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Physical Management for Neurological Conditions 4E
2018 4th Edition Gita Ramdharry Bsc(Hons) Pg Cert
Msc Phd & Geert Verheyden Phd & Sheila Lennon Phd
Msc Bsc Fcsp Digital Instant Download
Author(s): Gita Ramdharry BSc(Hons) PG Cert MSc PhD & Geert Verheyden
PhD & Sheila Lennon PhD MSc BSc FCSP
ISBN(s): 9780702071744, 0702071749
Edition: 4
File Details: PDF, 8.11 MB
Year: 2018
Language: english
 Also available

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Physical
Management
for Neurological
Conditions
Content Strategist: Poppy Garraway
Content Development Specialist: Veronika Watkins
Project Manager: Nayagi Athmanathan
Designer: Amy Buxton
Illustration Manager: Amy Faith Heyden
Physical
Management
for Neurological
Conditions
FOURTH EDITION
Edited by

Sheila Lennon, PhD, MSc, BSc, FCSP

Professor of Physiotherapy
College of Nursing and Health Sciences
Flinders University of South Australia
Adelaide, AUS

Gita Ramdharry, BSc(Hons) PG Cert, MSc, PhD

Associate Professor
Faculty of Health, Social Care and Education
Kingston University & St George’s University of London
London, UK
Consultant Allied Health Professional
Queen Square Centre for Neuromuscular Diseases
The National Hospital for Neurology and Neurosurgery
University College London NHS Foundation Trust
London, UK

Geert Verheyden, PhD

Associate Professor
Department of Rehabilitation Sciences
KU Leuven - University of Leuven
Leuven, BEL
© 2018 Elsevier Limited. All rights reserved.

First edition 1998

Second edition 2004
Third edition 2011
Fourth edition 2018

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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
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Printed in Poland
 CONTENTS
Preface, vii 13 Motor Neurone Disease, 285
Acknowledgements, ix Vanina Dal Bello-Haas, (Elizabeth) Caroline Brown
Contributors, xi 14 Polyneuropathies, 309
Gita Ramdharry, Aisling Carr, Matilde Laurá
15 Muscle Disorders, 331
SECTION 1 Background Knowledge Ros Quinlivan, Aleksandra Pietrusz
16 Functional Motor Disorders, 355
Guiding Principles in Neurological
1 
Glenn Nielsen, Kate Holt
Rehabilitation, 3
Sheila Lennon, Clare Bassile
Common Impairments and the Impact on
2 
Activity, 21 SECTION 3 S
 pecific Aspects of
James McLoughlin Management
Observation and Analysis of Movement, 37
3 
17 Self-Management, 379
Elizabeth Cassidy, Amanda Wallace, Lisa Bunn
Fiona Jones, Stefan Tino Kulnik
Measurement Tools, 77
4 
18 Virtual Rehabilitation: Virtual Reality
Geert Verheyden, Sarah F. Tyson
and Interactive Gaming Technologies in
Goal Setting in Rehabilitation, 91
5 
Neurorehabilitation, 397
William Mark Magnus Levack
Belinda Lange, José Eduardo Pompeu
Respiratory Management, 111
6 
19 Falls and Their Management, 411
Adrian Capp, Louise Platt
Dorit Kunkel, Emma Stack
20 Physical Activity and Exercise in Neurological
Rehabilitation, 433
SECTION 2 M
 anagement of Specific Helen Dawes
Conditions 21 Vestibular Rehabilitation, 445
Dara Meldrum, Rory McConn-Walsh
Stroke, 131
7 
22 Pain Management, 473
Janne M. Veerbeek, Geert Verheyden
Mark I. Johnson, Chih-Chung Chen
Traumatic Brain Injury, 153
8 
23 Clinical Neuropsychology in Rehabilitation, 499
Gavin Williams
F. Colin Wilson
Spinal Cord Injury, 171
9 
24 Complex Case Management, 513
Sue Paddison, Benita Hexter
Liesbet De Baets, Stephen Ashford, Hannes Devos,
10 Multiple Sclerosis, 205
Abiodun E. Akinwuntan
Jennifer A. Freeman, Hilary Gunn
11 Parkinson’s, 227
Bhanu Ramaswamy, Mariella Graziano Appendix: Answers to Self-Assessment Questions, 539
12 Inherited Neurological Conditions, 253 Abbreviations, 555
Monica Busse, Lori Quinn, Noit Inbar, Jonathan Marsden Index, 559

v
This page intentionally left blank

     
 P R E FAC E

We are delighted, as the new editorial team, to pres- impairments, movement analysis, goal setting, standardised
ent the 4th edition of this popular textbook on Physical measurement tools, inherited neurological disorders, func-
Management for Neurological Conditions. This new edi- tional motor disorders, virtual reality and interactive gaming
tion has been fully revised by internationally renowned technologies, and complex case management.
clinicians and researchers to appeal to all members of the Each chapter contains self-assessment questions and
healthcare team, with a special focus on physiotherapy. answers to enable the reader to test his or her understand-
We have also concurrently edited the second edition of the ing. We hope this new edition provides clinically relevant
Neurological Physiotherapy Pocketbook, which comple- theories and tools backed up by the current evidence base
ments this book. to help clinicians deliver high quality, evidence-based care
This book is organised in three sections starting with to people with neurological conditions.
background knowledge presenting an overview of guiding Sheila Lennon,
principles underlying neurological rehabilitation, followed Adelaide, Australia
by chapters on common and complex neurological condi- Gita Ramdharry,
tions, then concluding with specific aspects of management London, United Kingdom
such as self-management and pain management. There are Geert Verheyden,
many new authors and eight new chapters on common Leuven, Belgium

vii
This page intentionally left blank

     
 AC K N OW L E D G E M E N T S

We the editors have all worked at some point in the United on track in such a supportive way, with special thanks to
Kingdom, and we have shared ideas at many international our content editor Veronika Watkins.
conferences. It truly has been such an easy and collegiate We are indebted to all our authors for generously
experience to collaborate as editors on this book, despite our sharing their knowledge and expertise. Last but not least,
now far-spread locations and different time zones! Fitting thanks to the patients who have informed our own prac-
it into our busy clinical, academic, research and adminis- tice and have also been willing to share their stories in the
trative workloads has been rather more challenging! chapter case studies.
We would like to express our appreciation to Professor Sheila Lennon
Maria Stokes, the lead editor of all previous editions, for Adelaide, Australia
convincing us (Maria is a very persuasive woman) to take Gita Ramdharry
over the 4th edition of this well-known textbook. London, United Kingdom
Thanks to all the students, clinicians and academic col- Geert Verheyden
leagues, who have provided invaluable feedback on this Leuven, Belgium
new edition. We thank the team at Elsevier for keeping us

ix
This page intentionally left blank

     
 CONTRIBUTORS
Abiodun E. Akinwuntan, PT, PhD, Lisa Bunn, BSc (Hons), PhD Chih-Chung Chen, PhD, MPhil,
MPH, MBA Programme Lead MClinRes BSc (Hons)
Dean and Professor University of Plymouth Assistant Professor
School of Health Professions Devon Department of Physical Therapy
University of Kansas Medical Center UK Chang Gung University
Kansas City, KS Taoyuan, 333
USA Monica Busse, BSc, BSc(Hons), TW
MSc, PhD
Assistant Research Fellow
Stephen Ashford, PhD, MSc, BSc, Professor
Department of Physical Medicine and
PGC Education, PGC Prescribing, Centre for Trials Research
Rehabilitation
MCSP Cardiff University
Chang Gung Memorial Hospital,
Clinical Lecturer and Consultant Cardiff
Taoyuan, 333
Physiotherapist UK
TW
Regional Hyper-acute Rehabilitation
Unit Adrian Capp, BHSc Physiotherapy,
Vanina Dal Bello-Haas, PT, PhD
London North West Healthcare MSc Adult Critical Care
Assistant Dean (Physiotherapy),
University NHS Trust Head of Therapy
Associate Professor
London Therapy & Rehabilitation Services
School of Rehabilitation Sciences
UK The National Hospital for Neurology
McMaster University
and Neurosurgery
Clinical Lecturer Hamilton, L8S 4C7
University College London NHS
Department of Palliative Care, Policy CAN
Foundation Trust
and Rehabilitation
London
King’s College London Professor Helen Dawes
UK
London Director Centre for Movement,
UK Occupational and Rehabilitation
Aisling Carr, MRCP Neurol. PhD
Sciences
Consultant Neurologist
Clare Bassile, PT, EdD Department of Sport. Health Sciences
Queen Square Centre for
Assistant Professor and Social Work
Neuromuscular Diseases
Program in Physical Therapy Faculty of Health and Life Sciences
The National Hospital for Neurology
Columbia University Medical Center Oxford Brookes University
and Neurosurgery
New York, NY Oxford
University College London NHS
USA UK
Foundation Trust
London
(Elizabeth) Caroline Brown, MSc Liesbet De Baets, PT, PhD
UK
Management in Health & Social Doctor-assistant
Care, BSc(Hons) Physiotherapy Hasselt University
Elizabeth Cassidy, MSc, PhD
Principal Physiotherapist in Department Rehabilitation Sciences
Freelance Academic and Research
Emergency, General & Respiratory and Physiotherapy
Consultant
Medicine Diepenbeek
Graz
Therapies Directorate BEL
AT
Trent Building
Stoke on Trent
Staffordshire, ST4 6QG
UK

xi
xii CONTRIBUTORS

Hannes Devos, PT, PhD, DRS, PhD Kate Holt (Ms), BSc (Physiotherapy) Matilde Laurá, MD, PhD
Assistant Professor Clinical and Research Physiotherapist Consultant Neurologist
Department of Physical Therapy and Neurosciences Research Centre Queen Square Centre for
Rehabilitation Science Molecular & Clinical Sciences Research Neuromuscular Diseases
University of Kansas Medical Center Institute The National Hospital for Neurology
Kansas City, KS St George’s University of London and Neurosurgery
USA Cranmer Terrace University College London NHS
London, SW17 0RE Foundation Trust
Jennifer A. Freeman, BAppSci UK London
(Physiotherapy), PhD UK
Professor in Physiotherapy and Noit Inbar, MABPT, MA
Rehabilitation Gerontology Sheila Lennon, PhD, MSc, BSc, FCSP
Faculty of Health and Human Sciences Movement Disorders Unit Professor of Physiotherapy
School of Health Professions Tel Aviv Sourasky Medical Center, College of Nursing and Health Sciences
Plymouth University Tel Aviv Flinders University of South Australia
Plymouth ISR Adelaide
UK AUS
Fiona Jones, PhD, MSc
Mariella Graziano, BSc (Hons) Professor of Rehabilitation Research William Mark Magnus Levack,
Neuro Physiotherapy Practice Faculty of Health, Social Care and PhD, MHealSc(Rehabilitation),
Esch-sur-Alzette Education BPhty
LUX Kingston University & St George’s Associate Professor
University of London Rehabilitation Teaching & Research
Hilary Gunn, PhD, MSc, Grad Dip London Unit, Department of Medicine
Phys UK University of Otago
Lecturer in Physiotherapy Wellington
Faculty of Health and Human Sciences Stefan Tino Kulnik, PhD, MRes, PT NZ
School of Health Professions Postdoctoral Researcher
Plymouth University Faculty of Health, Social Care and Mark I. Johnson, PhD, BSc
Plymouth Education Professor
UK Kingston University and St George’s Centre for Pain Research, School of
University of London Clinical and Applied Sciences
Benita Hexter, BSc(Hons) London Leeds Beckett University
Clinical Specialist and Lead UK Leeds
Physiotherapist UK
London Spinal Cord Injury Centre Dorit Kunkel, PhD
The Royal National Orthopaedic Faculty of Health Sciences Jonathan Marsden, BSc, MSc, PhD
Hospital NHS Trust University of Southampton Professor
Stanmore Southampton School of Health Professions Faculty of
UK UK Health and Human Sciences
University of Plymouth
Honorary Clinical Teaching Fellow
Belinda Lange, BSc, BPhysio(Hons), Plymouth
University College
PhD UK
London
Associate Professor, Head of
UK
Physiotherapy Professor Rory McConn Walsh,
College of Nursing and Health Sciences MA, MD, FRCS(ORL)
Flinders University of South Australia Consultant Otolaryngologist
Adelaide Beaumont Hospital
AUS Dublin
IRL
 CONTRIBUTORS xiii

James McLoughlin, BAppSc, MSc, Aleksandra Pietrusz, BSc(Hons) Bhanu Ramaswamy, OBE, FCSP,
PhD Physiotherapy, MCSP DProf, MSc, Grad Dip Physiotherapy
Associate Professor Specialist Neuromuscular Physiotherapist Faculty of Health and Wellbeing
Clinical Rehabilitation Queen Square Centre for Sheffield Hallam University
College of Nursing and Health Sciences Neuromuscular Diseases Sheffield
Flinders University of South Australia The National Hospital for Neurology UK
Adelaide and Neurosurgery
AUS University College London NHS Gita Ramdharry, BSc(Hons) PG
Foundation Trust Cert, MSc, PhD
Director Advanced Neuro Rehab
London Associate Professor
Payneham
UK Faculty of Health, Social Care and
Adelaide
Education
AUS
Louise Platt, MSc in Advanced Kingston University & St George’s
Neurophysiotherapy, BSc (Hons) University of London
Dara Meldrum, BSc, MSc, PhD
Physiotherapy, BA (Hons) Business London
Research Fellow
Studies UK
Academic Unit of Neurology
Therapy Team Lead in Neurosurgery
School of Medicine Consultant Allied Health Professional
Therapy and Rehabilitation Services
Trinity College Dublin Queen Square Centre for
The National Hospital for Neurology
IRL Neuromuscular Diseases
and Neurosurgery
The National Hospital for Neurology
Physiotherapist University College London NHS
and Neurosurgery
The Balance Centre Foundation Trust
University College London NHS
Dublin London
Foundation Trust
IRL UK
London
UK
Glenn Nielsen, BSc (Physiotherapy) José Eduardo Pompeu, PT, PhD
Hons, PhD Neuroscience and Behavior
Emma Stack, GradDipPhys, MSc,
Senior Lecturer in Neurological Professor
PhD
Physiotherapy Department of Physical Therapy
Faculty of Health Sciences
Neurosciences Research Centre Speech and Occupational Therapy
University of Southampton
Molecular & Clinical Sciences Research School of Medicine
Southampton
Institute University of Sao Paulo
UK
St George’s University of London BR
Cranmer Terrace
Sarah F. Tyson, PhD, MSc, FCSP
London, SW17 0RE Ros Quinlivan, BSc (Hons), MBBS,
Professor of Rehabilitation
UK DCH, FRCPCH, FRCP, MD
Stroke Research Group
Consultant in Neuromuscular Disease
School of Health Sciences
Sue Paddison, Grad Dip Phys Queen Square Centre for
University of Manchester
Clinical Specialist Lead Physiotherapist Neuromuscular Diseases
Manchester
London Spinal Cord Injury Centre The National Hospital for Neurology
UK
Royal National Orthopaedic Hospital and Neurosurgery
Trust University College London NHS
Janne M. Veerbeek, PhD
Stanmore Foundation Trust
Post Doc, Physical Therapist
Middlesex London
Department of Neurology
UK UK
University of Zurich/University
Honorary Clinical Teaching Fellow Hospital Zurich
Lori Quinn, EdD, PT
University College London Zurich
Associate Professor
University College London Hospitals CH
Department of Biobehavioral Sciences
NHS Foundation Trust Teachers College, Columbia University
UK New York, NY
USA
xiv CONTRIBUTORS

Geert Verheyden, PhD Gavin Williams, PhD, Grad Dip, F. Colin Wilson, BSc, MMedSc,
Associate Professor BAppSci, FACP DClinPsych, AFBPsS
Department of Rehabilitation Sciences Associate Professor of Physiotherapy Consultant Clinical Neuropsychologist
KU Leuven - University of Leuven Research Regional Acquired Brain Injury Unit
Leuven Department of Physiotherapy Belfast
BEL Epworth Healthcare UK
Melbourne
Amanda Wallace, PhD, BSc(Hons) AUS
Senior Lecturer
Department of Physiotherapy
Physiotherapy
The University of Melbourne
Brunel University
Melbourne
London
AUS
UK
 SECTION 1
Background Knowledge

1
This page intentionally left blank

     
 1
Guiding Principles in
Neurological Rehabilitation
Sheila Lennon, Clare Bassile

OUTLINE
Introduction, 3 Principle 6: Motor Control: A Systems Model, 11
Why is a Conceptual Framework Important?, 4 Principle 7: Functional Movement Re-Education, 11
Guiding Principles for Neurological Rehabilitation, 5 Principle 8: Skill Acquisition, 12
Principle 1: The ICF, 5 Task Practice Issues, 12
The Value of Participation, 6 Role of Feedback, 14
Principle 2: Team Work, 7 Amount of Practice, 14
Principle 3: Person-Centred Care, 7 The Optimal Theory of Motor Learning, 14
Principle 4: Prediction, 9 Principle 9: Self-Management (Self-Efficacy), 15
Principle 5: Neural Plasticity, 10 Principle 10: Health Promotion, 15
What Type of Training Drives Neural Plasticity and Conclusion, 16
Recovery of Function?, 10

rehabilitation team together with the patient and his or her

INTRODUCTION
family collaboratively agree on joint treatment goals before
Neurological rehabilitation has been defined as a process devising a treatment plan.
that assists individuals who experience disability to achieve Developing a treatment plan is not easy; therapy is a
and maintain optimal function and health in interaction complex intervention composed of multiple components
with their environment (World Health Organization which are combined to tailor the intervention to each
[WHO] 2011, 2017). Rehabilitation is a complex process patient’s needs and preferences. A structured treatment
that combines the knowledge, skills, education and advice plan is essential to provide appropriate interventions,
needed to support patients and their families to cope with which should be based on the best available evidence.
a different life after neurological injury and disease (Barnes Standardised measures with published reliability, validity
2003). It requires an active partnership between the and sensitivity should be used to establish a baseline of
patient, their family and a whole range of health and social performance before rehabilitation and then at key strate-
care professionals. This book provides an explanation of gic points to document change as a result of rehabilitation
the theories, tools and techniques that underpin the physi- interventions (see Chapter 4 on measurement tools for fur-
cal management of people with neurological conditions in ther information). The assessment, interventions and mea-
rehabilitation practice. surement tools specific to each neurological condition are
Health professionals use a clinical reasoning approach discussed in subsequent separate chapters.
to plan physical management across any neurological con- Theory is important to inform the development of com-
dition. Fig. 1.1 summarises the key steps in the clinical plex interventions to change health behaviours in patients
reasoning process. Assessment is always the starting point with chronic, long-term conditions (French et al 2012,
for clinical reasoning. This assessment process is used to Michie et al 2005, Michie et al 2009); however, understand-
guide intervention by identifying clinical problems. The ing the theoretical beliefs and assumptions that influence

