II anniversary of our book: Stroke rehabilitation: an activity based approach

It is 2 years since I and Vasanthan (with great deal of contribution from V. Prakash) released our book stroke rehabilitation: an activity based approach. I still consider it to be my best achievement in terms of scholarly work, even though when I read it, I find the language to be pedestrian.
So what is the book about? Well it is evidence based stroke rehabilitation with non-linearity ideas implemented within the task oriented paradigm.

The ICF model of functioning tells us that function of humans is in 3 levels body level, at the activity and participation level.  Importance to context was given its due diligence and the made clear the multifactoral nature of the influencing factors. Influencing factors were shown in a complex manner influencing each other rather than in a straight line.

Above picture shows- model of influencing factors of activity and participation in stroke. © Stroke Rehabilitation: A Functional Activity Based Approach, K. Hariohm

One of the assumptions I made when I read this was these influencing factors will influence each other in a complex non-linear manner. This was the time we were learning dynamic theory and I interpreted this model as non-linear model. (Well as Vasanthan always accused me – I always interpreted science as I like it or according to my bias rather than looking at it objectively.).
At the same time motor control ideas and motor behavior ideas were also pointing towards a dynamic perspective.

The Venn diagram shows where we have derived our ideas from for our book-as principle of treatment.

Our model within the task oriented paradigm shifted (as you can imagine- we have to be within task oriented paradigm as that is what is evidence pointing towards). We started to look at the system as non-linear system with inseparable subsystems. Even though it looks like the system is made up of many subsystems with unique function, my contention was it behaved as one unit and not separately.  Even though all this mumbo jumbo language is confusing to some it is in reality very simple.
The human system has many sub-systems- the motor, sensory, cognitive, cardio-pulmonary etc., while doing a function all of them act together rather than as individual systems.
What this lead to change in our model of stroke rehabilitation? Well, as you know task oriented treatment is the evidence based proven model, but the problem is definition what task to choose and whether the underlying impairments were to be treated.
Most of the text we read at that time –we started with Carr and Sheppards MRP and moved to other models and around 2005 we were with Anne shumway cooks motor control theory and practice- were not in tune with our changing perception.  The idea we were evolving at that time was- you don’t need to treat the underlying impairment- as I said earlier the subsystems in a non-linear complex system cannot function independent of the whole system. We also thought meaningful ask which are patient centric are the “task” to be selected rather than anything.
So, we started writing our book starting around 1999. Vasanth was dead against writing it as he wanted to find evidence for what I was saying rather than model validation. Well, we went ahead and when I finished one chapter I send it to 3 publishers got reply from 2 and one of them was willing to publish it- The Atlantic publishers (just grateful to those guys). We wrote our book for issues in Indian setting- example in sit to stand- deep knee flexion activities, in and out of an auto etc. Even though writing a book is such a pain it felt good when it was released 10-27-2013.    

If you want to read more about stroke rehabilitation with evidence and the underlying motor control and behavioural ideas-

AMAZON.IN
http://www.amazon.in/Stroke-Rehabilitation-Functional-Activity-Approach/dp/8126918543     

For international shipping

http://www.indianbooks.co.in/bookmart/stroke-rehabilitation-a-functional-activity-based-approach.html?currency=USD                for international shipping
U READ- http://www.uread.com/book/stroke-rehabilitation-k-hariohm-r/9788126918546          

Or mail me: hariohm@hotmal.com         

Should i be afraid- i dont know NDT

Lots of people think NDT or the Bobath approach is the pinnacle of rehabilitation model or the model for Neuro-rehabilitation.

Well is it true?

The simple answer is “no”. But because we have many people who think it is true and some even wear it proudly we will look into the long answer.

So we will start with the fundamental question- what and how was this method developed?

Well it was developed by one of a pioneering therapist in Europe along with her husband around the 1960s.

What was their basic premise?

They took cutting edge science of that time- mostly from Sherrington’s experiments and principles of neuro-physiology and along with it added their own ideas- from observation of cerebral palsy patients.

So what was their basic premise?

They say these children with UMN lesion and the one common denominator they could observe was – “Spasticity”. So they like many others in that time they considered this as the primary impairment and thought this is stopping the patient to move normally. They also tried analyzing the abnormal posture from reflex theoretical idea. (I would ask readers to read this book if you are interested in this kind of stuff- THE NORMAL POSTURAL REFLEX MECHANISM AND ITS DEVIATION IN CHILDREN WITH CEREBRAL PALSY- it was available in British council library  -last time I checked in the late 90s)

So one of the basic premises was “you can do normal movement on abnormal tone” – which was the held it dear even in hers last book- ADULT HEMIPLEGIA: EVALUATION AND TREATMENT in 1990. When I went and listened to this nonsense in 2003 they said the same thing.

What was the basic treatment technique?

Well people are going to go berserk (the followers I mean) for saying this-

Step I- you normalize the tone (ask me how and you need to pay me is still their motto) and next question is how?  Nothing extraordinary just holding in static postures- which they called RIP- reflex inhibiting postures and some other bull shit they called handling.  She gave little credence to “motor learning” like in the era where everything was based on bio-physiological model- she thought if you give appropriate sensory stimuli of normal movement s it will change the system.

