9.3 The role of physiotherapy in rehabilitation

The role of Physiotherapy in the rehabilitation of individuals after an acquired brain injury involves an understanding of the kinematic and kinetics of normal movement, motor control processes and motor learning. The emphasis for motor relearning is placed on specific motor tasks which have meaning for the patient in a functional context.

There are several factors deemed important for the learning of motor skill and therefore deemed to be essential for relearning of motor control. These include the following:

• The elimination of unnecessary muscle activity and prevention of development of muscle imbalances.
• Timely and specific feedback which may take on the form of - visual cues such as use of mirrors or video taping, - verbal cues such as correcting and prompting with verbal instructions - environmental set up. Feedback needs to be used carefully for reinforcement of appropriate technique or behaviour and may be withdrawn or reduced as performance of the task improves. Instructions for client with challenging behaviours and cognitive impairment may also need to be simple, clear and repeated in a consistent manner.
• Practice is a prerequisite for acquiring a motor skill. Practice needs to be well directed and goal oriented. Goals should be client focussed and challenging yet attainable. They should be written in a SMART format, being Specific, Measurable, Attainable, Relevant and have a Timeframe in which they should be achieved.
• Recognition of the interrelationship between postural adjustment and movement

For clients with challenging behavioural and cognitive impairments, other considerations need to be taken into account. These include structuring the environment to reduce overstimulation, providing simple instructions and/or cues to reduce confusion and trying to combine therapy times when the client is most attentive.

For an exercise programme to be effective, it is important that the programme be undertaken regularly (5-7 times per week). Cognitive problems such as memory difficulties, reduced planning and initiation, are common after an acquired brain injury, and thus, it is often the responsibility of carers to assist in ensuring an exercise programme is routinely carried out. This can be facilitated by using strategies such as:

• a weekly timetable structuring exercise into a daily routine (Example: Attachment 1 )

• exercise programmes with pictures and explanations to easily follow (Example: Attachment 2 )

• log books so that the client and/or carer is able to mark off each exercise as it is performed.

Practice can be structured into other activities that the client may be performing, such as sit to stand practice when getting out of bed in the morning.