3
4 SECTION 1 Background Knowledge

Assessment (collect information)

• Subjective
review chart, liaise with the rehabilitation team, interview the patient and family
• Objective
identify impairments, functional restrictions, and participation limitations
• Use standardised outcome measures

Interpretation (hypothesis formation)

• Establish a problem list
• Agree goals with patient and family
• Develop a treatment plan

Implement the plan

• Reeducation of movement and function
• Introduce self-management
• Consider maintenance, prevention & health promotion

Evaluate, Reassessment, Review

• Measure outcome and progress towards goals
• Consider modification to the plan, transfer of care, or discharge
• Plan next review

FIG. 1.1 Clinical Reasoning in Neurological Rehabilitation. (Garner & Lennon, 2018, with
permission)

practice is also important, because these beliefs determine explanation for the actions and decisions of the health-
how interventions will be delivered (Lennon et al 2006). care team (Shephard 1991). It is critical to state explicitly
Since the late 1980’s there has been an explosion of the theoretical assumptions underlying our interventions,
knowledge in neurological rehabilitation providing sound because this enables hypotheses to be formulated and
evidence upon which to base healthcare interventions, yet tested. Understanding the theoretical framework to which
to date incorporating evidence into practice has remained therapists subscribe can also lead to the development of
challenging. The beliefs and attitudes of both patients new treatment strategies (Carr & Shepherd 2006). The
and health professionals may actually impose barriers to beliefs of health professionals influence how they deliver
implementing evidence-based interventions in practice intervention, as well as the techniques they select in their
(McCluskey & Middleton 2010). This chapter will explain intervention plans (Lennon 2003, Lennon et al 2006).
why theory and evidence-based practice (EBP) are import- Physical management in neurological conditions needs
ant, and discuss the key neurophysiological, kinesiological, to be based on beliefs that are substantiated by evidence,
motor learning and behavioural principles that guide neu- bearing in mind that the theoretical explanation under-
rological rehabilitation within a conceptual framework. lying intervention may have to change as the evidence
evolves. Historically, specific treatment approaches such as
WHY IS A CONCEPTUAL FRAMEWORK the Bobath concept have influenced the content, structure
and aims of physical therapies based on therapist preference.
IMPORTANT? Although such approaches remain popular today, to date
Health professionals need to subscribe to a conceptual there is no evidence to suggest that adopting a treatment
framework for intervention, because theory provides the approach such as the Bobath concept is more effective than
 CHAPTER 1 Guiding Principles in Neurological Rehabilitation 5

other approaches (Kollen et al 2009). An updated Cochrane KEY POINTS

review by Pollock et al (2014) has reiterated that physical
rehabilitation should not be limited to named approaches, • Understanding the beliefs that guide practice helps
but rather should be composed of evidenced-based physical explain the content, structure and delivery of therapy.
techniques, regardless of historical or philosophical origin. • A conceptual framework is essential to enable clini-
The evidence base underlying physical interventions is cians to determine their assessment and intervention
expanding year upon year. The challenge for clinicians is to strategies.
keep up to date with that evidence, to transfer/implement • Components selected within rehabilitation sessions
that evidence into practice, but also to be prepared to change should be evidence based rather than based on ther-
their preferred practice, when the evidence clearly identifies apist preference for a specific treatment approach.
that their preferred intervention is not effective or that a • Evidence needs to be individualised through shared
different intervention would be more appropriate. There decision making within the context of the clinician–
are many examples of specific training strategies, such as patient relationship.
strength training or task-specific practice, which are effective
at improving movement and function (Verbeek et al 2014;
French et al 2016; see http://www.cochrane.org for relevant GUIDING PRINCIPLES FOR NEUROLOGICAL
systematic reviews). There are also many clinical guide-
REHABILITATION
lines that provide a comprehensive review of all the avail-
able evidence to date for the management of people after Neurological rehabilitation requires that health profes-
stroke (National Clinical Guidelines for Stroke 2016, Stroke sionals keep up to date with evidence across many practice
Foundation 2017, Winstein & Stein 2016), with Parkinson’s fields. A conceptual framework is essential to enable clini-
(Keus et al 2014) and with multiple sclerosis (MS; National cians to determine their assessment and intervention strat-
Institute for Health and Care Excellence 2014, Haselkorn egies. This conceptual framework should be independent
et al 2015). These guidelines, developed by a multidisci- of treatment approaches, integrating neurophysiological,
plinary panel and subjected to peer review, provide a useful kinesiological, motor learning and behavioural perspec-
starting point for busy clinicians, when available. tives to focus on both physical and psychological recovery.
Components selected within therapy sessions should We propose 10 key principles for consideration in the con-
be evidence based rather than based on therapist prefer- ceptual framework to guide clinicians working in neuro-
ence for a specific treatment approach. However, it is also logical rehabilitation: the WHO International Classification
important to realise that there are still many key areas of of Functioning, Disability and Health (ICF), team work,
clinical practice with no evidence or conflicting evidence; patient-centred care, prediction, neural plasticity, a sys-
therefore therapists will always need to rely on their clinical tems model of motor control, functional movement reed-
reasoning skills to select treatment techniques appropriate ucation, skill acquisition, self-management (self-efficacy)
to the needs, wishes and goals of patients and their carers. and health promotion (Fig. 1.2).
This meets the requirements of EBP, which is defined as
the integration of best evidence with clinical expertise and Principle 1: The ICF
patient values (Sackett et al 1996). In 2001 the WHO developed the ICF (http://www.who.in-
Since the turn of the 21st century, EBP has attempted t/classifications/icf) with the aim of shifting the focus from
to replace tradition and anecdote with high-quality ran- disability and impairments to health (Fig. 1.3). The ICF has
domised controlled trials to guide neurological reha- become accepted as a universal framework for describing
bilitation; getting this research adopted in practice has neurological disability, composed of five categories: body
proved problematic, possibly because the emphasis on functions and structures, activities, participation, envi-
integrating clinical expertise with the needs and wishes of ronmental factors and personal factors. The ICF provides
patients and their families has been devalued (Greenhalgh a systematic way of understanding the problems faced by
et al 2014). Complex patients do not easily map to a sin- patients, illustrating the multiple levels at which neurolog-
gle evidence-based guideline (Greenhalgh et al 2014). The ical rehabilitation may act. The activities dimension covers
founders of EBP are demanding a return to real EBP, which the range of activities performed by an individual. The par-
respects professional knowledge and applies appropriate ticipation dimension classifies the areas of life in which for
research evidence to inform dialogue with our patients and each individual there are societal opportunities or barriers.
families about what best to do and why at each point in the Impairment is defined as a deficit in body structure or
patient’s illness in a more personalised way with sensitivity function. Following a stroke, an example of impairment
to context and individual goals (Greenhalgh et al 2014). would be weakness, leading to a limitation in the activity
6 SECTION 1 Background Knowledge

ICF Patient-centred Team work

Prediction
(participation) care (goal setting)

Health promotion Neurorehabilitation Neural

(prevention) conceptual plasticity
framework

Skill Functional
Self-management Motor control
acquisition movement
(self-efficacy) (systems model)
(motor learning) reeducation

FIG. 1.2 A conceptual framework for neurological rehabilitation.

Health
condition

Body functions
Activities Participation
and structures

Environmental Personal
factors factors
FIG. 1.3 Interactions Between the Components of International Classification of Functioning,
Disability and Health. (WHO 2001, p. 18)

of walking and thus requiring the use of a wheelchair for goal setting, as well as selecting appropriate interventions
mobility. Being in a wheelchair may restrict that individual and outcome tools. However, further research is required
from resuming his or her job, a limitation in participating to determine the benefits of using the ICF within clinical
in that individual’s previous role in society. Environmental practice.
and personal factors are the contextual factors that enable
the rehabilitation team to identify facilitators and barriers The Value of Participation
for the neurorehabilitation process such as having a house Changes at the level of impairment and activity are only
that is wheelchair accessible without stairs. really meaningful for the patient and the family carer if they
Within the ICF framework, physical interventions may enable them to participate in their family and community
directly target both impairment (a loss or abnormality of life by resuming albeit in a different way their desired life
body structure) and activity (performance in functional roles. That is why health professionals need to measure
activities) with the overall aim of improving quality of life the effects of their interventions at different levels of the
and participation in desired life roles. Lexell and Brogardh ICF; they should use standardised measures that have been
(2015) have reviewed how the ICF can be used to enhance shown to have meaningful clinically important differences
the clinical reasoning process by facilitating assessment and (see Chapter 4 on measurement tools).
 CHAPTER 1 Guiding Principles in Neurological Rehabilitation 7

The concept of person-centred care is fundamental to not just to share information, but rather to collaborate as
ensuring that patient and family preferences and priorities a team in goal setting, care planning and decision making.
are central to the clinical reasoning process of team mem- The evidence on which the model of team working works
bers. Although it is important to identify the main clinical best is unclear (Clarke & Forster 2015). The Stroke Unit
problems that can be modified by our intervention, assess- Trialists’ Collaboration (2013) has identified that patients
ment should also identify strengths, interests and desires who receive organised stroke unit care provided in hospital
that are specific to the achievement of a patient’s goals. by nurses, doctors and therapists who specialise in look-
Goal setting also needs to be adapted to different stages ing after stroke patients and work as a coordinated team
in the rehabilitation process (see Chapter 5 on goal set- are more likely to survive their stroke, return home and
ting). For example, more consideration needs to be given become independent in looking after themselves. Thus it
to community-based training in context to enable people would appear that team working is an essential factor in
with neurological disability to gain confidence and skills improving patient outcomes.
in their own environments. Innovative strategies such as Developing an appropriate plan of care revolves around
wearable and assistive technologies may also help to trans- collaborative goal setting within the team. Team goal set-
late gains in rehabilitation departments to the home and ting is recognised as a core component of neurorehabili-
community environment (Kimberley et al 2017). The tation. Setting goals aims to motivate the team and the
influence of assistive technology in neurorehabilitation is patient, coordinate activities, and ensure that all import-
discussed in Chapter 18. ant goals are identified (Wade 2009) (see Chapter 5 for a
An optimal treatment plan will use a range of outcome review of goal setting). Team goals need to be based on the
tools that will evaluate whether improvements in impair- patient’s wishes, expectations, priorities and values; one
ments and function (activity) translate into improved way of facilitating appropriate goal planning is to use the
participation such as quality of life and improved health SMART acronym, which recommends that goals should
status. It is not sufficient to choose measures that mainly be specific, measurable, achievable/ambitious, relevant and
measure impairment or function (see Chapter 4 and timed (Playford et al 2009; see Bovend’Eerdt et al 2009 for
the pathology-specific chapters for selected outcome some practical guidance on how to set SMART goals).
measures). Clarke and Forster (2015) offer the following recom-
The wider context of society also plays a major role. mendations for improving team working in stroke survi-
The government and society have a responsibility to vors during the rehabilitation phase:
develop policies, systems and services to ensure inclusion • Have written protocols and pathways which help
and access to health services, education, work and leisure remove organisational and professional barriers.
opportunities for people with neurological disability in • Have specialist training and knowledge.
the global health agenda (Tomlinson et al 2009). A WHO • Agree on a consistent approach for clinical problems.
(2017) report entitled ‘Rehabilitation 2030: A Call for • Share treatment sessions.
Action’ has called for global action by all key stakeholders • Understand the thinking and beliefs of different
to upscale rehabilitation services worldwide. Clinicians are disciplines.
mostly concerned about the impact of their interventions • Have an information provision strategy with consis-
at an individual level, but they also need to consider how tent messages and access to further information when
they can influence and improve practice at the policy and required.
service delivery. These recommendations may also benefit people with other
long-term neurological conditions (e.g. MS, Parkinson’s).
Principle 2: Team Work After the initial rehabilitation phase, patients will continue
Neurological rehabilitation requires an active partner- to need long-term follow-up, with collaboration between
ship between the patient, the family and a whole range of different disciplines remaining important; supported
healthcare and social care professionals; thus team work is self-management may be a more appropriate mode of care
a critical element of care. The current evidence base distin- at this later review stage of care.
guishes teams who are multidisciplinary versus interdisci-
plinary in their way of working. Teams have been defined Principle 3: Person-Centred Care
as multidisciplinary where there is sharing of information Person-centred care can be defined as a philosophy of care
on assessments and interventions, whereas team members that encourages and supports patients and their carers to
have been defined as interdisciplinary where there is a high develop the knowledge, skills and confidence they need to
level of communication, mutual goal planning and evalu- effectively manage and make decisions about health (Health
ation. It should be emphasised that it is really important Foundation 2014). Person-centred care can be viewed as a
8 SECTION 1 Background Knowledge

partnership from the perspective of the patient, the family THE PICKER PRINCIPLES OF PATIENT-
and the healthcare professional. Whalley Hammell (2009)
CENTRED CARE (http://www.picker.org)
has identified the characteristics of person-centred practice
(see Characteristics of Person-Centred Practice box). 1. Fast access to reliable healthcare evidence
2. Effective treatment by trusted professionals
3. Continuity of care and smooth transitions
CHARACTERISTICS OF PERSON-CENTRED 4. Involvement of and support for family and carers
PRACTICE (Whalley Hammell 2009, with 5. Clear and comprehensive information, and support
permission) for self-care
6. Involvement and shared decision making with
• Respect for clients’ values, priorities and perspec-
respect for patient preferences
tives
7. Emotional support, empathy and respect
• Respect for clients’ autonomy and rights to choose
8. Attention to both physical and environmental needs
and enact choices
Growing evidence links patient experience to health
• Seeks to realign and equalise power between thera-
outcomes, adherence to recommended clinical prac-
pist and client
tice, as well as safety (Doyle et al 2013). Parish et al
• Provides client-orientated information to enable
(2015) offer the following suggestions for getting per-
informed choices
son-centred care into practice:
• Enables clients to identify their priorities, needs and
• ensure that services are well coordinated;
goals
• support and empower people to take charge of their
• Facilitates client participation in the rehabilitation pro-
health;
cess
• adopt a coproduction approach to health care; and
• Strives for collaboration and partnership in achieving
• produce a cultural change within policy and practice.
clients’ goals
• Individualises service delivery
• Assesses the achievement of outcomes that matter
Emphasis on involving family members, and their pref-
to the client
erences and needs, in the rehabilitation planning process
• Focuses on ensuring that service provision is useful
is important, especially when the family carers may be the
and relevant
only ones providing ongoing support for patients after they
leave the health service (Tang Yan et al 2014). Caring for
people with neurological conditions can be very challeng-
Person-centred care is not just about working in part- ing; the healthcare team needs to also focus on the health
nership and sharing decision making with individual and well-being of the carer to reduce caregiver burden and
patients and their families within the rehabilitation pro- burnout (Krishnan et al 2017). Key strategies to help relieve
cess, it also means using that patient and carer experi- caregiver stress and burden are (Krishnan et al 2017): edu-
ence to plan, deliver and evaluate health care to improve cation, effective communication, maintaining physical
care; this is often referred to in the literature as co- and psychological well-being and building a local support
production (Batalden et al 2015). Thus active involve- system. Getting involved with voluntary organisations and
ment should be encouraged at all levels and at all stages peer and caregiver support groups can also reduce feelings
of the rehabilitation process including research and of isolation and provide additional support.
service development and design. The Picker Institute, Heath professionals are encouraged to listen to the per-
which focuses on using patient experience to improve spectives of both patients and carers. The personal expe-
health and social care, has identified eight principles rience of Fuller (2016), who cared for her husband for 21
of person-centred care (see The Picker Principles of years after a devastating stroke at age 50 years, sends some
Patient-Centred Care box). strong messages on understanding the carer experience to
Having a team approach is a key step to promoting per- help the patient live as full a life as possible (Table 1.1):
son-centred care, where the team discusses and explains
treatment options; patients and their carers then use this ‘From day one of Clive’s stroke, my family stepped out of
information to make decisions about their goals and choose a life we once knew and took for granted, and stepped
treatment solutions. The process of goal setting provides a into an alien world; a world which we knew we would
mechanism for patient-centred care by enabling autonomy have to embrace to move forward with our lives. Our
and appropriate pacing of information and responsibility lives, especially mine, revolved around Clive’s therapy
(Playford et al 2009). sessions, as I was very aware how important therapy
 CHAPTER 1 Guiding Principles in Neurological Rehabilitation 9