What was her major influence in neuro-rehabilitation?

Apart from half educated people making money in her name- her contribution is in the recovery model. Brunstrom thought we have to work with the synergy and then break it later (normal movement) and formulated 6 stages of recovery- Bobath said if we reduce the tone then normal movement can be brought about and changed our thinking about recovery. There is never working with the synergy in Adult hemiplegia according to Bobath.

So what is wrong with it?

Well nothing! It just was not the complete picture of what a patient with UMN lesion is. They did not believe after many experiments- that there is anything called weakness in umn lesion. The operative word here is “believe” not proved or anything. Bobath herself was convinced at the end the aptly named RIP did not work and she said so in her last book.  Well the truth of the matter is she could never be right as she was in a different time. Even Newton was wrong, Arayabatta made a small error in calculation, people are questioning Einsteins quantum mechanics ideas- how can medicine be frozen in time.

Last and the most importantly- most of the studies done all around the world- as this was popular in Europe and Australia – and well they all said do anything else- when compared to bobath or NDT- both are equal. There goes 5000- 4 Lakhs in the toilet for people who studied this.

The newer argument:

The newer argument is very clever and it has all the markings of wonderful marketing by a resourceful pharma.

This is the new definition (anyone who can read the whole thing should get a price)- NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. Using the International Classification of Functioning, Disability and Health (ICF) model, the therapist applies a problem-solving approach to assess activity and participation to identify and prioritize relevant integrities and impairments as a basis for the establishment of achievable outcomes with clients and caregivers. An in-depth understanding of typical and atypical development, and expertise in analysis of postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activation of optimal sensorimotor processing, task performance, and skill acquisition for achievement of participation in meaningful activities.

(try writing the above paragragh in the exam for the answer what is NDT)

Well what is wrong you moron you ask me. The answer is that is not the definition of NDT that is the principle of rehabilitation not even neuro-rehabilitation. You can’t define your 2 bit nonsense as that of rehabilitation. For example if you ask what is task oriented approach- you simple say- you keep on doing the task as a whole rather than parts –something like that.  You don’t put a- 15 page definition so that no one can do any study in neuro-rehabilitation without being in your scope. If that is what you want then you should call it science not NDT.

Task oriented practice is NDT:

Well, that is physiotherapy not NDT.  The idea was developed by many people especially 2 Aussies- Shepard and carr (incidentally they also learnt Bobath) and researched by the whole world. (There are 2 wonderful studies from India if anyone wants to read). So you can’t call it yours and charge some poor sap- 2 lakh rupees.

We incorporate from all the new findings as NDT is fluid!

Of course, that is what every PT does- especially if you take the good and practice it is called EBM.  If you add evidence with some mumbo jumbo like handling, key points than it is called NDT and charged 2 lakhs. You don’t brand latest science in physics as Indian physics or European or cipla physics and sell it. you cant take latest finding in research and call it NDT- you should call it PT.

We are educating the masses what is wrong (genuinely there are some people who do that).

Well if you are propagating pseudoscience- I think it is a crime and unethical thing to do. Well any one with half a brain will not take medicine which is not good, then why teach things which don’t work.  So you are not educating the masses you are encouraging half educated nitwits from other country to exploit our novice PTs.
Some nitwits also think they have brought some experts from the land of science and they are doing a service to the society by teaching this nonsense for just 50 thousand. Really?   

How are these people surviving even after so many studies, so many criticism- well they find new ways to market old garbage as antique to gullible PTs.  We as a people have fascination with the word international, certified etc and this is exploited. Over this we have syllabus which still has these in the syllabus- if you ask the nitwits who are experts in academics will tell you- these are important traditions. Well physiotherapy student does not come to study history – they come to study science.

So what should an intelligent Therapist do?

Well it is fairly simple and it is free. Don’t worry about any technique. If someone says he/ she is certified NDT therapist- laugh at them for wasting their money.
Read simple task oriented approach literature or just remember if you want swim- dont go to the gym go to the pool- that in a nut shell is latest neuro-rehabilitation principle.

PS- no homer simpson quote- as the definition of NDT is enough for the joke

On cerebral palsy day PT the 10 things we should do:

1. Just come out our cult- whether it is NDT or SI and read science

2. remember there is no abnormal movements

3. well we cant change abnormal movements- but we can make them achieve there goals

4. Educate patients with level IV and V regarding accepting - wheelchair

5. keep you hands of pelvis and trunk and allow the patient to explore options

6. Posture correction -well if this is physiotherapy for children with cp- well just quit peadtrics

7. If you are putting the child in a dark room, binding them etc- well that is child abuse and you should be locked up

8. If you are encouraging kneeling for 15 minute or something- well you are a moron-stop practicing physiotherapy

9. for a child with sitting balance if you are treating the patient in lying or on a swiss ball- well quit or read

10. If you are one the morons who keep on asking me if not NDT what else is there - just read or do nothing- because NDT is as effective as doing nothing.

PS: please for god sake only uneducated people will be impressed if you are trained and certified in NDT

additional reading: 

A systematic review of interventions for children with cerebral palsy: state of the evidence.

http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/epdf