the motor units (1). PNF uses a
variety of facilitative and inhibitory techniques, repetition, patterns, and stretching to
achieve desired outcome.
Kazumi Kawahira performed a study aimed to determine the effects of repetitive
facilitation exercises (RFE) on a patient. The RFE sessions used a novel facilitation
technique to elicit movements of the shoulder, elbow, an each finger isolated from
synergy (3). It was found that both groups of patients in this study showed
improvements with upper limb motor function after a 2-week repetitive facilitation
exercise program. This is crucial information because PNF utilizes repetitive facilitation
exercises. The results of this study justify the use of PNF techniques to improve motor
control. The purpose of this case study is to describe the use of RFE with a patient with
decreased motor control following an anoxic brain injury.
Case Description
Patient
The patient is a 70 year old Caucasian female who presents with decreased motor
control, coordination, motor planning, task sequencing, and strength. The patient was at
home when she became dizzy and had a fall, resulting in an anoxic brain injury and
leaving her with bruising to her forehead, right arm and leg. Patient was found to have
acute hypoxemic respiratory failure with accompanying pneumonia and COPD (chronic
obstructive pulmonary disease). The patient’s previous medical history is positive for
COPD, emphysema, myocardial infarction, and hyperlipidemia. The patient states that
she was independent with ambulation at home and in the community without the use
of an assistive device. The patient lives alone in a one level mobile home with three
steps to enter with bilateral rails. The patient quit smoking six years ago. The patient is
usually on supplemental O2 (oxygen) at four liters per minute via nasal cannula from
concentrator. The patient states that she has social support near her home and family
support in Rock Springs.
Examination
The following examination was performed by a physical therapist upon admission to a
long-term acute care facility, seven days after suffering the fall. The date of onset is
09/29/2015 and the patient was seen beginning on 10/06/2015.
Bed Mobility
Transfers
Ambulation
Gait
Mobility
Balance
Range of Motion
Strength
Endurance
Pain and Edema
Safety
Stand by assist (SBA)
Contact guard assist (CGA) for safety
CGA for safety with forward wheel walker
(FWW) for several steps forward and back
to bed.
Patient ambulates with decreased,
asymmetrical step length, which
contributes to poor standing dynamic
balance.
Mobility is limited by O2 desaturation with
exertion. After standing for less than sixty
seconds, oxygen saturation (SaO2) fell to
high seventies.
Sitting balance is good. Standing balance is
poor with FWW.
Grossly within normal limits (WNL) for
bilateral lower extremities (BLEs).
Grossly 3/5 for BLEs.
Patient fatigues with minimal exertion.
Patient reports no pain.
Patient has impaired safety awareness.
Patient is a fall risk. Patient on high flow
O2 at twenty liters per minute and sixty
percent SaO2.
Interventions
The patient was admitted to a long-term acute care facility for further rehabilitation
following her fall at home. Rehabilitation consisted of 5-7 treatment sessions per week
for 4 weeks. The initial plan of care set by the physical therapist consisted of bed
mobility, transfer training, gait training, balance reeducation, neuromuscular
reeducation, therapeutic exercise, and safety skills.
Following the examination and evaluation, the following goals were discussed between
the physical therapist and the patient.
Short-Term Goals:
1. Patient will transfer sit to stand with SBA.
2. Patient will maintain SaO2 above 80% while standing for five minutes.
3. Patient will ambulate 25 feet with FWW and SBA.
Long-Term Goals:
1. Patient will perform all bed mobility and transfers safely and independently.
2. Patient will maintain SaO2 greater than ninety percent with gait.
3. Patient will ambulate greater than 150 feet with least restrictive assistive device
(LRAD) and SBA.
Bed mobility
Following the initial evaluation, the patient performed bed mobility including
transferring from supine to sitting at edge of bed (EOB) with SBA and returning to
supine with SBA. Patient was able to perform these transfers with SBA for safety
throughout the remaining treatment sessions. Patient utilized bilateral bed rail
assistance when performing bed mobility.
Transfer training
Transfer training involved sit-to-stand (STS) transfers from edge of bed and from
reclining chair up to FWW. Patient required CGA at time of initial evaluation, but
consistently required moderate to minimum assistance with transfers throughout
remaining treatment sessions. During transfer training, the patient required moderate
tactile and verbal cues for correct and safe hand placement for pushing off of chair
when standing up and reaching back prior to sitting down.
Gait Training
Gait training was not performed due to the patient’s mobility being limited by O2
desaturation with exertion and due to the patient’s fatigue with minimal exertion. Pregait training activities were performed including forward, lateral, and retro stepping
with moderate assistance and maximum verbal and demonstrational cueing to improve
poor motor control with the right lower extremity.
Balance reeducation
Initially, the patient demonstrated unsteadiness upon standing, even with FWW use and
CGA. Balance slightly improved after nine treatment sessions, as patient was able to
perform static standing balance training for approximately fifteen seconds with FWW
and CGA, and then for approximately 40 seconds after twelve treatment sessions,
having bouts of posterior leaning. During balance reeducation, the patient required
minimal assistance and cueing for proper weight shifting. Standing dynamic activities
were performed with FWW and moderate assistance to CGA including high marches, hip
extension, hip abduction, hamstring curls, mini squats, single leg stance, and unilateral
multiple directional reaching across midline and slightly outside base of support (BOS).
Neuromuscular reeducation
Neuromuscular reeducation activities were demonstrated by therapist prior to patient
initiation. Verbal, tactile, and demonstrational cues were given for correct form and
safety as patient performed these activities. The following table delineates what
activities were performed for patient neuromuscular reeducation.
Unilateral,
multidirectional
reaching across
midline and outside
BOS
Unilateral dynamic
upper extremity
(UE) activity
including reaching
for objects,
throwing object,
and hitting balloon.
Unilateral dynamic
LE activity including
kicking ball and
tapping cones in
various directions.
PNF for bilateral UE
and LE including D1,
D2 patterns,
rhythmic initiation,
and repeated
contractions.
While seated,
placing left UE and
lower extremity (LE)
in various positions
and having patient
mirror position with
right UE/LE.
Progressing to eyes
closed.
Stereognosis
activity, placing
various items in
patients hands to
identify with eyes
closed.
Therapeutic exercise
Exercises were demonstrated by therapist prior to patient performing them. Verbal cues
were given as needed for proper form and safety awareness. The following table
delineates what therapeutic exercises were performed.
Standing 3 Way Hip: hip
flexion, hip abduction, hip
extension 3x15 repetitions
Seated long arc quads 3x15
repetitions
Seated hip adduction with
moderate manual
resistance 3x15 repetitions
Standing high marches 3x15 Standing mini squats 3x15
repetitions
repetitions
Standing Hamstring curls
3x15 repetitions
Seated hip abduction with
moderate manual
resistance 3x15 repetitions
Seated hip flexion 3x15
repetitions
Standing heel raises 3x15
repetitions
Supine bilateral ankle
pumps 3x15 repetitions
Supine bilateral short arc
quads 3x15 repetitions
Supine bilateral straight leg
raise 3x15 repetitions
Safety Skills
Patient was educated on proper deep breathing techniques and importance of taking
seated rest breaks when exerted. Frequent verbal and demonstrational cues provided
for patient increased safety awareness with transfer training, therapeutic activity, and
therapeutic exercise.
Outcomes
The following table contains the patient’s outcomes at the time of discharge. The
patient was discharged to her home where she will remain on hospice due to being
diagnosed with brain cancer. Patient was not given a home exercise program as her
prognosis is poor and her health is declining rapidly.
Bed Mobility
Transfers
Ambulation
Gait
Mobility
Balance
Range of Motion
Strength
Endurance
Cognition
Safety
SBA
Minimal assistance (Min A) to CGA for
safety
Unable to perform due to increased
patient weakness.
Unable to perform due to increased
patient weakness.
Mobility is limited by O2 desaturation with
exertion and by increased weakness.
Unable to perform standing balance
activity. Sitting balance is good with CGA.
Grossly WNL for BLEs.
Grossly 2/5 for BLEs.
Patient fatigues with minimal exertion.
Patient presents very somnolent, with
reports of nursing staff recently
medicating her.
Patient safety awareness improved
throughout therapy including ability to
properly deep breathe. Patient remains on
high flow O2 at 24 liters per minute and
60% O2.
Discussion
Due to the patient’s unfortunate diagnosis of brain cancer, the treatment plan was not
as effective as it could have been. The patient was unable to meet any of her short-term
or long-term goals, due to her increased weakness from her previously undiagnosed
condition. The patient was seen for a total of 4 weeks and all aspects of her treatment
utilized repetition of tasks and skills to promote increased independence with functional
activities.
Progressive facilitation exercises and proprioceptive neuromuscular facilitation have
been shown to be effective with the improvement of physical function. The treatment
plan provided for this patient could be beneficial to other patients presenting with
decreased motor control. The authors of one study observed a general decline in the
use of the PNF technique among physiotherapy clinicians in their practice environment
(2). This could be due to increased patient caseloads and the physical endurance it
takes to administer PNF techniques. It is imperative that physical therapists do not get
set in their ways but rather utilize PNF techniques in the rehabilitation of not just their
patients with decreased motor control, but with all patients who may benefit from it.
Conclusion
People will continue presenting with decreased motor control due to a variety of
reasons, an anoxic brain injury being just one of them. Physical therapy has been shown
to be a crucial component in the rehabilitation process following an anoxic brain injury
to help patients to be at decreased risk for falls, decreased dependence on caregivers,
and increased mobility. PNF is just one RFE method that can be used improve patients’
motor control. It does this by stimulating proprioceptors within the muscles and
tendons, thereby improving their functions and increasing muscle strength, flexibility,
balance, and coordination, effectively maximizing responses of the motor units (1). PNF,
along with other RFE was performed with the patient presented in this case study, with
the goal of improving her motor control. The use of RFE is beneficial in the rehabilitation
process of a patient with an anoxic brain injury.
References
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2. Heinz, Ute E., and Jens D. Rollnik. "Outcome and Prognosis of Hypoxic Brain
Damage Patients Undergoing Neurological Early Rehabilitation." BMC Research
Notes BMC Res Notes 8.1 (2015): Web.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4469251/25 Nov. 2015.
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Noma, and Nobuyuki Tanaka. "Effects of Intensive Repetition of a New
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2015.
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