TABLE 1.1 Key Messages from a Carer on the Rehabilitation Process (adapted from
Fuller 2016 with permission)
Overwhelming disbelief, shock and grief  ive patients time to absorb that they have suffered a
• G
life-threatening illness.
Fear of the unknown, depression • Evoke negative thoughts – is the effort worthwhile?
Take into consideration the extent of the stroke, the • L
 anguage barriers may impede the process of understanding
hidden disabilities: aphasia/dysphasia and dyspraxia a directive thereby sending an erroneous message to the
patient and resulting in misinterpretation by the therapist.
(e.g. the client has plateaued)
Chronic fatigue • Inhibits clients to work at their full capacity
Medication and side effects may play a negative role • Affects comprehension
Changes regarding rehabilitation centres: closures/ • C
 lient having to travel longer distances to access therapy
reallocation causing disorientation – intensifies fatigue and/or anxiety
Limited parking or car parks situated some distance • D
 ifficult for carers and clients who require the use of
from venue. wheelchairs – increases anxiety
Do not discourage, give the client the chance to prove • They all want to improve – they want to be the best they can be
his/herself:
Give encouragement, even if the session is a • S
 ome will do better than others – there may be an underlying
nonevent issue
Listen to the client and/or carer • They may have experienced/witnessed some significant gain
Introduce achievable hobbies • All work and no play is not a good balance
Never, ever rule out HOPE • F
 or some, hope is the only ‘positive’ they can aim towards to
create a change in their life

was in an endeavour to regain any sort of movement; and maintaining the right type of hope may be the first sign
always at the back of my mind was the golden rule: “if that the patient is taking control towards managing his or
you don’t use it you lose it”. The only way I could her own recovery and rehabilitation by identifying his or
give Clive the support he needed, was to step into his her own goals and developing his or her own strategies to
shoes; try to feel what he was feeling and continual- pursue these goals (Soundy et al 2010). This can in fact be
ly ask myself: ‘What would I want if the tables were viewed as self-management, another guiding principle of
turned and it was I who had experienced the stroke?’ rehabilitation that will be discussed later in this chapter.
Research highlights the importance of the patient’s
Fuller, personal communication, with permission and the carer’s voice, and representing their expectations
in clinical decisions (Trede 2012). Dialogue between the
One of Fuller’s key messages is ‘to never rule out hope, patients and their carers can be dominated by professional
as hope is the only “positive” they can aim toward to cre- authority; thus another important aspect of person-centred
ate a change in their life.’ The exploration of hope as a key care is training healthcare professionals to be more person
concept in rehabilitation is relatively new. Hope supports centred. An updated Cochrane Review by Dwamena et al
adjustment, perseverance and positive outcomes; it can (2012) has confirmed that training healthcare professionals
reflect expectations, goals and optimism, as well as act as a to promote person-centred care in clinical consultations is
motivator and source of strength (Bright et al 2011). There successful in improving person-centred skills, with some
can be a tendency among health professionals to empha- evidence that person-centred care has beneficial effects on
sise the importance of being ‘realistic’ in the early stages of patient satisfaction, health behaviour and health status in
recovery or being worried about giving false hope to patients general medical conditions. Person-centred care is a cor-
and their families. However, hope is not just about physical nerstone of the rehabilitation process.
improvement; it can represent the possibility of returning to
activities that are important and meaningful to a patient’s Principle 4: Prediction
past self (Soundy et al 2014). The meaning of hope in neu- Therapists are being asked to make predictions about
rological rehabilitation requires further exploration. Getting patient recovery every day, regardless of practice setting. In
10 SECTION 1 Background Knowledge

KEY POINTS: PERSON CENTRED CARE confirmed that plasticity (defined as enduring changes
in structure and function) does occur after damage to
• Patient and carer involvement are valued by service the nervous system also as a result of experience and
users and improve clinical outcomes. therapy. The brain responds to injury by adaptation
• Active involvement of the patient and carer should aimed at restoring function. Thus cortical maps can be
be encouraged at all levels and at all stages of the modified by a variety of inputs such as sensory inputs,
rehabilitation process including research and service experience, learning and therapy, as well as in response
development. to injury (Nudo et al 2013). Rehabilitation is likely to
• Health professionals need skills and training in be most effective when principles of neuroplasticity
person-centred care. are considered (see Principles of Neuroplasticity for
Clinicians box).

the acute care hospital setting in the USA, the team must
make a discharge recommendation soon after initial assess- PRINCIPLES OF NEUROPLASTICITY
ment of the patient after acute stroke. What forms the basis FOR CLINICIANS (from Hordacre &
of that recommendation? Embedded along with the home McCambridge, 2018 with permission)
situation, previous and current level of functioning is the
therapist’s prediction bias about recovery for the patient • Neuroplasticity is use dependent and specific.
(Bland et al 2015, Magdon-Ismail et al 2016, Mees et al • Repetition and greater intensity induce neural
2016, Stein et al 2015). Will recovery be fast and attainable changes.
in the home or outpatient department setting, or will it be • Neuroplasticity is time sensitive; early intervention
slow and possibly not full so that a subacute setting is more may be better.
appropriate, or will recovery be fast enough to be attained in • Neuroplasticity is influenced by salience, motivation,
a 2- to 3-week stay on an acute inpatient rehabilitation unit? feedback and attention.
We are also asked by our patients: ‘Will I walk again?’ ‘Will I • Neuroplasticity is strongly influenced by features of
be able to use my hand again, move my arm, run again?’ The the environment.
list goes on. Having knowledge of the prediction literature • Enhanced sensory, cognitive, motor and social stimu-
allows the therapist to be realistic with the patient and carer. lation facilitate increased neuroplasticity and learning
Much research has been performed to identify predictors of (Nithianantharajah & Hannan 2006).
recovery for arm and walking function for a variety of neu- • Adjunct therapies prime the motor system to facil-
rological diagnoses (see relevant chapters for predictors spe- itate greater neuroplastic response (Ackerley et al
cific to conditions). For example, as early as 72 hours after 2014, Byblow et al 2012).
stroke slight shoulder abduction and minimal digit exten- • Neuroplasticity is influenced by patient characteris-
sion predicts good arm recovery (Nijland et al 2010). tics such as age, genetics and stress levels.
Ambulation recovery after stroke has also been linked to early • Pharmacology influences neuroplasticity.
static sitting attainment (Verheyden et al 2006). Predictors
for ambulation recovery after Spinal Cord Inju­ry using
American Spinal Cord Injury Association Impair­ment What Type of Training Drives Neural Plasticity and
Scale levels have been documented (Dobkin et al 2007). Recovery of Function?
Prediction is never 100% accurate, and there will always Task-specific training facilitates functional and neural
be those patients who defy the odds. However, having this plasticity (Dimyan & Cohen 2011, Dobkin et al 2004,
knowledge allows us to express optimism to those patients Hubbard et al 2009). When patients practice tasks, their
who exhibit the positive predictors. It also encourages us focus is on achieving success of the task. It is the therapist’s
to intervene to promote the exhibition of these motor expertise that structures the task in such a way as to get the
responses, and thereby enhance recovery. Thus EBP requires movements they wish to encourage and to have the task be
therapists to know and utilise the prediction literature to challenging yet achievable to enhance self-efficacy, but also
influence their assessments and interventions. Prediction of varied enough to encourage generalisation. The practice
outcomes will lead to clearer patient expectations and better of actual tasks enhances positive transfer of training prin-
selection of interventions (Kimberley et al 2017). ciples both on a musculoskeletal level and by repetitively
activating pathways that are engaged in the activity being
Principle 5: Neural Plasticity practiced (Blennerhassett & Dite 2004, Dayan & Cohen
Although there is always a degree of spontaneous recov- 2011, Dean & Shepherd 1997, Dean et al 2000, Dobkin et al
ery after brain damage, advances in neuroimaging have 2004).
 CHAPTER 1 Guiding Principles in Neurological Rehabilitation 11

Aerobic exercise enhances neural plasticity, by the individual, the task and the environment. Although it
increasing blood flow to the brain, facilitating the release is important to understand the role of major circuits and
of neurotrophic factors and improving brain health pathways of the central nervous system, and the effects of
(brain volume). A variety of individuals with neurolog- lesions on these structures and circuits, it is important to
ical diseases have been shown to lack aerobic condition- understand that there are many subsystems and multiple
ing either as a result of their impairments interfering connections within the nervous system that work in hierar-
in physical activity or adoption of a sedentary lifestyle chy and in parallel to generate movement (Shumway Cook
(Brazzelli et al 2012, Dean et al 2000). This puts them at and Woollacott, 2017, pp. 7–18). This means in clinical
risk for further comorbidities, including hypertension, practice, it is essential to work on functional tasks, rather
diabetes mellitus and stroke. Thus aerobic conditioning than mainly focusing on movement patterns to improve
should be part of every patient’s programme for multi- quality of movement.
ple reasons. The actions of a person with damage to the nervous sys-
Actively engaging patients in problem solving when tem are the result of an individual’s best effort at that time
relearning motor tasks also influences neural plasticity. to organise a movement to achieve a successful task (A.M.
Enhancement and diminution of neural activation within Gentile, personal communication). It is a consequence of
the brain is dependent on the stage of skill acquisition the impairments caused by the damage, the compensa-
(Dayan & Cohen 2011). The early stage of learning has tory strategies that enable function to be achieved in the
shown enhanced excitation of multiple regions of the presence of impairments, the effects of the environment
brain, including cerebellum, visual and prefrontal corti- the person has been experiencing since the lesion and the
ces, where the learner is identifying the relevant features person’s confidence in his or her ability to achieve success
of the task to pay attention to and attempting to organise (Shumway-Cook & Woollacott 2017, pp. 7–18). An exam-
a movement pattern that is successful at accomplishing the ple of a compensatory strategy related to a seated reaching
goal. During the later stage of skill acquisition, there is a task in a patient after a stroke might be reaching to an ante-
diminution of activity in the aforementioned areas and an rior target using scapular elevation with shoulder abduc-
enhancement in the motor cortices, where the learner is tion and trunk lateral flexion.
modifying the successful movements to become efficient The key points to remember when designing therapy
and less effortful. programmes are that therapists can reduce impairments
Although evidence to date in humans is limited, animal and compensatory movement strategies by promoting
studies suggest that there may be a critical time period for functional recovery and return to participation. This can
rehabilitation poststroke, with early intervention deter- occur through structuring the environment or the task in
mining greater functional gains (McDonnell et al 2015). a way that enables the patient to elicit or practice both the
Thus it is also important to consider when best to deliver desired movement and the tasks required to achieve his or
rehabilitation to maximise any critical time windows her goals. As previously stated, changes to the task instruc-
to promote neural plasticity and to optimise functional tion and increasing a person’s confidence can also enhance
recovery. goal attainment.

Principle 6: Motor Control: A Systems Model Principle 7: Functional Movement Reeducation

Motor control is an area of science that explores how the Normative data for everyday activities help therapists
nervous system interacts with other body parts and the to understand motor performance and the impact
environment to produce purposeful, coordinated actions of impairments on these everyday activities (Carr &
(Muratori et al 2013); thus it is critical for therapists Shepherd 2006; see Chapter 3 for an overview of how
involved in neurorehabilitation to understand how differ- therapists observe and analyse movement). Therapists
ent systems within the nervous system interact to produce place an emphasis on training control of muscles and pro-
movement and perform tasks. For example, when a patient moting learning of relevant actions and tasks. Therapists
is learning to dress himself, he must use the movement he aim to optimise movement and function; however, with
can reproduce in terms of his available range, strength, the majority of neurological conditions, recovery of nor-
pain level, and so on, as well as his cognitive ability to plan mal movement and function is not achievable for many
the task alongside external factors in the environment, for patients; this depends to some extent on whether the
example bed surface, clothing type and location and envi- patient has a progressive, deteriorating condition or a
ronmental distractors, to perform the functional task. stable condition (Edwards 2002, p. 256).
There are many different models of motor control. A One of the key roles of the therapist working in neu-
dynamic systems model considers that solutions to patient rology is to help the patient experience and relearn opti-
problems change according to the interaction between mal movement and function in everyday life within the
12 SECTION 1 Background Knowledge

the pathology and the prognosis for recovery in collabora-

tion with patients and caregivers to establish desired goals
will help determine which of these aims should be empha-
sised in physical interventions.
Therapists use an array of techniques in their tool kit
Restore Adapt
to reeducate movement. It is always preferable to prioritise
the practice of functional activities selected in collabora-
tion with the patient; however, if the patient has impair-
ments that make it difficult to practice these tasks directly,
Movement
therapists may also need to address impairments or prac-
and
function tice specific movements either before or during a modified
version of functional task practice. For example, a patient
may not have any signs of motor activity in the lower limb
to practice the task of walking. In this case, the patient may
Prevent Maintain require either hands-on assistance from therapists or sup-
port from assistive technologies, e.g. a partial body weight
system to practice the task of walking.

Principle 8: Skill Acquisition

Evidence from motor learning and skill acquisition can
FIG. 1.4 Aims of Neurological Rehabilitation: Re- provide some guiding principles about how to structure
covery, Adaptation, Maintenance and Prevention practice within therapy sessions to improve these aspects of
(RAMP). skilled performance (Muratori et al 2013, Marley et al 2000;
Winstein et al 2014). Motor skill learning can be divided
constraints imposed by the disease process and presenting into three phases: an early cognitive phase, an intermediate
impairments. Therapists are not only interested in which associative phase and an autonomous phase (Fitts & Posner
functional activities patients can or cannot perform, but also 1967, cited in Schmidt & Lee 2005 Ch. 13: The Learning
in how the patient moves (the quality of movement) to exe- Process pp. 357–383). When subjects are in the initial stage
cute these activities. The aims of neurological physiotherapy of learning, individuals should be encouraged to actively
can be summed up using the acronym RAMP − recovery, explore the environment through trial and error. In the
adaptation, maintenance and prevention (Fig. 1.4). later stage of skill acquisition, the focus switches from ‘what
Therapists ideally aim to restore movement and func- to do’ to ‘how to do’ the movement better (Schmidt & Lee
tion in people with neurological pathology, but this may 2005, Ch. 13: The Learning Process pp. 357-383). Some tips
not always be possible. Adaptation (compensation) refers for structuring therapy sessions are outlined in Table 1.2.
to the use of alternative movement strategies to complete
a task, in other words performing an old movement in a Task Practice Issues
new way (Levin et al 2009). Therapists focus on promot- Task-specific or task-oriented practice is an approach to
ing compensatory strategies that are necessary for func- rehabilitation that focuses on performance of functional
tion and discouraging those that may be detrimental to tasks that are meaningful to the individual. For this type of
the patient, e.g. promoting musculoskeletal damage such practice to be successful, a therapist must be able to accu-
as knee hyperextension (Levin et al 2009). Interventions rately assess their patient and identify their limitations and
aimed at recovery of function need to be emphasised over deficits. The therapist then alters the task (e.g. simplifying)
compensation if the patient has the potential to change. or the environment to allow for repetitive successful practice
Maintenance of function is just as important as recovery while achieving the task and reducing the impairment(s).
and should be viewed as a positive achievement; several The task difficulty is progressed as the patient’s success
reviews have now confirmed that functional ability can be increases. Different techniques may work better with differ-
maintained despite deteriorating impairments in progres- ent patients; sometimes it will be necessary to practise the
sive neurological disease (Keus et al 2014). Therapy also components of movement that comprise an activity, such
aims to prevent the development of complications such as as pelvic tilting, before placement in the functional activity.
contracture, swelling and disuse atrophy. There are differ- Sometimes it will work best to break tasks down and repeat-
ent stages in patient management, where these aims may edly practice the different temporal sequences before get-
have differential priorities. Understanding the nature of ting the patient to practice the whole sequence of activity in
 CHAPTER 1 Guiding Principles in Neurological Rehabilitation 13

TABLE 1.2 Key Motor Learning Variables for Neurological Rehabilitation

Issues to Consider (adapted mainly from Muratori et al 2013, Winstein et al 2014,Wulf &
Key Variables Lewthwaite 2016)
Practice •  mount (intensity or dose) (Kwakkel 2006, Lang et al 2015, Hornby et al 2015)
A
• Frequency (number of repetitions)
• Duration (number of minutes per session)
• Variety (alter regulatory features) (Gentile 2000), e.g. transfers from different height chairs and
different surface types
• Practice schedule (e.g. blocked practice, e.g. five reps at each seat height) versus random prac-
tice (e.g. different seat heights each time) (Gilmore & Spaulding 2001, Murtori et al 2013)
• Choosing the practice schedule depends on a number of patient-centred issues such as expe-
rience, age, memory and task. However, there are insufficient data on which sequence works
best for which patient (Muratori et al 2013, Boyd 2001,Wulf & Lewthwaite 2016)
Specificity of • F unctional task practice must be both task and context specific; therefore whenever possible,
training practice the task (Kwakkel et al 2004, Verbeek et al 2014)
• Consider critical requirements for each task (Carr & Shepherd 2003), as well as the impairments
being targeted (Muratori et al 2013, Winstein et al 2014)
Transfer of training • Impairment-focused training such as strength, range, symmetry and postural sway may improve
(generalisability) the parameters being trained, but these changes do not generalise to the activity or participation
level (Kwakkel et al 2004, Muratori et al 2013, Verbeek et al 2014)
• Consider two types of transfer of training (Winstein 1991): (a) part task training: break the task
down into simple steps, then put the steps back together again by practising the whole task;
and (b) adaptive training: simplify the task by controlling a particularly difficult part, e.g. using a
body weight support system that gradually adds the body weight into gait
• Task-related practice: some transferability will occur to a task which incorporates the compo-
nents of transferring the centre of mass from the trunk to the lower extremities (e.g. practice
of reaching greater than arm’s length in sitting transfers to the sit to stand transitional activity)
(Dean & Shepherd 1997, Dean, Richards, Malouin 2000).
Feedback • F requency (How often? All or some of the time?) Do not give feedback on every trial (Muratori
et al 2013, Winstein 1994)
• Timing (when to deliver the information: before, during or after?)
• Delivery mode (visual, verbal, manual)
• Consider using extrinsic feedback or feedback with an external focus (Wulf 2013); e.g. for a sit
to stand task the focus should be on ‘pushing into the floor’, rather than ‘push your feet into the
floor’, or ‘stand tall’ rather than ‘straighten your spine/back’
Modelling • D emonstrate what you want the patient to do
• Consider delivery mode, e.g. live versus videotaped versus written instruction (Reo & Mercer,
2004, Laguna 2000, Williams & Hodges 2004, pp. 145–174)
Mental Practice • D efined as the act of repeating imagined movements several times with the intention of improv-
ing motor performance (Jackson et al 2001); an adjunct to physical practice, it is not better than
physical practice (Braun et al 2006, Nilsen et al 2010; Malouin & Richards 2010)
• Consider when to use it, e.g. when patient needs additional personnel to set up environment for
independent practice, during rest periods or when patient is not safe to practice independently
• Reference point for imaging – ‘seeing’ themselves or ‘feeling’ themselves (Nilsen et al 2010)
14 SECTION 1 Background Knowledge

