Section 2 Clinical Research

#### **Chapter 5**

## Effect of Unilateral Neglect with Basal Ganglia Bleed in Stroke Survivor

*Ashna Sinha and Meena Gupta*

#### **Abstract**

Basal ganglia accounts to most common site of hemorrhagic stroke (50%). Right hemisphere lesions that are restricted to basal ganglia are responsible for perceptual disorders such as unilateral neglect. Unilateral Neglect is a very common perceptual disorder that occurs after stroke. Unilateral neglect when compared to the stroke severity results in poor overall recovery. It may involve longer hospitalization period, functional dependency, long term disability in ADLs as well as increased risk of falls. Postural imbalance is more prevalent with right hemisphere lesions. Stroke survivors with right hemisphere damage have less ability to ambulate. As the stroke patient's balance is impaired and can lead to serious consequences like falls. So, if we know the questions related to balance and gait in stroke patients then it would be very important for us to understand these two physical capabilities among the hemiparetic subjects. It is therefore believed that it will lead to a better direction regarding the rehabilitation of these stroke patients. The case report presented here describes the clinical presentation of a right basal ganglia bleed patient who had unilateral neglect.

**Keywords:** unilateral neglect, BG bleed, Catherine Bergego scale, Fugl Meyer assessment

#### **1. Introduction**

Stroke is the 3rd major cause of morbidity and mortality in many countries. It is basically of three types: ischemic, thrombotic & hemorrhagic. Ischemic stroke results from reduced blood supply, thrombotic stroke results from clot formation in a blood vessel whereas hemorrhagic stroke results from rupture of blood vessel. The latter is of following two types: intracerebral and subarachnoid [1]. Among the intracerebral hemorrhage, basal ganglia bleed is most common. It usually results from poorly controlled or long-standing hypertension [2]. Cigarette smoking and alcohol consumption further adds on to the risk of developing such stroke. Basal ganglia accounts to most common site of hemorrhagic stroke (50%). Other sites are cerebral lobes (10%), pons & brainstem (10–20%), thalamus (15%) and cerebellum (10%) [2, 3]. Right side cortical stroke is closely related to perceptual disorders. Many studies suggests that right hemisphere lesions that are restricted to

basal ganglia are responsible for perceptual disorders such as unilateral neglect [4]. Unilateral Neglect is a very common perceptual disorder that occurs after stroke. It can be defined as the inability to respond, report or orient to stimuli on contralateral side to brain lesion [5]. ULN is of different types. On the basis of behavior that is elicited it is classified into sensory, motor, and representational type and on the basis of abnormal behavior distribution ULN is of personal & spatial type [6]. Unilateral neglect can be assessed by many qualitative as well as quantitative tools such as Behavioral Inattention Test, Cancelation test, Line bisection test, Copying & drawing test, Catherine Bergego Scale etc. Unilateral neglect when compared to the stroke severity results in poor overall recovery. It may involve longer hospitalization period, functional dependency, long term disability in ADLs as well as increased risk of falls [7]. Postural imbalance is more prevalent with right hemisphere lesions. Stroke survivors with right hemisphere damage have less ability to ambulate. This is because they have lesser ability to shift weight on the non-paretic leg [8]. Acquiring independence of gait is one of the prime goals in rehabilitation of stroke subjects. Unilateral Neglect leads to poor gait recovery of activity of daily living as well as gait [9, 10]. Unilateral neglect when clubbed with cognitive impairment has a negative impact on independent gait recovery. Thus, this indicates that the unilateral neglect when combined with cognitive impairments is a strong negative predictor for independent gait [11]. Postural instability is the main cause of falls & limited functional independence among the stroke patients. Posture deficits as well as balance deficits is very common. This is because the good limb has to bear a greater proportion of the body weight. The correlations of parameters of balance and gait is utmost important for thorough assessment of stroke subjects as well as for their proper rehabilitation. This is because a reliable correlation means that resources used to improve balance could also influence gait. As the stroke patient's balance is impaired and can lead to serious consequences like falls. So, if we know the questions related to balance and gait in stroke patients then it would be very important for us to understand these two physical capabilities among the hemiparetic subjects. It is therefore believed that it will lead to a better direction regarding the rehabilitation of these stroke patients. The case report presented here describes the clinical presentation of a right basal ganglia bleed patient who had unilateral neglect.

#### **2. Case presentation**

A 40-year male presented with weakness in left arm & and leg along with difficulties in doing ADLs as well as walking since last 2 years. He also complained of occasional headaches. It is a known Follow up case of right basal ganglia bleed with Left Complete Hemiplegia. 2 years prior to episode of stroke, the patient had gone to pick up his elder son from school. He suddenly felt weakness on left side of his body while he was talking to some other parent on the street. He lost control of his body and fell on the ground. He was then immediately taken to Safdarjung hospital where CT Scan of brain was done which revealed intracranial bleed. His family members then took LAMA from there and admitted the patient to Max Super-Speciality Hospital for further management. NCCT head was done which showed a large hematoma in right basal ganglia region with intraventricular extension and midline shift to the left. The doctors then performed right sided decompressive craniectomy with evacuation of hematoma on 1st Feb 2019. He was managed in ICU on ventilator & necessary support. His condition gradually improved and he was then discharged

#### *Effect of Unilateral Neglect with Basal Ganglia Bleed in Stroke Survivor DOI: http://dx.doi.org/10.5772/intechopen.104383*

from the hospital. He received regular physiotherapy sessions during his stay in the hospital. He was advised for cranioplasty after 1 month. He was then admitted in Vimhans hospital on 19th July 2019 for cranioplasty. He underwent regular physiotherapy sessions again during his stay at the hospital. After being discharged from the hospital he did exercises at home but since there was not much improvement even after 2 years so his neurologist referred him for regular PT sessions at hospital's Physiotherapy OPD. Patient has history of hypertension since last 5 years and the medicines he was currently taking for that included Tab levesam 500 mg BD, tab Serta 25 mg OD, tab tryptomer 10 mg BD, tab Napra D 250 mg BD and Pantocid 40 mg OD and anti-hypertensive drugs. Patient has habit cigarette smoking (2–3 cigarettes/week). He lives with his wife and 4 kids who help the patient with his activity of daily living. He lives on first floor of the building which has no lift facility. The staircase has proper railings. So, the patient moves up & down through stairs with support of his family members.

On observation the patient was found to be ectomorphic with left side facial asymmetry. He was wearing a shoulder sling. He had circumductory gait but was using quadripod cane for ambulation. On examination he was alert, attentive & oriented with intact short term & long-term memory but impaired immediate memory. He had slurred speech. He was depressed and had MMSE score 20/30 along-with presence of unilateral neglect. All the cranial nerves were intact except left facial nerve. He had left facial nerve palsy with jaw deviated towards right side. Superficial and deep sensations were impaired. Babinski sign was positive on left side. All the DTRs had grade 3+ except supinator jerk which was normal. Tone was remarkedly increased in left upper & lower limb. PROM was within normal ROM but patient had no AROM. Voluntary Control grading for synergy pattern had grade 0 initially with brunnstorm stage 3. Tremors were present in left hand whenever patient did any activity with concentration. Limb girth for both upper & lower limb was remarkedly reduced. