As we have seen in episode 1 & 2, when a new patient comes in to the clinic for assessment we are searching for the ‘critical cues’ that inform us of their presenting difficulties in their movement and postural control, and we are also identifying their potential to move and function better than they are now. We create a ‘movement diagnosis’ that spring boards us into the treatment plan, using clinical reasoning to formulate a clinical hypothesis.

Then we get started taking the patient into a treatment situation, based on our treatment plan, that targets the development of postural strength and movement control skill, working through carefully set up functional tasks to achieve opportunities for practice.

How do we successfully achieve opportunities for practice that allow the patient to strengthen and move better, compared to them just practicing things in their ‘less efficient than normal’ way, themselves? If all it takes is practice and repetition, to move from their newly impaired movement style, to a more ‘efficient’ movement style, then why do you need a neurological therapist to work with you to do that?

Well, because it comes down to identifying what the patient can do, and what the patient can ‘nearly’ do…and working in that difficult ‘can nearly do’ zone with the use of facilitation to make it achievable to do practice in a good quality way. When a person is not able to move as efficiently as they used to (eg after they had their stroke compared to before they had their stroke) then they are likely to move in a compensatory, and less successful way; and so ‘practicing’ needs to be guided to get the best opportunity for developing useful skill. There’s not much point practicing the poor movement pattern, you need to practice the most efficient and accurate movement pattern. Its not the pure repetition alone that matters, its the quality and performance of the repetition that matters. And through quality task performance and repetition of this ‘best practice’ then we know from the motor learning literature that neuroplasticity will drive recovery and new functional skill.

So what does this mean? What does the therapist do to facilitate this ‘can nearly do’ zone, to make it more successful? Well, facilitation is defined as ‘to make something easier or more likely to happen’, and a neurological therapist does this using;

• Manual facilitation – that is using ‘hands on contact’ with the patient around a certain area of their body to create a stimulus and a guidance to help them move more successfully
• Environment facilitation – this is using the environment around you such as a kitchen work surface, or a wall, or the back of a chair for example, to give a point of contact or a prompt, and adapting to the environment, for improved movement control.
• Verbal facilitation – such as using your voice to guide and reinforce movement responses during the task, and giving appropriate feedback