a functional task, such as getting the legs off the bed before The Optimal Theory of Motor Learning
elevating the trunk in a supine to sit task, or scooting for- Wulf and Lewthwaite (2016), through their ‘Optimal
ward in the chair before attempting to stand up. On other Theory of Motor Learning,’ provide a template by which
occasions, it will work best to practice the functional task in enhanced learning may be achieved. The theory proposes
its entirety, emphasising the critical impairment/movement that optimising the intrinsic motivation of the learner and
component that influences the task. providing verbal cues to enhance the attentional focus of
the learner enhances learning on multiple levels of analysis.
Role of Feedback First, enhance the learner’s expectation. Second, enhance
Feedback can be delivered in many modes (visual, verbal, the learner’s autonomy. Third, provide an external focus
manual) at various times (before, during or after) and in of attention for the learner.
varying quantities from continuous to intermittent fash- To enhance the learner’s expectation and increase his
ion (absolute, relative, bandwidth) (Muratori et al 2013, or her confidence level, the therapist must find ways which
Shumway Cook & Woollacott 2017, pp. 33–37). Certain reinforce the learner’s ability to achieve success. By pro-
types of feedback may be beneficial at different points in viding positive feedback, confidence levels are increased,
skill acquisition. For example, manual guidance should thereby creating the learner’s expectation that he or she
mainly be used at the early cognitive stage of motor learn- will achieve success (self-efficacy). Both achieving success
ing, especially when safety is a concern, to give the patient and the patient’s perception on this success are associ-
the idea of the movement or to control a degree of freedom. ated with dopamine release in the brain (Schultz 2013).
However, during the later associative and autonomous Dopaminergic systems are involved in motor, cognitive
stages of skill acquisition, it is preferable for the learner to and motivational functioning (Nieoullon & Coquerel
actively problem-solve without relying on the therapist for 2003). Ways to enact this in the clinic are:
feedback (Schmidt & Lee 2005, Chapter 13: The Learning 1. Provide feedback after good trials, e.g. ‘That was a good
Process pp. 357–383. Sidaway et al 2008). one’, ‘Do that again.’
2. Reduce perceived task difficulty: Define success liberally
Amount of Practice so the criterion for a successful performance is not too
Prescribing the most appropriate dose of practice for indi- difficult.
vidual patients is a challenge because minimal data are 3. Alleviate the learner’s concerns.
available and a large number of factors are unknown (Lang 4. When using self-modelling, show their best perform­
et al 2015, French 2016). Studies investigating neuroplastic ance.
adaptations poststroke typically require animals to com- The learning literature supports enhancing learner
plete hundreds of repetitions of a task daily or twice daily autonomy. Allowing the patient to have choices, even if
(Birkenmeier et al 2010, Byblow et al 2016). these choices are incidental, has a positive effect on learn-
Amount has been quantified as the number of repetitions ing. Using autonomy-supported language (e.g. ‘I’ve placed
or the number of minutes of active therapy. Current research you in the parallel bars for this balance activity, if you wish
suggests that the amount of practice is critical largely based to use the rail to stabilise yourself after a loss of balance
on the constraint-induced movement therapy (CIMT) you may’ (even though the therapist knows that if a loss
literature. The general consensus is that more is better. of balance occurs, the patient will most likely reach for the
However, some recent studies have indicated that timing rail). ‘Here is your cane, you may place it wherever you
may interact with dose (Bernhardt et al 2015), for exam- wish while we work on this activity’) and linking the envi-
ple more therapy may not be better in the first few hours ronmental effect with the learner’s intention to produce it
and days after stroke and could lead to slower recovery. The has been shown to enhance learning (Sanli et al 2013).
VECTORS study (Dromerick et al 2009) demonstrated that Most of Wulf’s (2013) research on attentional focus
an increased dose of CIMT during acute inpatient rehabil- during learning of motor skills has supported an external
itation was detrimental when compared with a lesser dos- focus of attention to achieve the desired movement result
age or conventional therapy. Lang et al (2016) showed that rather than an internal focus on body movements regard-
gains in upper-limb function did not improve as a function less of the phase of learning that the learner is in. Cues
of dose for task-specific therapy in patients, beginning 6 should be as external from the person as possible (e.g. for
months or more poststroke. Current best practice suggests a golf swing, focus on club tip swing, not the arms/body;
that a minimum of 300–400 repetitions of upper extremity for a sit to stand task the focus should be on ‘pushing into
actions or tasks is required per session to demonstrate gains the floor’, rather than ‘push your feet into the floor’, ‘stand
(Birkenmeier et al 2010, Dean et al 1997) and a minimum tall’ rather than ‘straighten your spine/back’). The move-
of 20 minutes walking practice duration over 12 sessions to ment patterns which emerge from using an external focus
improve gait in stroke survivors (Peurala et al 2014). have been shown to be smoother, more coordinated and
 CHAPTER 1 Guiding Principles in Neurological Rehabilitation 15

TABLE 1.3 Key Components of self-management skills. Tailoring self-management sup-

port requires an appreciation of factors that act as barri-
Self-Management (Based on Chapter 17 by
ers to or enablers of behaviour change. Two systematic
Jones & Kulnik With Permission) reviews have found that self-management programmes
Problem solving • Deciding on the problem improve quality of life and self-efficacy for stroke survi-
by the patient • B reaking it down into small steps vors in the community, but further research is required to
• Thinking of various solutions identify key features of effective programmes (Fryer et al
• Selecting a course of action 2016, Lennon et al 2013).
• Trying out the action or strategy
• Evaluating success Principle 10: Health Promotion
• Choosing an alternative action if Promoting health is of critical importance to the field of
necessary neurological rehabilitation. The WHO (2017) has empha-
Target or goal • T ranslating thoughts into actions sised that accessible and affordable rehabilitation plays a
setting • Providing mastery experiences fundamental role in ensuring healthy lives and promot-
ing well-being for all ages (sustainable development goal).
Resource • A ccessing local self-help group
Promoting health can be considered on three levels: pri-
utilisation • Seeking expert advice
mary, secondary and tertiary prevention. Primary preven-
• Using friends or family for support
tion seeks to prevent the onset of disease through healthy
Collaboration • W orking together with a healthcare living. It is achieved by health education and lifestyle and
professional behavioural changes. Secondary prevention aims to stop
• Sharing expertise or slow disease progression, and prevent complications
through early diagnosis and adequate treatment. Tertiary
prevention is focused on reducing impairments and activ-
success achieved earlier when compared with those using ity restrictions. All members of the rehabilitation team
an internal focus. Wording of instructions for an external have a role to play in enabling people to return towards
focus requires a change from what is most often used by meaningful roles in the wider community with a focus on
therapists and may present a difficult challenge. health and wellness, rather than a focus mainly on ill health
and disability (Cott et al 2007, Dean 2009). Ultimately this
Principle 9: Self-Management (Self-Efficacy) means that rehabilitation involves changing behaviour.
A recent report by National Health Service England (2016) Neurological rehabilitation has to date focused on ter-
defines self-management as ‘any form of formal education tiary prevention, delivering short bursts of physical ther-
or training for people with long-term conditions that focuses apies to restore function after acute events or declines in
on helping people to develop the knowledge, skills and con- function resulting in a loss of the initial gains, resumption
fidence to manage their own health and care effectively.’ In of a sedentary lifestyle and worsening levels of disability
Chapter 17, Jones and Kulnik have outlined the key com- over time (Ellis & Motyl 2013). The goals of physical inter-
ponents involved in effective self-management (Table 1.3). ventions must extend beyond impairments and function
Self-efficacy is a cornerstone of self-management; it is to include health promotion with an emphasis on physical
defined as people’s beliefs about their capabilities to influence activity and exercise. There is growing evidence that reha-
key events that affect their lives (Bandura 1997). People with bilitation can prevent secondary complications if we inter-
a strong sense of efficacy set themselves challenging goals and vene early to delay onset of motor symptoms in progressive
maintain strong commitment to them; they continue to sus- disease (Kimberley et al 2017).
tain their efforts in the face of failure or setbacks (Bandura Physical therapists should encourage fitness through
1997). A review specific to physiotherapy by Barron et al participation in enjoyable activities that follow American
(2007) has shown that self-efficacy can be related to better College of Sports Medicine guidelines (see Chapter 20
health, higher achievement, more social integration and on physical activity for further guidance). Diseases like
higher motivation to act. Growing evidence provides support hypertension and diabetes mellitus may be prevented
for the importance of self-efficacy as a correlate of adherence (1° prevention) or if present may be controlled (2° pre-
to therapy (Rhodes & Fiala 2009); however, evidence is still vention) through regular exercise, thus preventing other
emerging regarding the most effective ways of supporting and diseases (stroke or heart attack). For instance, in the
enabling individuals with neurological problems to manage event of a stroke, the medical team will use 2° prevention
ways of living with their chronic disability (Jones 2006). measures to stop or slow the progression of the stroke
Health professionals need to consider how they (e.g. give tissue plasminogen activator for ischemic
can promote self-efficacy and enhance their patients’ stroke if in time window, remove blood for intracerebral
16 SECTION 1 Background Knowledge

hemorrhage), as well as prevent a recurrence (e.g. lower 5. When do therapists make predictions about functional
blood pressure, correct cardiac arrhythmias). Physical recovery for their patients? How is the prediction liter-
therapists are well equipped to promote health and par- ature useful for clinicians?
ticipation across all levels of prevention through identi- 6. What are the three types of prevention for health promo-
fying, modifying and encouraging appropriate enjoyable tion? Explain how physical therapy can influence both 1°
exercises and physical activities for patients. and 2° prevention of some neurological disorders.

CONCLUSION
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 2
Common Impairments and
the Impact on Activity
James McLoughlin

OUTLINE
Introduction, 21 Disorders of Motor Planning, 28
Weakness, 22 Apraxia, 28
Upper Motor Neurone Weakness, 22 Bradykinesia/Akinesia, 28
Lower Motor Neurone Weakness, 22 Freezing of Gait, 28
Fatigue, 23 Vestibular Disorders, 28
General Fatigue, 23 Peripheral Vestibular Disorders, 28
Motor fatigue, 23 Central Vestibular Disorders, 29
Disorders of Muscle Tone, 23 Visuospatial Disorders, 29
Hypertonus, 23 Hemianopia, 29
Hypotonus, 24 Unilateral Spatial Neglect, 29
Dystonia, 25 Contraversive Pushing, 29
Involuntary Muscle Spasms, 25 Sensory Disorders, 30
Dyskinesias, 25 Sensory Loss, 30
Rigidity, 26 Paraesthesia and Dysaesthesia, 30
Disorders of Coordination, 26 Pain, 30
Cerebellar Ataxia, 26 Secondary Complications, 30
Sensory Ataxia, 26 Contracture, 30
Resting Tremor, 26 Physical Inactivity and Deconditioning, 31
Intention Tremor, 27 Learned Non-Use, 31
Loss of Dexterity, 27 Conclusion, 32

many different ways. Optimal clinical reasoning begins with

INTRODUCTION an ability to identify all relevant neurological impairments.
It is important for any clinician who is working in neuro- The next major challenge facing the neurotherapist is the
logical rehabilitation to be familiar with common neurolog- ability to tease out the many overlapping impairments that
ical impairments. The knowledge and ability to identify and impact on physical performance and function, and select
assess neurological impairments are crucial, in addition to evidence-based rehabilitation strategies based on all of this
a clear understanding of how these impairments impact on information.
movement and activity. Many of the impairments discussed A common example of overlapping impairments is the
in this chapter relate directly to neurological injury or pathol- spectrum of signs that can exist in a stroke survivor present-
ogy, whereas other issues relate to secondary physical, cogni- ing with upper limb hemiparesis. Within the upper motor
tive, and behavioural adaptations. In clinical practice, most neurone (UMN) syndrome, impairments include negative
people with neurological conditions present with a complex features of weakness, slowness and loss of skill, in addition to
mixture of impairments that impact on activity levels in positive features of increased muscle tone and hyperreflexia.

21
22 SECTION 1 Background Knowledge

Both features might be addressed with various interventions, on function and will briefly indicate current directions for
depending on the level of function and individual goals of managing these issues within neurological rehabilitation.
therapy. Often in this situation, rapid secondary changes as
a result of reduced activity will contribute to weakness and WEAKNESS
contracture, which will further impact on the overall impair-
ment of movement. In addition to this, motor fatigue and Upper Motor Neurone Weakness
balance impairments can influence movement adaptations. Weakness in muscle will occur following a lesion to
Coexisting impairments in motor planning, visuospatial descending UMNs. A UMN lesion can occur at any level
awareness and cognition often also impact on movement above the anterior horn of the spinal cord, in either the
behaviour. A skilled neurotherapist will assess the degree of spinal cord itself, brainstem or brain. UMN weakness is
each impairment, consider the overall situation and develop therefore present in many congenital or acquired central
strategies based on the individual’s presentation. nervous system (CNS) neurological conditions, including
This chapter will outline some of the most common stroke, traumatic brain injury (TBI), cerebral palsy (CP),
impairments seen in neurological practice (Table 2.1), will multiple sclerosis (MS) or spinal cord injury (SCI).
highlight clinical presentations, possible causes and impact Without adequate descending control of movement,
UMN lesions can lead to a number of clinical signs often
referred to as the ‘UMN syndrome’, which includes weakness,
TABLE 2.1 Common Neurological fatigability and reduced skill/dexterity of movement (Ivanhoe
Impairments & Reistetter 2004). In addition, there can be an overlay of
Weakness Upper motor neurone weakness additional ‘hyperreflexive’ responses to muscle stretch and
Lower motor neurone weakness cutaneous sensory stimulation such as velocity-dependent
‘hypertonus’ (increases in muscle tone), hyperreflexia, clonus
Fatigue General fatigue
and Babinski sign (exaggerated cutaneomuscular reflexes).
Motor fatigue
Collectively, the increases in muscle tone and hyperreflexive
Disorders of Hypertonus responses are often termed ‘spasticity’ (Stevenson 2010).
muscle tone Hypotonus Although the UMN syndrome can lead to a number of
Involuntary muscle spasms limitations to active movement, it is the underlying UMN
Dystonia weakness that has the most impact on overall performance
Dyskinesias of functional activities such as mobility and upper limb use.
Rigidity Physical therapy therefore aims to improve muscle recruit-
Disorders of Cerebellar ataxia ment and control, then develop strength and endurance in
coordination Sensory ataxia key functional movements. Contemporary practice recog-
Resting tremor nises that, whenever possible, functional strengthening of
Loss of dexterity muscles affected by UMN weakness is an important part of
Disorders of motor Apraxia physical rehabilitation. Previous ideologies concerned about
planning Bradykinesia the influence of effort and exertion increasing unwanted mus-
Akinesia cle tone have now taken a step back because of an increasing
Freezing of gait recognition of the importance in the relationship between
strength and function. However, it is the neurotherapist who
Vestibular Peripheral vestibular disorders identifies the optimal way to both teach movement and design
disorders Central vestibular disorders functional strengthening programmes to maximise the reha-
Disorders of Hemianopia bilitation of motor control (Guadagnoli & Lee 2004).
visuospatial Unilateral spatial neglect
perception Contraversive pushing Lower Motor Neurone Weakness
Disorders of Sensory loss Lesions at the level of the anterior horn in the spinal cord
sensation Paraesthesia/Dysaesthesia or the lower motor neurone (LMN) output below this level
Pain will result in weakness plus may include additional clinical
Secondary Contracture
signs. In addition to weakness the ‘LMN syndrome’ may
complications Physical inactivity and decon-
include signs of ‘hyporeflexia’ with reduced or absent ten-
ditioning
don or cutaneous reflexes, reduced muscle tone and muscle
Learned non-use
fasciculations. These additional signs become important
from a diagnostic point of view.
 CHAPTER 2 Common Impairments and the Impact on Activity 23

LMN weakness can be caused by trauma to the peripheral additional effects of fatigue on cognitive function. This may
nervous system or as a result of congenital or infectious dis- have important implications when considering the import-
ease affecting the LMNs such as peripheral motor neuropathy. ant role of cognition on balance, gait (Morris et al 2016)
Amyotrophic lateral sclerosis, otherwise known as motor neu- and falls risk (Hoang et al 2016). The impact of fatigue can
rone disease or Lou Gehrig’s disease, can result in both UMN also impact on processing speed (Barr et al 2014, Claros-
and LMN signs (Kiernan et al 2011). LMN signs in motor neu- Salinas et al 2013), which may have implications for activi-
rone disease, including progressive weakness, are the result of ties such as employment and safe driving (Yang 2015).
premature death to anterior horn cells in the spinal cord.
The resulting weakness that occurs with the LMN syn- Motor Fatigue
drome has the largest impact on function. Depending on The decremental motor performance observed as weakness
which muscle groups are affected, weakness can lead to dif- with the repetition of physical tasks is often labeled ‘motor
ficulty with mobility, respiratory function, speech or upper fatigue’. Evidence suggests that in CNS disorders such as MS
limb use. Physical therapy aims to limit any decline and and stroke, motor fatigue is caused by both peripheral and
maintain and/or increase muscle strength where possible. central mechanisms (Kuppuswamy et al 2014, Schwid et al
The peripheral nervous system has some ability to repair, 1999). Understanding the physical decline with performance
so many conditions presenting with LMN weakness such has important implications for physical therapy because
as Guillain–Barré syndrome (Willison et al 2016) and it impacts on issues such as gait (McLoughlin et al 2016),
peripheral nerve injury (Li et al 2014) can improve slowly balance, strength (McLoughlin et al 2014) and walking per-
with time and specific physical rehabilitation. Assisting formance (Hutchinson et al 2009). Exercise interventions
longer-term support and control through splinting or an should monitor motor fatigue with performance (Dawes
orthosis can limit instability and enable active movements et al 2014), and therapists should design programmes that
while also preventing secondary complications such as incorporate frequent rests and consider the risk for falls and
musculoskeletal injury, pain and deformity. injury. This may allow for increased participation as fatigue
is often a major barrier in important exercise programmes
FATIGUE that aim to increase activity levels (Smith et al 2015).

General Fatigue DISORDERS OF MUSCLE TONE

Chronic fatigue is common in people with neurologi-
cal disorders. It is one of the most common self-reported Hypertonus
symptoms after stroke (Kuppuswamy et al 2014) and TBI Hypertonus or increased muscle tone associated with the
(Mollayeva et al 2014), and it is often rated as the most UMN syndrome can influence movement in many ways.
disabling symptom by people with MS (Bakshi 2003). The Historically, there has been considerable debate regarding
subjective feelings of general fatigue impact on physical, ‘tone’ and its relevance to therapeutic intervention. Most
cognitive and psychological dimensions of life. For exam- of this debate stems from difficulties and differences in
ple, poststroke fatigue is described as ‘a feeling of early defining ‘hypertonus’ in the context of the entire package
exhaustion with weariness, lack of energy and aversion of impairments associated with the UMN syndrome. In the
to effort that develops during physical or mental activity area of rehabilitation, it is difficult to find definitions that
and is not usually ameliorated by rest, page 75’ (Staub & satisfy both researchers (definitions that can be measured)
Bogousslavsky 2001). Fatigue permeates all facets of life and and clinicians (definitions that describe movement perfor-
can impact heavily on employment and quality of life. It mance). Explaining hypertonus is also difficult because it
is this impact that distinguishes the fatigue experienced in can be observed during both active and passive movements.
healthy people. Over the years there have been varying defi- Unfortunately, ‘spasticity’ and ‘hypertonus’ are often used
nitions for fatigue experienced by people with neurologi- interchangeably, despite some key differences in definition.
cal conditions. Kluger and colleagues (2013) have recently The clinical term ‘spasticity’ has been previously defined
proposed a definition which defines perceived fatigue ‘as as ‘a motor disorder characterised by a velocity-dependent
a subjective sensation of weariness, increasing sense of increase in tonic stretch reflexes (muscle tone) with exag-
effort, mismatch between effort expended and actual per- gerated tendon jerks, resulting from hyper excitability of
formance, or exhaustion, page 411.’ For all conditions, a the stretch reflex, as one component of the upper motor
multidimensional approach to managing fatigue is rec- neurone syndrome, page 485’ (Lance 1980). Spasticity is
ommended. Sleep, pain and depression can have a strong measured in the laboratory by examining the electromyo-
relationship with fatigue, as well as the side effects of many graphic reflexive muscle response to stimulation of 1a affer-
medications. Although physical performance can deterio- ent sensory nerves, and is thought to arise from both neural
rate with fatigue, the neurotherapist must also consider the and biomechanical adaptations following UMN lesions.
24 SECTION 1 Background Knowledge

Most clinical outcomes measures assess ‘hypertonus’ by both stability and mobility (Meadows & Williams 2009).
the passive resistance to movement at different velocities, Neurotherapists often chose these techniques taught within
which represents part of the hyperreflexive response that these treatment approaches to improve muscle alignment
occurs to muscle stretch (Pandyan et al 1999). In a clini- and recruitment, and to explore a greater repertoire of
cal context, hypertonus can also be described during active movement performance, which can be incorporated into
movement and may well be influencing movement quality. functional movements. In addition, as mentioned earlier in
Examples of this might be velocity-dependent hypertonus this chapter (see Upper Motor Neurone Weakness section),
in knee extensors limiting rapid knee flexion in swing phase the negative consequence of reduced strength also needs to
of gait, or clonus in plantar flexors destabilising balance, or be addressed to also change movement quality in the longer
driving the knee back into hyperextension in stance phase term. As active control improves, task-specific practice is an
of gait. Hypertonus in elbow flexors may also contribute to effective form of functional exercise which does not specifi-
muscle imbalance and limitations in elbow extension. It is cally target hypertonus (French et al 2016). Active interven-
therefore important that neurotherapists assess and mon- tions shown to reduce muscle tone in stroke include:
itor hypertonus actively and passively, and under different • task-specific training such as constraint-induced move-
postural demands. ment therapy (CIMT) (Kagawa et al 2013) and
Neurotherapists have long realised that hypertonus • body weight support treadmill training (Manella &
can be temporarily reduced by providing additional sen- Field-Fote 2013).
sory inputs, such as hands-on facilitation. Hypertonus can The other advantage of task-specific practice is that
also be reduced by actively or passively improving postural it allows for greater autonomy and dose, particularly for
stability with either tactile hands-on input or passive assis- those capable of practicing tasks outside of closely super-
tance such as seating systems and supports (Kheder & Nair vised therapy sessions.
2012). This indicates that hypertonus is influenced by sen- The neurotherapist should also be aware that other exter-
sory input, effort and other more global postural demands nal triggers such as painful, noxious stimuli and infection
on movement (Stevenson 2010). usually increase hypertonus. These increases in tone can
When learning movement, altering sensory inputs may help identify hidden complications such as pressure sores
be used to enhance the exploration of movements with or urinary tract infections. In some circumstances, hyper-
reduced tone. Some simple ‘bottom-up’ methods of reduc- tonus that emerges as part of the UMN syndrome may pro-
ing hypertonus can include vide stability. A common example of this is increased lower
• electrical stimulation (Mills & Dossa 2016); limb extensor tone in standing, which becomes part of a
• botulinum toxin injections (Stevenson 2010); and functional movement strategy. For some patients, a large
• positional supports, seating and bed systems, and pos- proportion of stability is provided by hypertonus. Care must
tural changes (Herman & Lange 1999). therefore be taken if considering reducing tone with anti-
These methods of reducing hypertonus can influence spasmodic medications because this may unintentionally
not only movement, but can aid with pain and hygiene lead to further weakness and instability in some patients.
care, which can both be directly affected by hypertonic If hypertonus is targeted with therapy interventions, it
muscles. It is also critical to identify hypertonic mus- will be influenced by sensory inputs, postural control and
cles that remain in a shortened position, because this functional strengthening programmes. The interventions
can quickly lead to contracture. Contracture prevention selected by the neurotherapist will depend on the severity
and management are covered later in this chapter in the of the impairment, the patient’s capacity for active prac-
Secondary Complications section. tice, access to direct treatments, skill level and training of
Other interventions used by neurotherapists that provide therapists, and the resource availability for relevant medi-
hands-on sensory inputs include neuromuscular facilitation cations and rehabilitation equipment.
techniques, such as those used within proprioceptive neu-
romuscular facilitation (Knott & Voss 1968) or the Bobath Hypotonus
concept (Mayston 2016). There is considerable debate about Hypotonus or ‘low tone’ also becomes difficult to define
the effectiveness of these treatment approaches. Evidence for because it again can be observed and assessed with both
physical rehabilitation approaches for recovery of function passive and active movements. Many neurological popu-
and mobility following stroke suggests that rehabilitation lations present with hypotonus as measured by reduced
should comprise evidence-based techniques regardless of resistance to passive movement. Hypotonus can be seen
historical or philosophical origin (Pollock et al 2014). Labels in cerebellar ataxic patients and in CP. Even early after
aside, providing additional hands-on sensory stimulation stroke UMN lesions, paresis presents as ‘low tone’ possi-
has been shown to guide movement, reduce associated tone, bly because of changes in supplementary motor areas of
provide feedback, and allow exploration and experience of the cortex, before activity-dependent adaptations lead to a
 CHAPTER 2 Common Impairments and the Impact on Activity 25

hypertonic presentation (Florman et al 2013). In a relaxed that integrate somatosensory input for movement, such as the
state, patients with hypotonus may have difficulty in gen- basal ganglia, cerebellum, thalamus and cerebral cortex. Some
erating muscle activity because of reduced tension and of these maladaptive neuroplastic changes may be triggered by
‘readiness’ in the muscle. Hypotonus can result in slower long-term intense movement practice in genetically suscep-
movements and changes in joint stability and flexibility. tible individuals and may partly explain writer’s cramp and
Patient with hypotonic postural muscles often use more musician’s dystonia (Stahl & Frucht 2016).
inactive, stable postures against gravity. Dystonia can have an impact on many facets of daily
As with hypertonus, hypotonus should never be con- life, including chronic pain, balance/mobility, employ-
sidered in isolation when designing intervention strategies. ment and driving. Mobile dystonia can cause tremor,
Again, hypotonia can be difficult to define, despite its role which can lead to severe embarrassment in social situa-
in movement performance. Part of the difficulty is that tions. Recent research also highlights other important
even within the normal population, degrees of hypotonus functional limitations to consider, because people with
can be observed. Secondary weakness is a key factor, and cervical dystonia also show reduced balance, slower
interventions that aim to increase muscle tone through choice stepping reaction times and increased fear of falls
tactile stimulation and quick stretch could be paired with (Barr et al 2017) (Table 2.2).
faster muscle activity with strength and power training. As
with hypertonus, hypotonia can impact on posture and Involuntary Muscle Spasms
movement, yet it may not need to be specifically targeted in Sudden involuntary movements in muscle groups can occur
therapy. Strength, power and neuromuscular control may spontaneously or more often triggered by some sensory or
therefore be key targets when hypotonia is present. visceral stimuli (Nair & Marsden 2014). This can be com-
mon in any neurological condition with UMN lesions such
Dystonia as MS, SCI and TBI. The identification of any trigger is very
Dystonia is defined as a movement disorder characterised by important, such as skin lesions, pressure ulcers, musculo-
sustained or intermittent muscle contractions causing abnor- skeletal pains, ill-fitting splints or infections (especially uri-
mal, often repetitive, movements, postures or both (Albanese nary tract infections). Positioning and postural triggers have
et al 2013). A number of dystonia types have been classified implications for lying postures, which impact on sleep and
and can occur throughout the life span as either inherited, sexual relationships. Seating systems can be designed to min-
acquired or idiopathic dystonia. Specific muscles groups com- imise spasms and improve comfort and control. Unexpected
monly affected may include cervical (spasmodic torticollis) spasms can limit standing mobility and can contribute to
wrist and hand (writer’s cramp) and around the eyelid (bleph- unexpected falls. Physical management needs to explore
arospasm). Dystonia can be present in any focal muscle group postural control, injury management and other biomechan-
and can be triggered by either postural or task-specific func- ical influences that are commonly targeted within specific
tional activities, or can even occur spontaneously. Dystonia neurological physiotherapy. Direct communication with
can be seen as a primary disorder, or with other common medical colleagues is also needed to explore the medical
neurological conditions such as Parkinson’s. A form of spas- options that may target spasms, pain and/or sleep.
tic dystonia can also occur in stroke as part of the UMN syn-
drome (Nair & Marsden 2014). The underlying physiological Dyskinesias
cause is not well understood but is believed to be associated Dyskinesias are another form of abnormal involuntary
with maladaptive neuroplastic changes in areas of the CNS choreiform or athetoid movements. Tardive dyskinesias

TABLE 2.2 Interventions for Dystonia

Medical management consists mainly of botulinum toxin injection into the affected Castelão et al 2015
muscles, and there is growing evidence for neurosurgical deep brain stimulation to the
internal globus pallidus as an effective option for many.
The addition of specific exercise–based physiotherapy may further improve symptoms Ramdharry 2006
and possibly allow for lower doses of botulinum toxin and more effective management.
Exercises may focus on recruitment and strengthening of muscles that oppose the dys- Bleton 2010
tonic movement. Aims of this approach are to improve voluntary range and control of
movement, reduce tension, and relieve pain.
The identification and use of somatosensory facilitation to relieve dystonic postures with Franco & Rosales 2015
‘sensory tricks’ or ‘geste antagoniste’ may help with self-management.
Graded sensorimotor training has also shown benefit with focal hand dystonia. Byl et al 2003
26 SECTION 1 Background Knowledge

often involve movement of the tongue and jaw, and are KEY POINTS
strongly associated with antipsychotic medication side
effects (Aquino & Lang 2014). A more common dyskine- • Weakness in muscle will occur following a lesion to
sia observed within neurorehabilitation is associated with descending UMNs or LMNs.
Parkinson’s (Pilleri & Antonini 2015). Onset of dyskinesias • Fatigue is one of the most common self-reported symp-
in Parkinson’s is due to a combination of chronic levodopa toms in neurological conditions (Kluger et al 2013).
use and disease-­ related degenerative factors leading to • Disorders of tone can impact on posture and move-
postsynaptic changes to dopamine receptor sensitivity. ment, yet tone may not need to be targeted in ther-
Although treatment focuses on adjustments to type and apy. Strength, power and neuromuscular control are
dose of Parkinson’s medical management, the neurother- the key targets for therapy intervention.
apist plays a key role in identification and advice, liaising • Abnormal tone is influenced by sensory input, effort
with the medical team and providing reinforcement about and other more global postural demands on move-
medication dose and timing over the 24-hour cycle. ment (Stevenson 2010).

Rigidity
Rigidity is characterised by a resistance to muscle stretch of movement (Therrien & Bastian 2015). Depending on
felt with passive movement and can occur in a number of the site of lesion, these changes can influence limb
neurological conditions. It is one of the common features of movement, balance and/or changes in oculomotor con-
idiopathic Parkinson’s and many of the Parkinson’s plus dis- trol. Coordination changes with cerebellar ataxia can be
orders such as multisystem atrophy and corticobasal degen- described as jerky, slow and inaccurate, or may be observed
eration. Unlike spasticity, rigidity is not velocity dependent; as tremor with active limb or postural muscle activity.
however, the increased resistance to stretch may be occurring Clinical terms used to describe these signs include:
because of a heightened response to sensory inputs (Delwaide • dyssynergia: decomposition of multijoint movements
et al 1991, Rothwell et al 1983). Rigidity often has a lead-pipe • dysmetria: variable speed, path and accuracy of movement
nature of resistance that is velocity independent to the move- • dysdiadochokinesia: slow, alternating rate of movement
ment direction, usually tested by flexing and extending the • tremor: kinetic, intentional or postural tremor of vary-
wrist or elbow. Cogwheel rigidity is common in Parkinson’s ing amplitude and frequency
and describes the rigidity felt in the presence of an underly- Oculomotor changes may include gaze-evoked nystag-
ing tremor. The overall rigidity can also be combined with mus, reduced fixation, saccadic or broken smooth pursuit,
other ‘rigid’ movement strategies that result in cocontraction slow or dysmetric saccades and abnormal vestibulo-ocular
that may be used for stability to compensate for instability or reflex reducing gaze stability. Cerebellar signs can also include
weakness. Rigidity can contribute to the overall flexed pos- changes to the coordination of mouth and tongue move-
ture seen in Parkinson’s and can lead to joint, tendon and ments for speech, which is termed ‘dysarthria’ (Table 2.3).
muscle changes with possible associated pain. Many of the
secondary problems associated with rigidity are managed Sensory Ataxia
with physical therapy that aims to improve posture, strength, Reduced sensation can lead to the loss of important pro-
range and general conditioning. Movement strategies used prioceptive awareness and feedback need for well-coordi-
to help with bradykinesia are also useful in mitigating some nated movement and balance. Rehabilitation approaches
issues associated with rigidity and should be recommended may seek to increase additional alternative sensory feed-
in conjunction with dopaminergic replacement therapy (see back through vision (Hamman et al 1992) and tactile cues
later Bradykinesia/Akinesia section). Recently, there has been (such as textures insoles) (Dixon et al 2014, Kelleher et al
some interest in the effect of interval exercise training for 2010) to improve motor control. Training techniques that
people with Parkinson’s resulting in some improvement in encourage sensory integration can help to improve bal-
motor impairments, including rigidity (Marusiak et al 2015). ance and mobility. It is not uncommon for people with
MS to have a combination of cerebellar and sensory ataxia.
DISORDERS OF COORDINATION In this instance, a thorough assessment of sensation and
coordination may help design individualised exercises
Cerebellar Ataxia that combine restorative and compensatory approaches to
Lesions to the cerebellum or its incoming or outgoing maximise adaptation and functional independence.
connections can lead to difficulties in the coordination
of movement. Because of the theorised role of cerebel- Resting Tremor
lum in the feedforward sensorimotor control, damage can Resting tremor is the most common form of tremor seen
lead to problems with the temporal and spatial control in Parkinson’s that can be observed at rest or with an
 CHAPTER 2 Common Impairments and the Impact on Activity 27

TABLE 2.3 Interventions for Cerebellar Ataxia

Rehabilitative treatments can focus on compensatory aids to simplify and dampen Gracies et al 1997, Morgan 1975
the effects of ataxia. Example of this may include:
• external weights
• tight garments
Counterbalance weights to alter directional balance stability. Gibson-Horn 2008, Widener et al
2009
Cooling can also reduce cerebellar tremor temporarily. Feys et al 2005
Restorative approaches may include exercises for strength, and to practice control Crowdy et al 2002
and accuracy of limb, balance or visual gaze with the use of sensory feedback.
Speech therapy which focuses on loudness of phonation often used with people Sapir et al 2003
with Parkinson’s can also be of benefit for dysarthria.
The influence of postural control also needs to be explored because postural train- Stoykov et al 2005
ing may also reduce limb ataxia.

TABLE 2.4 Interventions for Intention Tremor

Some medications can sometimes be helpful for many types of tremor. Connolly & Lang 2014
Deep brain stimulation to subcortical structures such as subthalamic nucleus, globus pallidus Okun 2014
or thalamus can also show beneficial effects.
Innovative technology such as vibration absorbers may emerge as effective ways of reducing Gebai et al 2016
tremor and improving function.
External weight may dampen tremor during tasks, and peripheral cooling to upper limbs has Feys et al 2005
shown to reduce intention tremor in people with MS.
Botulinum toxin injections have been shown to have benefit for tremor. Kim et al 2014

unchanging posture. As it can occur with postural activ-

ity, it is best termed ‘classic tremor’ in Parkinson’s (Hallett Loss of Dexterity
2014). At present, the aetiology of classical tremor is Many of the neurological impairments already mentioned
unknown but may involve changes within the oscillatory can result in a loss of important fine motor control of the
networks of basal ganglia and cerebello-thalamo-cortical hand, fingers and thumb. Sensory loss, UMN and LMN
motor circuits (Dirkx et al 2016). weakness, tremor, dystonia and motor fatigue can all result
in impaired motor dexterity. Dexterity often refers to
Intention Tremor reduced individualised and selective control of each digit
Intention tremor can involve dyssynergia and dysmetria of the hand, reduced ability in the complex shaping of the
often with increased oscillations or tremor as limb actively palm/fingers to manipulate objects and reduced fine motor
approaches the intended target. This perhaps indicates the control (Backman et al 1992). Loss of dexterity can have
key role the cerebellum plays in the feedforward anticipatory a dramatic effect on hand function with a major impact
control of movement, with dysfunction leading difficulties on overall activities of daily living. Interventions used to
with temporal and spatial control, reduced skill and reduced improve dexterity will depend greatly on the capacity for
accuracy of movement because of a reliance on slower feed- active practice. Unilateral loss of dexterity can quickly lead
back control. Essential tremor can be familial and can involve to ‘learned non-use’ of the limb (discussed later under
any number of muscle groups, but it commonly involves Secondary Complications), where behaviour modification
involuntary intention tremor of the hands or neck/head. and intense practice such as CIMT are recommended for
Tremor can have enormous impact on an individual, those with adequate active movement. Particular aspects
especially when considering the importance of hand func- of impairments may be targeted to improve dexterity such
tion. It is also worth considering that all forms of tremor as sensory discrimination/sensorimotor training (Byl et al
can be extremely embarrassing, impacting on all aspect of 2003, Carey et al 2011) and part practice of a task (Carr &
social and working life (Table 2.4). Shepherd 2003).
28 SECTION 1 Background Knowledge

TABLE 2.5 Nonpharmacological Interventions for Bradykinesia/Akinesia

Movement strategies that focus on increasing movement amplitude can help speech and Fox et al 2012
mobility.
Aerobic exercise has the potential to further enhance these neuroplastic training effects Petzinger et al 2013
by enhancing brain function.
Specific exercise regimes focus on high-speed or forced high-velocity cycling exercise, Ni et al 2016, Ridgel et al
which may also improve some of the motor signs associated with Parkinson’s. 2009
External auditory or visual cues have been long known to help with bradykinesia with Lu et al 2017, Spaulding
tasks such as gait by possibly bypassing dysfunctional automatic movement planning et al 2013
pathways in the brain.
Various genres of dance show benefit and should be considered alongside all of these Shanahan et al 2015,
strategies. Sharp & Hewitt 2014

DISORDERS OF MOTOR PLANNING facial expression and speech, as well as lower limb and gait.
It can respond well initially to levodopa or dopamine ago-
Apraxia nist medications (Gao et al 2017), but the neurotherapist
Apraxia is defined as the lack of ability to understand an needs to be aware of the many nonpharmacological strate-
action or perform an action on command or imitation. gies used to reduce the effects of bradykinesia (Tomlinson
When partial effects of apraxia are present, it can be termed et al 2014) (Table 2.5).
‘dyspraxia’ (Koski et al 2002). Various subtypes have been
defined based on where the dysfunction to movement plan- Freezing of Gait
ning may be occurring in relation to the cognitive, percep- Freezing of gait (FOG) is common in Parkinson’s and occurs
tual and execution of movements – for example, ideomotor as brief episodes of an absence or marked reduction of the
apraxia, ideational apraxia and conceptual apraxia. Other forwards progression of the feet despite the intention to walk
subtypes are defined by the actual task – for example, gait (Heremans et al 2013). FOG has an enormous impact on
apraxia, dressing apraxia and speech apraxia. Dyspraxia function and quality of life (Walton et al 2015) and is strongly
can therefore be very frustrating for those presenting linked to falls (Moore et al 2007). It is also linked to cognition,
with this disorder, and can be very difficult for family and such as executive and visuospatial dysfunction (Peterson et al
friends to fully comprehend. Identification, education and 2016), and is thought to involve disorders in both cognitive
support become very important before addressing move- and motor processes (Nutt et al 2011). As with bradykine-
ment dyspraxia with various rehabilitation strategies. sia, FOG may be managed with medical adjustments, exter-
Interventions for apraxia include the following: nal cueing strategies, education and support (Nonnekes et al
• There is very limited evidence to guide interventional 2015), although the responsiveness to these strategies remains
training for apraxia (West et al 2008), such as panto- mixed, making FOG often very difficult to manage.
mime and imitation gesturing and compensatory strat-
egy training (Smania et al 2000). VESTIBULAR DISORDERS
• Errorless learning, forwards or backwards chaining, sen-
sory stimulation/cueing and instructional approaches Peripheral Vestibular Disorders
for cognitive rehabilitation may all be considered help- Vestibular dysfunction and management are fully dis-
ful with motor planning. cussed in Chapter 21. Peripheral vestibular disorders such
as benign paroxysmal positional vertigo (BPPV), vestibu-
Bradykinesia/Akinesia lar neuronitis and vestibular hypofunction are common
Bradykinesia is described as an overall slowness of move- disorders seen in the general population, but can also be
ment with a reduction in the amplitude and speed as the commonly seen secondary to many neurological condi-
movement is continued (Postuma et al 2015). It is a very tions. For example, BPPV can occur following TBI (Ahn
common feature of Parkinson’s, partly caused by a reduc- et al 2011, Motin et al 2005) and can be the most common
tion in the neurotransmitter dopamine within the basal cause of vertigo seen in MS (Frohman et al 2000). Vertigo
ganglia (Bologna et al 2016). Bradykinesia can impact on associated with peripheral vestibular disorders can be
all movements and postures in upper limb and hands, severe and can have enormous impact on all aspects of life.
 CHAPTER 2 Common Impairments and the Impact on Activity 29

Very effective treatments for BPPV and individualised VISUOSPATIAL DISORDERS

vestibular rehabilitation (VR) exercises for those with uni-
lateral and bilateral vestibular hypofunction show benefit Hemianopia
for enhancing early vestibular adaptation and multisensory Homonymous hemianopia (HH) is common after stroke
compensation to reduce dizziness and improve balance and results in visual field loss on the same side of both eyes.
(Hall et al 2016). VR has been shown to be of benefit for It is caused by any lesion along the retrochiasmal visual
peripheral vestibular dysfunction such as: pathway (Zhang et al 2006). Monitoring and encouraging
• vestibular neuronitis, early compensatory head turning is important. HH can lead
• labyrinthitis, to reduced functioning and quality of life (Gray et al 1989),
• Meniere’s disease, and and increase risk for falls (Ramrattan et al 2001). The impact
• bilateral hypofunction (McDonnell & Hillier, 2015). of HH on activities of daily living may be further reduced
with specific visual field training (Pollock et al 2011).
Central Vestibular Disorders
Central lesions that involve vestibular inputs and key inte- Unilateral Spatial Neglect
grative pathways in the brainstem and cerebellum can also Unilateral neglect (UN) is a perceptual disorder commonly
lead to oculomotor dysfunction, signs and symptoms of seen in stroke, more often with lesion in the right hemi-
imbalance, disequilibrium and vertigo. Approximately 5% sphere. Pathways within the perisylvian neural network
to 10% of all strokes occur in the brainstem/cerebellum include superior/middle temporal, inferior parietal and
(Karatas 2008), and lesions in this region are very com- ventrolateral frontal cortices (Karnath & Rorden 2012).
mon in MS (Prosperini et al 2011). Diffuse axonal injury Patients with UN fail to respond to any stimuli from the
is also common following TBI (Johnson et al 2013), and contralateral space (often left), with characteristic ipsi­
vestibular symptoms can be associated with certain types lesional bias of head and eye gaze. Additional deficits in
of migraine (Stolte et al 2015). Many of the balance impair- internal body schema are also common, in addition to
ments observed following stroke may result in diaschisis, problems ‘disengaging’ from visual stimuli in the ipsi­
with an interruption to important corticobulbar path- lesional space (Morrow & Ratcliff 1988). It is also common
ways from the cortex to vestibular nuclei in the brainstem for a person with UN to not be aware of these deficits (ano-
(Marsden et al 2005). sognosia) (Dai et al 2014), which creates a further chal-
In the acute setting, careful assessment to differentiate lenge with rehabilitation. UN can have a marked effect on
both peripheral and central vestibular signs is important functional recovery (Jehkonen & Laihosalo 2006) and can
when considering the possibility of stroke (Kattah et al be difficult to manage (Kwasnica 2002). Interventions for
2009). Often both peripheral and central vestibular signs neglect that have shown some benefit include prism adap-
coexist (Frohman et al 2000, Pula et al 2013) and influence tation, eye patching, visual scanning, neck muscle vibra-
the optimal rehabilitation strategies used (see Chapter 21 tion and brain stimulation (Yang et al 2013).
for a comprehensive overview of VR).
Signs of vestibular dysfunction include oculomotor dys- Contraversive Pushing
function such as gaze evoked and/or nystagmus, reduced Contraversive pushing, often referred to as ‘pusher syn-
gaze stability because of altered vestibular-ocular reflex, drome’ or ‘lateropulsion’, is another perceptual disorder
reduced balance and sensitivity to various types of motion. following stroke that leads to a postural bias towards the
Vestibular signs and symptoms can have enormous hemiplegic side. This disorder can be quite difficult to
impact on activity levels and balance confidence. It can manage because of the characteristic ‘pushing’ or resis-
contribute to reduced mobility levels, increased anxiety, tance to postural correction to vertical upright in either
reduced quality of life and falls risk. Training in vestibular sitting or standing. It is thought to be caused by an altered
assessment and VR has been recognised as an important perception of postural verticality. This altered perception
part of specialist training within neurological physiother- may underlie the pushing behaviour, resulting in a reorien-
apy (Cohen et al 2011). tation to an altered sense of gravity (Karnath et al 2000) or
VR has shown to be of benefit for central disorders a balance response to correct perceived vertical (Perennou
such as: et al 2008). Because this pushing behaviour is thought to be
• MS (Hebert et al 2011), a perceptual problem, the neurotherapist should consider a
• stroke (Brown et al 2006), multisensory approach to integrate correct feedback from
• brain injury/concussion (Kleffelgaard et al 2015, visual, tactile and vestibular feedback regarding postural
Murray et al 2017), and vertical. Theoretically, the more intact systems, the better
• vestibular migraine (Vitkovic et al 2013). prognosis with therapy (Babyar & Peterson 2015).
Discovering Diverse Content Through
Random Scribd Documents
 “Thank you, no,” said Mr. Waters firmly. “I seldom do any business
out of business-hours.”
I turned my ring again ostentatiously. I hope he knew I was
pointing out to him how my “business” had to go on all day long—
the woman’s work, in fact, being never done!
My next mild suggestion was, “Do you play picquet?”
“Don’t know one card from another.”
I sighed, as if with mingled regret and boredom.
It was a very insincere sigh! for, to begin with, I loathe any form
of card-playing myself; I don’t believe the story that cards were
invented to please a mad king. I believe he was driven mad by the
card-games of the period! Secondly, I wasn’t one bit bored. I was
revelling in the spectacle of this wretched young man—imagine
being able to employ such a phrase to the Grand Panjandrum
himself!—this wretched young man looking so acutely uncomfortable
and at such a loss.
Gleefully I allowed yet another long and awkward pause to take
place.
Then, I put my hand—the left one—up to my mouth as if to stifle
a yawn. Then I glanced at the ship in full sail that rocked to and fro
on the face of the grandfather’s clock, and murmured resignedly:
“Only twenty minutes past nine?”
“I am afraid that clock is always kept ten minutes fast,” said my
host.
I sighed again, more deeply.
Then I allowed my eyes to wander, as if vainly seeking the way of
escape!—round the comfortable, masculine-looking room. Actually,
my glance was caught by an odd-looking arrangement of wires
across the ceiling.
“Oh, what are those for?” I asked. “Telegraphy?”
 “No; I had those put there to improve the acoustics of this room.
It was otherwise so bad to play and sing in.”
“Oh!” I said, and wondering why Blanche didn’t use the drawing-
room to sing in, I glanced at the somber shape of the piano at the
other end of the den.
“I wonder if you would allow me to practise in here sometimes—of
course, only in the mornings?” I requested meekly. “When I go back
to London, I shall want to see about a situation as music-teacher or
something of that kind. I must have some definite work to do—
besides yours, I mean!—and I ought to furbish up my playing.”
“Ah, you play, do you?” said Mr. Waters, in a tone of the deepest
relief. “Good!”
He got up, switched on some more lights, and opened the piano.
“I wonder if you have a rarer accomplishment still. Can you
accompany?”
“I should be able to,” said I, with a little bitter smile to myself.
For I’ve certainly spent hours enough at the piano with Sydney
Vandeleur, practising or transposing his lyrics. He has a gift for
pretty, tender melody-writing; he “sets” all his favourite verses....
“Will you try over a song with me, then?”
(What! It was he who sang?)
“Certainly!”
This was not my subdued, Leadenhall Street office “Certainly.” It
was the way in which I might have spoken to Sydney, or to Major
Montresor, or the Somervilles, or any of the men who came to my
father’s house in the old days, and for whom I played in the evening.
“Wait a minute. This gets in the way; clicks on the keys,” said I,
glancing at those weighty diamonds that blazed on my finger. And I
drew off his ring, pushing it with a careless little flick out of my way
on the glassy black top of the piano. He had put up before me
Schubert’s “Still wie die Nacht.”
 Appropriate enough, for Still Waters! “Still as the night, deep as
the sea——”
I took up the first chords.
Then came surprise again.
I had expected him to possess a big, bull-dog bass, full of sound
and fury, and without a touch of feeling in it. To my amazement, his
voice turned out to be a particularly sweet, true tenor. Shut your
eyes, and you could imagine that it was the most sympathetic and
delightful of men who was singing, instead of the Governor!
Can there be many more surprises about this man? However, I
flatter myself that I’ve given him several. The crushed-looking,
deferential typist in the ready-made delaine blouse, and with the
carbon-stained fingers, that shook with nervousness when he rattled
off his far-too-quick dictation to them, was a distinct contrast to this
dainty, well-dressed young woman, who lays her own plans for him
to see that she is laughing at him in her sleeve.
And it’s his turn to use deference to me.
“Thank you, so much—er—Nancy.” This last word brought out with
a jerk of resolution. “It’s a treat to be accompanied by someone who
can do it so unusually well; it’s like waltzing with a partner whose
step just suits one’s own.”
Good gracious! Where and when has this man learned to dance?
But he can sing. I quite enjoyed playing for it. I think we went
through quite half a dozen songs—“Widdicombe Fair” was one of
them—before I remembered that this wasn’t the form I meant my
enjoyment to take.
So, when he put up yet another—“Drake’s Drum” this time—and
said, “Shall we try this?” I relapsed into my wickedly mild manner
once more, and replied hesitatingly: “Don’t you think that would be
enough—for Mrs. Waters? I mean, that she would consider I had
stayed the right length of time? May—mayn’t I get down, now?”
 “Oh! Sorry if I have tired you,” said the Governor quietly.
He walked across the room to open the door for me.
There, with his hand on the door-knob, my employer paused and
looked down at me almost as if he were looking at me for the first
time.
It was a curious sort of stare, half-amused, half-frowning. I should
think it must have lasted while one could count five. Was there a
sort of threat in it? Yes! I suppose it meant that he wasn’t going to
stand any more of my masquerading impertinences, that somehow
he meant to overawe me, to keep the upper hand over me still. But
he won’t. Of course it’s rather flurrying to be looked at like that, so
hard and unexpectedly.... But I wasn’t really flurried——only a little
glad when he opened the door, said “Good night!” and shut it after
me.
I was turning towards the haven of the drawing-room when, half-
way across the hall, I heard the door of the “den” open again, and
the Governor’s step behind me.
“I think you forgot this, didn’t you?” he said, holding out to me the
ring I had left lying on the top of the piano.
“Oh, thank you,” I said apologetically. He went back into the den. I
slipped my “engagement” ring on to my finger again.
As a matter of fact I hadn’t “forgotten” it.
And he needn’t imagine that he is ever going to have me “quelled”
again. I intend taking it out of him all the time I am here!
 CHAPTER XIV
THE FIRST QUARREL

So far I have had things all my own way.

During the three days that I have now been staying at The Lawn,
I have managed to “keep up” without difficulty two utterly distinct
and different manners.
“Manner A.”—assumed for the benefit of the Governor’s family—
the rather shy but charming and devoted young fiancée.
“Manner B.”—well, to be frank, a perfect little cat!
But to begin with the first manner.
I should be ashamed to act it as well as I do, if it weren’t that I
must keep the whip-hand over the Governor, and that this is the only
way, for his mother and sisters are really too sweet with me.
Never, during all the palmy days of the Trant family, have I had so
many pretty and generous things said about me as I’ve heard in
these three days from my employer’s unsuspecting mother.
She told me yesterday, “When Billy was ten I’d begun to wonder
whether, somewhere, some other mother was watching a pink-lined
cot that held something which was to become very precious, later
on, to my little son. And—twenty-one, are you, dear?—it must have
been so, then. How glad I am it was you! Ten years is such a nice
difference in age, too; I was twenty-one——”
And her soft grey eyes looked at me as if they saw, through me,
into the past.
Her young daughter Blanche, on the other hand, gazes at me as
wistfully as though, through me, she could look into the future. I feel
as if I were supposed to be standing beside a wall which only I am
tall enough (for once!) to see over.
“Sister Anne, do you see anyone coming?” That, of course, isn’t
what she says.
“Nancy, I suppose you knew almost at once what you felt about
Billy?”
“Oh, yes!” (Readily.)
“You knew he was absolutely the one and only? How lovely!” A
pause. “I suppose the way to find out is to imagine him among
seventeen other young men, all frightfully good-looking and nice and
good sorts, and the right kind of voice, and all wanting to marry you
at once, and all that? Then, if you still feel you could choose him out
of all those——”
“But, Blanche, I should have had to,” I explained, truthfully
enough, as I thought of the five hundred pounds. “Couldn’t help
myself!”
“I see,” sighed Blanche. “Mustn’t it be glorious for you both?”
And thirteen-year-old Theo, pouring upon her “new sister” the
wealth of superfluous adoration which will some day be wasted, I
suppose, upon some quite ordinary young man, proclaims at
frequent intervals, “Isn’t it ripping having her here?” and lives
entirely in the present. Theo, by the way, is the only one of them
before whom I feel I have to be careful not to over-do Manner A.
Manner B. is reserved for those hours which, for the sake of
appearances, his official fiancée is obliged to spend alone with Mr.
Waters; going for dull walks—that is, for me they’re kept from being
too deadly dull by the certainty that I am making them so for him!—
and sitting with him in the den, where I will not play
accompaniments to his songs except as a last resource after I’ve
exhausted every possibility of the stilted remark, the awkward
pause, the resigned glance, and the languor that stops short only at
the visible yawn. Since that first tête-à-tête I have brought the
contrasting of Manners A. and B. to a fine art. I’ve been revelling in
the idea that for a whole fortnight this is what my employer will be
forced to put up with. After all, it’s what the whole lives of some
married men amount to! And, according to the terms of the
Governor’s own agreement, there’s nothing in all this of which he
can openly complain!

* * * * *

He has complained!
Really, I need not have been surprised when it occurred, though I
was scarcely expecting it.
It began this (Saturday) morning, at breakfast. Now, any outsider
peeping into the sunny dining-room might have considered that the
group round the breakfast-table made an ideal picture of English
family life.
There was the gentle, grey-gowned mother pouring out coffee.
The big, blonde son of the house, dressed for the City, sitting
opposite to his fiancée—rather silent, but presumably only out of
devotion.
The fiancée herself, a small brunette in dull-pink linen, looking, I
think I may say, the picture of girlish sweetness, and being made
much of by the two younger, taller, fair-haired sisters.
For no outsider could have suspected that the small, dark girl and
the big, blonde man were secretly at daggers drawn. Nor have the
family a notion that I’m anything less than “the ideal wife for Billy.”
I had come down last, to be greeted by the clarion voice of Theo,
now no longer muffled in my presence.
“Nancy! Here’s news for you! Juno what? Our celebrated Uncle
Albert Waters is coming down to inspect Billy’s sweetheart!”
“Oh!” I said smiling. I didn’t see then why I shouldn’t smile. I
hadn’t yet heard anything about this other Mr. Waters.
 “It’s to be hoped that he will admire her as much as we all do,”
proclaimed Theodora; “because, if he doesn’t, won’t it be a ghastly
week-end, Mother?”
“Nonsense, dear! Don’t try and alarm poor Nancy about the new
relation she has to meet.”
“But—fancy! Meeting Uncle Albert for the first time! Golly!”
“Theo-dora!”
“I know. I did promise to chuck saying ‘Golly,’ but really it’s the
only word that seems at all like Uncle Albert,” declared the child.
“Uncle Albert’s a terror! Talk about me-ee! Yes, talk about me saying
everything that comes into my head! Why, it’s from him that I inherit
that! Only, I’m not in it with him!”
“It would be a good thing if you were, Theo,” reproachfully from
Mrs. Waters. “I am sure your uncle has a heart of gold.”
“Always means there’s something else the matter with a person”—
thus the irrepressible Theo. “People with ‘hearts of gold’ are either
fearfully rude like old Miss Crabbe, and never say ‘Thank you,’ or
they don’t care a rap what they do say, like Uncle Albert. If he
doesn’t happen to approve of Billy’s fiancée, he’ll think nothing of
telling Billy to break off——”
“Break off yourself, young woman. You talk a good deal too
much,” put in her brother, as he rose, big and well-groomed, from
the breakfast-table. “And keep Cariad, will you? He knows he never
follows anyone but his mistress, but I’ve had to send the station-
master’s boy back with him three times this week. Good-bye, all.”
“Good-bye,” said I sweetly. “Give my love to the Near Oriental,
especially to the typists’ room, will you? How stuffy it will be getting
there now! How thankful I am for anything that keeps me out of it
on a morning like this! Still, I suppose one ought not to abuse the
place where we first met.”
This with a glance at him, expressly for Blanche’s benefit, from
under my eyelashes. For I am acquiring a taste for positively
“baiting” my employer. I’m not going to be the one made to feel all
the awkwardness of the situation. Not I!
Let him redden with embarrassment before the guileless remarks
or questions that I aim at him before his mother and sisters. Serve
him right! As for my employer’s feelings towards me, I have seen
them ripening from obliviousness of my presence, through
indifference and dislike, into positive hatred!
I knew he’d felt the flick of my last remark. I also knew how he
would have liked to retaliate. Any time since that first evening in the
den I have seen in his eye the yearning to take me by the shoulders
and shake me.
But he said serenely: “It is a glorious morning, certainly. Too fine
not to walk down to Sevenoaks, so I’m starting a little earlier.”
Good! I thought. I always welcomed the moment that saw the
last, for the whole happy, idle day, of the only inhabitant of The
Lawn with whom I’m not on excellent terms. Once he’s out of the
house, I can enjoy myself and forget (almost) why I’m in it.
So it was an annoying shock to me when he stopped short on his
way to the door and added:
“Nancy, do you care to come part of the way towards the station
with me?”
He had me there. I saw there was no escape. For the first time
this week he was able to check me in having things all my own way;
and, mortified and irritated as I felt, I could only smile up at him in
Manner A, and reply, all eager delight:
“Oh, I’d love it! Give me two minutes to put on my hat.”
In five minutes—for I knew he’d loads of time for his train, and it
was still a further turning of the tables to keep the Governor waiting
—I joined him outside the front door.
Presently we were walking briskly together down the drive
between the green cliffs of laurel; the air was sweet with the scent
of sun-warmed lilac, the sky was cloudless, the morning all sunshine
—everything, in fact, was as unlike my own mood as might be.
For I’d guessed that I was “in for” something. And although I
didn’t yet know what this might be—although it seemed a whole
pre-existence since the day when the prospect of a few words from
the Head of the firm made his trembling typist feel that the end of
all things was at hand!—I still felt, amongst other emotions, a little
frightened. Again I saw in my mind that odd, half-amused, half-
threatening stare which the Governor had bent upon me that first
evening when I said good-night at the door of his den. Supposing I
wasn’t able to keep the reins in my own hands after all? A new
nervousness mingled in me with an utterly new form of resentment.
I hadn’t long to wait for my few words from the Governor.
He began—rather to my surprise—without his traditional “Now,
Miss Trant,” but grimly and stiffly as I don’t suppose Mrs. Waters
knows he can speak.
“Now! There is something I wanted to say to you. I am sorry to
trouble you, but I am afraid that I have to ask you to be a little more
careful in your manner to me.”
Which of the two manners was he going to fix upon? The one I
reserved for him alone, or the pretty one that I used to him before
his people?
“My manner? Oh!” I turned a dismayed face, the face of a typist
caught out in some careless mistake, up to his as we walked along.
“I am afraid I don’t quite know what you mean.”
“You do,” said his face.
But he only said concisely: “I mean the tone you sometimes feel
called upon to adopt towards me, as just now, at breakfast. Of
course when we are alone you must please yourself entirely. But that
will hardly do before others.”
Ah, it was for Manner A, then, that he’d settled to take me to task.
So none of it had been lost upon him, then; none of the unearthly
sweetness hiding home-thrusts that only he was able to recognize as
such! None of the elaborate ways in which I’ve been pretending to
think of little things to please him; quoting (in public) bits of his
songs that I call my favourites, picking a sulphur-coloured pansy—
that he daren’t not wear!—for his button-hole, then making him take
it out to let me change it for a leaf of scented geranium, because
there were table decorations of those at the Savoy “the day we
lunched there before you chose my ring; do you remember?” I hope
he’ll never cease to remember and to regret “that day!”
For the whole nature of the grudge I have against him has
changed in these few days. The thoughts have gone into the
background of all that office drudgery and Near Oriental
unpleasantness. I’ve forgotten that I used to hate him as part of a
life of being ordered about on a few shillings a week. But when, in
accepting this invitation to a house of luxury and leisure, I had the
feeling of “coming home” to my old sort of life, I hadn’t realized how
many of the feelings belonging to that by-gone life were going to
wake up again inside me, indignantly ashamed. I was my father’s
daughter. I was well accustomed to the ease and space and
comforts of such a house as The Lawn—the Waters don’t suspect
that, but I was born to them. I wasn’t born, however, to taking up
the position in such a house which he has forced upon me. Dully
simmering in my mind, for some time now, has been the thought of
this slight which he has put upon me, this insult.
This was the thought that softened my voice into the timid and
suppressed “office” key, which I felt I couldn’t keep up very much
longer.
“Have I been saying and doing the wrong things before your
people then? I am sorry!”
I hoped my voice was not going to run away with me, but I heard
myself beginning to lose control over that serviceable meekness as I
went on.
 “It is rather difficult for me, you know. Still, I did think I seemed
everything that your fiancée ought to be! I have been trying——”
“You have,” admitted Mr. Waters grimly. “Very.”
“Do you mean I haven’t been a success, then?” I heard myself
demanding quickly. “Oh! Because, if I don’t give satisfaction——”
I stopped. It wasn’t my place to finish the sentence with “I had
better give notice!”
“H’m,” said my employer curtly. “I see.”
Did he “see,” I wondered? Did he realize that, though I was bound
hand and foot by that absurd muddle of an agreement, he might
break it when he chose, and that I was longing, desperately, for him
to do so then and there?
“It’s very hard,” I explained as evenly as I could, hoping that this
explanation would give him his cue, “hard to manage to hit the right
note always, and to have to decide every minute upon the way I
should naturally behave if I really were engaged; Of course I’m
under contract, but——”
Here, very suddenly and unexpectedly, Still Waters broke out into
a tone I’d never heard from him before. He positively “let himself
go” as he lashed out with his walking-stick at an inoffensive dock-
leaf in the hedge-row we were passing, and exclaimed:
“By Jove! I’d pity any man who was ‘really engaged’ to you!”
Ah! So I had got him to speak his mind at last, his own mind that
he would have given anything not to have revealed to any
employee! More than that, I’d driven him into being inexcusably rude
to a woman. His face, where the tan had deepened to a sullen red,
his lips, compressed into what seemed like a thin, pen-drawn line,
showed me that he had realized this. I don’t mean him to forget
what he said. I said nothing. The most awkward of all the many
awkward pauses so far, elapsed between us as we walked along, and
before he spoke again. When he did, I saw that it cost him more
than he liked me to notice.
 “Yes. You see—I ought not to have said that. I beg your pardon.”
“Oh! Please don’t! I didn’t mind it at all,” said I, better able to
speak very sweetly now that I felt I had regained some of my
ascendancy. But all the fun of “scoring” off him had gone, though I
must not let him see that. “Of course you’ve every right to say
exactly what you think, just as Theo does.”
For his face, still flushed, ruffled, and without a trace of the
“office-mask,” wore a fleeting but quite laughable likeness to his
youngest sister’s. I have heard it said of some girl, “She isn’t pretty
exactly, but she has pretty looks,” and positively, if I didn’t dislike
him so intensely, I should say that the Governor, though never
handsome, has “handsome looks” himself.
I went on, still mildly: “Only, you know, Theo and Blanche and
your mother don’t happen to think—what you’ve just said. They
seem to consider that—well! that the man I was engaged to isn’t—
wouldn’t be at all to be pitied!”
“I know. You needn’t tell me that. You have contrived to make all
three of them ridic—extremely fond of you!” This resentfully,
realizing it as part of my insolence to him. “My mother and the girls
don’t see through it, when you are—are covertly reminding me, in a
hundred small ways, of what I don’t need to be reminded of. That
would be all right, therefore—only——Other people who came to the
house might not be so unsuspecting They might chance to notice
that there was something odd—unusual—unnatural in your attitude
to me.”
“But—but you said any strangeness would be put down to the
awkwardness of a girl so recently engaged?”
“No one would give you much credit for being ‘awkward!’” Still
more resentfully. “And something might come out. That is why I am
obliged to ask you to be a little more guarded.”
“‘More guarded,’” I repeated meekly, like a child who is learning by
heart. “Yes. I must. I must try harder to make it seem less
‘unnatural’ that we two should be engaged.”
 Again the look, instantly banished, that meant he pined to shake
me.
“Thank you,” he said.
“And by the ‘other people,’ I suppose you mean this other—
outspoken Mr. Waters who is coming over to ‘inspect’ me? Do you
think—are you afraid that he will be sorry for the man who is
supposed to be engaged to me?”
Under his breath Mr. William Waters muttered what sounded, at
least, like the one word, “IMP!”
I heard him.
Perhaps it was only the first syllable of the word “Impertinence!”
At all events, I heard that distinctly. And though it meant I had
scored another point and made His Imperturbability forget himself
yet again, I couldn’t enjoy the triumph of it, nor even laugh to
myself. There had been too much of all this.... I was suddenly tired.
Tears, of fatigue, I suppose, rushed unexpectedly into my eyes, and
I was obliged to turn my head and glare over the hedge at a may-
tree in full bloom that became a dancing blur of pink.
He was pretending that he hadn’t begun to speak at all. He began
again, stiffly:
“My uncle and another man are coming over to-night. This uncle
of mine is eccentric in some ways, but extremely shrewd; and no—er
—two-edged sort of remark would be lost on him.”
“I see,” I said, blinking angrily at the next may-tree, but still
controlling my voice. “I had better not make any sort of remark at all
then, before him. I could be too shy to open my lips. In fact, just as
I am—used to be, at the office. Would that be better?”
“Distinctly better than—er—recent methods,” said the Governor
dryly. “This other man is merely a business acquaintance with whom
I hope to have dealings. So——”
 “You want him to be favourably impressed,” I concluded
intelligently, “with your fiancée and all your other belongings.”
“If you choose to put it so. But——”
A pause.
“Above all,” said the Governor, “I don’t, on this particular occasion,
don’t want to be made to look a fool!”
It came out quite boyishly and slangily, and for a moment I could
almost have liked Still Waters for that. Then—yes! I thought,
savagely, he mustn’t be allowed to look a fool even for once, but I
may go on looking a fool and worse, for the next year! And then I
saw that he was inwardly rating himself for having, as he
considered, played into the enemy’s hands—having allowed me to
see exactly when and where I could get the better of him next.
He didn’t trust me.
“I will do my best,” I said, softly and bitterly. Let him suppose, if
he chose, that I meant doing my best to let him look a fool before
his uncle and his pompous fine business acquaintance, indeed. What
would he amount to, I wondered, this acquaintance of the
Governor’s for whom I, Monica Trant, was to be on my best
behaviour? Probably someone Father wouldn’t have had in the
house!
We reached the turning to the station and I stopped.
“Was there anything else that you wished to speak to me about?”
“No, thank you,” said my employer at his curtest. “That was all.
Good-morning!”
He lifted his hat; his face beneath it was set with temper. Good!
Let him vent it on Mr. Dundonald at the office!
“Good-morning,” I said, and turned away. I was glad that there
had been no one in the lane to see that parting; to anyone who had
watched, knowing who that tall, blonde, savage-looking man was
who had said good-morning so frigidly to that small girl with her
head held in a very straight line with her back, it would have looked
so ludicrously like the last thing in the world that it really was—a
lover’s quarrel!
How furiously he had marched off! I turned round, after walking
on a few yards, to catch another glimpse of that stampede.
Then I was sorry.
For at that very moment he had elected to turn round and see
me!
It just shows that people are quite right to teach children never to
turn round on the road.
I wish I hadn’t!
 CHAPTER XV
“THE LIGHT OF OTHER DAYS”

“Nancy! I say, Nancy! Here’s Billy and this new man of his turned
up hours before we expected them, and mother’s out calling
somewhere, and Blanche is in the middle of washing her hair, and
just look at the awful rip I’ve made in my frock; I can’t come!”
announced Theo in a voice subdued almost to a stage whisper when
I met her on the stairs this afternoon. “So you be a saint and go in
and talk pretty to the visitor till tea, will you?”
“All right,” I laughed; and passed on to the drawing-room.
It was cool and dim in there after the sunshine of the garden,
where I had been lazing over a book and forgetting this morning’s
stress, and for a moment my eyes could scarcely make out the two
figures that stood with their backs to the white-curtained French
windows.
Then, beside the Governor’s tall bulk, I saw a small, dapper,
masculine silhouette with a rather too abrupt “pinch-in” at the waist
of its coat, and a perky, quick turn of the head; the general effect of
Mr. Cyril Maude in some military part that I had once seen. Was it
this that seemed so familiar, I wondered?
A monocle fell with a click against a waistcoat-button; then, as I
came forward, a voice, also vaguely familiar, cried in amazement:
“Monica Trant! Little Monica! Well, I am blessed!”
Who in the world was this that knew my name? I looked harder at
him. Surely it—Was it?—yes! it was one of father’s old friends, Major
Montresor. So this was my employer’s “business acquaintance.” I felt
myself trying not to stare. The Governor, I know, was staring
undisguisedly at the pair of us.
 “Why, bless my soul, Monica! Who’d have expected to see you
coming in like this?”
“Or you, Major Montresor?” I retorted, obliged to smile at him as I
held out my hand to his always tenacious clasp.
To be frank, I can’t say I was at all pleased that the Governor’s
visitor had turned out to be someone who’d seen me so often in the
old days. I don’t want those days to be mixed up with these. Already
a ghost or so out of those days had seemed inclined to come and
haunt the lovely garden and the big, comfortable rooms at The
Lawn! And now I seemed to see a regular Richard-the-Third-like
procession of those ghosts rising up behind the little Major’s trimly-
waisted figure—people with whom I’d associated last time he’d seen
me—standing in judgment, echoing his “Who’d have expected to see
you?”—adding their phantom stares to those of the two men whose
eyes were actually upon me. It was tiresome; might mean all sorts
of adaptations; even the assumption of a “Manner C” for the benefit
of Major Montresor! As for him, he’s a rather amusing, tactless,
talkative, would-be-man-of-the-world sort of person, who’d been
quite ready to get up what Kipling calls the “You’re-only-a-little-girl
type of flirtation” with me when I was seventeen or so. I hadn’t met
him since, nor had I wanted to; though I had been distinctly
interested, five years ago, to find that someone who possessed
medals and a moustache cared to talk to me while I was still in the
school-room. He’d got to look ever so much older since then, balder,
stiffer of movement in his slim boots and his stays—I beg his
pardon, I expect he called it his belt—and, apparently, more
flirtatious than ever!
Now, any woman over thirty-five has to be fairly attractive before
she’s allowed to flirt on without fear of ridicule. But a man at fifty, or
fifty-five, seems to claim the right to monopolize the prettiest and
youngest girl he meets. It doesn’t matter if he hasn’t a hair on his
head or a tooth of his own in it. As long as he’s single and wears
trousers, he’s an eligible bachelor—or so he thinks. A mercy he
doesn’t hear the ideas of the favoured girl on this subject!
 So, quite unsuspectingly, Major Montresor beamed upon me, and
declared at least three times that this was a most delightful surprise,
upon his word!—seeming almost to forget his host, who stood a little
aside, looking utterly disconcerted, as far as I could see without
turning my eyes, to discover that this “business acquaintance” knew
his official fiancée better than her employer ever could!
Christian names, too!
“Monica—Bless my soul, what’s this?”
“This” was an interruption that precipitated itself through the
unlatched French window; a small white dog that bore in his mouth
a large bone, noisome-smelling and of the earth, earthy, which he
dumped upon the Major’s japanned boot.
“Cariad!” growled the Governor, more angrily than I’d ever heard
him speak except to me, “what do you mean? Here, sir.” He grabbed
him by the collar, kicking the bone violently over the shallow sill in
front of him. “Sorry, I shall have to get the little brute locked up.”
And he dragged the cheerfully resigned Cariad out and along the
gravel to the back of the house.
“Decent sort of young fellow, Waters; very clever business-man;
useful to know; quite a nice chap, too,” commented the little Major,
lowering his voice as he turned to me. “But, my dear child”—he
always used the word “child” to excuse his gesture while he patted
my shoulder, or smoothed my lace collar, or played with my silver
chain—“my child, how did you come to be here?”
“I am staying with Mrs. Waters”—demurely.
“Well, well! So you knew them! Your poor father didn’t, did he?
You were at school with the girls of the house, perhaps?”
“No. I met Mr. Waters”—still more demurely—“in business.”
“Business? Upon my word! Glad you’ve got such a business-
adviser. Glad you’re in the position to need one, Monica. I heard
rumours of your poor father having left you not very well off. Odd
how these untrue bits of gossip get about!”—with an experienced
eye upon the expensive new afternoon frock of my preferred pink,
with its creamy ruffle, black velvet bow, and small paste buckle. “You
look the picture of prosperity and health and good looks, if you’ll
allow an old friend to say so?”
Well, one simply has to “allow” things to people who call
themselves “old.” But for that, how many “old friends” would have
received the order of “Paws off!” or “No patting, please,” or a more
politely expressed equivalent from the girls who can’t be rude to
their father’s contemporaries?
I was only just about to draw my hand away from another long
and tender squeeze of Major Montresor’s, when his host came back
to us. Through the French window, as the Governor pushed it open,
a ray of sunlight caught and blazed on the magnificent diamonds of
the ring which had been bought at Gemmer’s for me to wear.
Instantly Major Montresor pounced on that other hand.
“Hal-lo! What’s this? It isn’t——?”
“Yes,” said I, sedately.
“Little Monica engaged?”
“Yes.”
“Come, not really, what? No! You don’t say so, really?”
“I am afraid I must, Major Montresor.”
“By—Jove! And I never heard! Here’s a blow!” He sighed
tempestuously. “Well! Youth will be served! Fortunate youth!” he
prattled on without a break. “I’m sure he’s to be congratulated, the
dog. Always hanging round you in the old days, I remember. Yes!
Cultured sort of young Johnny with a beard—what was his name,
now? Ah, I have it—Vandeleur, of course, young Sydney Vandeleur!”
Pleasant for me, wasn’t it? To have this voice from the Past
blurting out—less tactful even than Cicely!—the name of the lover I
had lost. In a flash I saw my employer’s slight movement—saw by
the passing look on his face that his “business-man’s memory,”
which never forgets a name, had instantly associated that of
“Vandeleur” with those people at the Carlton to whom I’d first
introduced my “fiancé.” What must he imagine? Still, that wasn’t the
point. The point was that he should explain to this gossiping little
Major, as quickly as possible, how things really—I mean officially,
stood! To my horror he didn’t speak. There was an agonizing pause.
I shot a glance at the Governor.... Heavens! He, of all people,
seemed utterly at a loss—fidgeting like a schoolboy; he who could
“break the news” to his staff at the office without turning a hair, was
leaving it all, here, apparently to me!
Well!
Hurriedly I was beginning:
“But, Major Montresor——” when the drawing-room door opened
to the entrance of Mrs. Waters, in her soft grey satin wrap and black
picture hat; Cariad, liberated and tail-wagging, in her wake.
Greetings were exchanged—what talk followed I scarcely heard,
until the gentle voice of the Governor’s mother exclaimed:
“Oh! Then you had met my son’s fiancée?”
“Fiancée?” echoed Major Montresor. His monocle dropped again,
so did his jaw. I never saw a man so utterly, so comically taken
aback. He wheeled abruptly, to stare from me to the Governor, then
back to his hostess again. “Your son’s? Am I to understand that it is
he who is engaged to Miss Trant?”
Here at last the Governor did find his tongue.
“I have that honour,” he said, clearing his throat, taking a step
forward, and looking down at the little Major just as some tawny
Great Dane might have looked at Cariad—but no! No big dog can
ever look as utterly silly—there’s no other word for it—as a man who
doesn’t know what to say next. And he who had, it appeared,
particularly wished to avoid being made to look a fool on this
occasion—Well! He must admit that it was none of my doing that he
stood there looking like that!
 “Well, well, well! I suppose I shall have to grin and bear it and
congratulate you, Waters,” rattled off Major Montresor. “I certainly
do congratulate you!”
“Doesn’t feel sorry for you,” I added mentally, hoping the
unspoken comment showed in the one glance I allowed myself to
steal at my employer as I crossed over to sit on the low chintz couch
beside his mother, while the visitor talked on.
“Still, you might have prepared me for this, my dear fellow. You
might have given your heart-broken rival some warning. Let me
down a bit gently, eh? about how you were robbing me of the one
girl I’d hoped might solace my declining years. Met Miss Trant, Mrs.
Waters? Bless my life, rather! Used to billet myself for months at
Colonel Trant’s house in the old days—ripping old place it was, too;
gorgeous beech avenue; lawn something like your own here, but
sweeping away down to the river—oh, ripping! What’s become of the
place now, Miss Monica; let, I suppose?”
“Sold,” I said, shortly.
Without looking up from the patch of carpet on which Missis’s little
dog slumbered with his muzzle resting against my shoe, I could feel
the change that came into my employer’s grey glance—the half-
disconcerted “M’m. News to me, all this!” expression that just flicked
across his face. His mother’s hand made a little movement towards
mine—and for some reason I felt that she was a little sorry.... I was
furious! Why on earth couldn’t this little he-gossip—though why they
should understand by the word “gossip” an old woman, I never shall
know—why couldn’t he allow these people to go on thinking that the
typist her employer had chosen to honour had never been before
inside any sort of house but one of a row of seventy or eighty, all
with the same sort of pot-plants hiding what lay beyond the
Nottingham lace curtained windows, with the same neat front door,
and the same metaphorical wolf crouched grimly in front of it!
Desperately I wished that something might suddenly deprive Major
Montresor of the power of speech, only I suppose nothing ever could
do that!
 Evidently he wasn’t going to spare me anything. I was to stand full
in the limelight of other days.
“Hope the new tenants will keep it up as they should, then, that’s
all”—genially. “They took on the fishing with it, I suppose?
‘Everything went together.’ What? I see. Hope they’ll take as much
pride as your poor father did in those magnificent hot-houses of his.
Ah, I’ve never tasted peaches like those, anywhere else! Remember
how you used to race me down to get the finest peach before
breakfast, Monica? Yes, hang it all, I think I shall have to ask your
leave to go on calling her that, Waters. Loved her from childhood’s
hour, y’see. Her childhood’s, not mine, of course!”
“Oh,” murmured the Governor.
Miss Robinson would have been kept in high spirits for the next
week by that “Oh.”
It didn’t amuse me much as I sat there, carrying out to the letter
my promise to say nothing and look shy. I was feeling at least as
embarrassed as I looked by the time tea was brought in and the girls
made their appearance; Blanche with her fair hair unmanageably
soft from its washing; Theo, as usual, all eyes for the visitor. I hoped
they might distract his attention from me—they’re quite young
enough!—but no! All the time he was sipping his tea and munching
slice after slice of cake, the little Major continued to pour out
comment after embarrassing comment upon my affairs, addressing
himself chiefly now to the Governor.
He sat looking still more hopelessly uncomfortable and bigger than
ever in contrast to the frail china tea-cup and the slice of wafer-like
bread-and-butter in his clutch. Why do people allow men in at
drawing-room teas? Why couldn’t those two have been having theirs
in the billiard-room—the garage—anywhere—where I could have
been saved from Major Montresor’s relentless flow of conversation?
“And to think I should have known you all these months without
suspecting that your gain was to be my loss—no, no, I don’t mean
the business part of it, my boy. I mean this engagement of yours,
ha, ha! And then—funny thing! to be congratulating the wrong man.”
“Oh, were you?” burst suddenly, irrepressibly, from Theo, unable
to check the following “Who?”
“Theo-dora, dear!”
“Ah, never mind, never mind!” took up the little Major, turning
quickly to the child and smiling from her to me. “I don’t tell tales out
of school, young lady. But brown eyes”—with another monocled
glance at those wide search-lights under the yellow curls—“brown
eyes always stand for fickleness! There must have been a dozen at
least of us that you treated disgracefully, Monica, eh? One comfort is
I’m not the only sufferer!”
He was not!
My heart sank lower and lower at the thought that this garrulous
little blunderer was to stay for dinner. And the other expected guest,
the outspoken uncle, was to be here for the whole week-end! What
would he be like? Not worse than Major Montresor—that was the
single ray of comfort. Nothing could be worse! Still, the two together
—what a prospect!
Even as I was shuddering over it, the sound of some confused
commotion was borne in to us from the hall; and then a loud, bluff,
breezy voice positively shouted:
“Name? My good woman, you’re pretty new to this house, or
you’d know my name. Same as your master’s. No! Don’t announce
me. I’ll announce myself.” (As if this were necessary!) “Where are
they all? Tea? Good! Young lady there too? Excellent!”
The door, this time, burst open, and in avalanched (it’s the only
word) Uncle Albert Waters.
 CHAPTER XVI
THE ORDEAL BY INSPECTION

In looks, Uncle Albert Waters was just like the John Bull of the
cartoons, minus the hat. In voice, he was Theo through a
megaphone. In manner, a genial form of hurricane.
“Now then, now then! How’s everybody?” he blared. “Mary!
Blanche! Theo!” (An explosive kiss to each.) “Ha! Billy, my boy!” (A
violent blow on the shoulder.) “Major Montresor, glad to see you
again—how are you? Still defying the enemy? Splendid!” (A pump-
handle shake of the hand.) “Now, Billy!” turning again to my
employer. “You needn’t introduce me to your sweetheart. She knows
who I am, and what I’ve come for. What I want is to have a good
look at her. Young lady,” to me, “will you be kind enough to oblige
an old man whose eyesight’s not quite what it was, by turning full to
the light?”
I did. What else could I do?
I sat, facing the low flood of late afternoon sunshine, and feeling
without seeing that all the others turned a little away from me, while
Uncle Albert fixed his prominent, honest grey eyes upon my face and
stared at it without reserve for—well! it seemed several of the
longest minutes I’d ever known. Then judgment was pronounced.
“Well done, Billy!” Here there would have been another of those
heavy blows upon the Governor’s broad shoulder, but he had edged
away. “You’ve chosen well, boy. A bonnie girl, and a well-bred one,
and one to do you credit. Now, Mary, I’m ready for that tea. And,
you, my dear”—meaning me—“pass me the bread and butter. What’s
your name, now?”
 “My full name is Monica,” I said for the benefit of Major Montresor
who had fixed the monocle with something like mild indignation
upon the last comer. “They call me Nancy, here.”
“Nancy. A pretty name for a pretty girl, appropriate, too. ‘All my
fancy dwells upon Nancy’—eh, William? You used to sing that song
once upon a time, dare say you haven’t forgotten it, now?”
And so on, and so forth. I really don’t know how much more of it
there was before the dreadful old man had finished his ample tea
and was carried off to his room by the Governor in much the same
humour, I thought, as he had dragged Cariad and his bone to the
back of the house.
A pity Uncle Albert Waters couldn’t be locked up in the tool-house!
I felt like murder when I reached my pretty room at last. What a
day it had been! It had seemed forty-eight hours long at least.
Beginning with that horrible walk to the station with the Governor—
Then there had been the unwelcome appearance of Major Montresor
and his clumsy blunderings, first about Sydney and secondly about
the old times at home—and now this terrible old Uncle turning up to
inspect and blare out his embarrassing verdict upon my looks and
suitability; oh, it’s the last straw!
It’s the worst that’s happened yet! There can be nothing to beat
the Governor’s Uncle at tea, even though the evening isn’t yet over. I
feel as if it were long past bed-time, and there’s only half an hour or
so before dressing for dinner! Even half an hour alone——
But I haven’t been allowed a minute of it alone.
The girls fluttered into my room almost as soon as I came up;
brimful of sympathy, but not sympathetic enough to keep
themselves from laughter.
“Poor dear Nancy! Wasn’t it awful?”
“Didn’t I tell you Uncle Albert was a terror? But you don’t think he
really talks like me, Nancy, do you? Billy will say he does!”
 “Theo! He can easily hear you from his room, and the window’s
open. Oh, I do hope that when I’m engaged my young man won’t
have quite such loud relations!”
“Better than having deceitful whispery voices and saying horrid
things in them about you behind your back,” retorted Theo. “And
anyhow, Uncle Albert did like her!”
“Yes,” said Blanche, deprecatingly, “but isn’t it nearly as terrible as
if he disapproved?”
“It’s worse,” I decided to myself as I dressed for dinner, in my
white, to please Theo, who apparently has some mysterious child’s
reason for wanting me to wear that particular frock to-night. “Even if
one were madly in love, a relation like that would be quite enough to
make one wonder if it were worth it! Yes! Even if one were really
engaged to be married to a man—the man Mr. Waters would ‘pity,’
one would break it off rather than put up with such an uncle-in-law.
Well! Thank goodness I’m spared that at all events! I hope Uncle
Albert won’t pay many of his visits of inspection during the next year.
One or two ought to be enough for him, and I’ve taken the plunge
now,” thought I, “and got it over. He can’t go on being much more
awful at dinner!”
 CHAPTER XVII
THEO SITS UP

Yes! It was all of a piece with the fiascoes of the day that my little
watch gained ten minutes, hurrying me through my dressing and
down, before I’d any need for such haste, into the drawing-room.
Here, big and black-and-white against the giant pink roses of the
chintz couch, I found (as I needn’t have hoped not to find, on this
day of contretemps!) my employer alone.
He sprang to his feet, of course, and wheeled forward a chair for
me (looking as if he wished he could have pushed it and me through
the French windows and out of the house for ever!—Goodness
knows I reciprocated that wish!) and I sat down.
Then ensued what I’m beginning to call to myself “one of our
pauses.”
But I felt that this evening my nerves wouldn’t stand silence—that
nothing could float me over these quicksands of awkwardness but
an unceasing ripple of small-talk. If he wouldn’t, I must say
something; anything! The first thing that came into my head!
“H—how close it is! Do you think there will be thunder to-night?”
There was suppressed thunder enough on his face as he answered
politely: “It is getting rather stifling. Perhaps you would like the
window open?” and he rose and walked across to it.
Then, from under the chintz valance of the couch where he’d been
sitting, there emerged at small and cringing form with an enormous
white satin bow tied to his collar.
“Poor Cariad!” I went on, patting the unusually subdued little dog,
“you have got a smart new tie! Don’t you like it?”
 A one-sided conversation didn’t meet the case, so the “dumb
animal” (as they call it) gave me the cue for my next remark to the
almost equally dumb human being.
“I’ve always wanted to know where he got his rather curious
name,” I said. “What does it mean?”
“It’s Welsh,” explained my employer abruptly, still standing by the
open window. “It means ‘Sweetheart’”—if you must know, his tone
concluded.
“Oh.... Is he a Welsh terrier?”
“We got him from Wales. From a little place in Anglesey where my
people sometimes go for the summer holidays,” my employer
vouchsafed, with an effort. “Porth Cariad the name of it is—‘Port
Sweetheart.’”
“Fancy calling a place that!” I took up, with the one idea of
keeping this conversation from coming to a dead stop. “But some
people call anything that!” (I was wondering inwardly what this last
remark could possibly mean even as I went on.) “Is it by the sea?”
“Er—I think so.”
“Oh, yes; ports generally are, of course.... Is it—is it a pretty place
at all?”
“Quite. It hasn’t been spoilt yet. Charming little bay. The usual
sort of thing.” (Pause.)
“Yes—? Do tell me about it!”
“Oh! I don’t know—There are about two cottages. No end of gorse
—heather.”
“How lovely!” Then, scenting another pause, I hurried on—“Isn’t
there anything else there?”
“Well—There’s a sort of woman.”
“A woman? Really? How interesting! What sort of a woman?”
 “Oh, a wooden one,” returned the Governor, who was too
obviously thinking about something else. A wooden woman! What
could he mean by it? But before I could begin my next question the
door opened; the Governor turned quickly, then, seeing who came
in, he exclaimed in accents of concentrated disgust:
“Theo! Isn’t it time you were in bed?”
“No! Because I’m not going! I’m going to sit up for dinner, just for
this once!” announced the child, triumphantly advancing upon us in
a Prize-Day “effect” of let-down white skirts and long, cream-silk-
stockinged legs. “I asked Mother, and that nice old man” (Poor Major
Montresor!) “begged her to let me, and I may! So there! Nancy,
don’t you like the way I’ve done my hair for it?”
She had tied a fillet of white satin—a bit of the same ribbon which
was disconcerting Cariad—about her short curls.
“What’s that for? To keep your brains from bursting through?”
demanded her brother crossly. But Theodora only tossed that yellow
posy of a head of hers, retorting that Major Montresor thought she
was sixteen, and was going to sit next her, and that there would be
a surprise at dinner!

* * * * *

The surprise—or the series of surprises—didn’t dawn upon me in

its full hideousness all at once.
In the dim-shaded dining-room, where the tall maids flitted
noiselessly to and from the hatch at one end, the round table about
which the seven of us sat down seemed, with its many candles in
the curving arms of Sheffield candlesticks, its gleaming white
porcelain, and its winking, patterned array of silver and cut glass,
like some great oasis of softly-radiant light. Upon it, as table-centre,
there was set the silver-bordered pool of an oval mirror, reflecting a
large silver goblet, round which I could read part of the inscription:
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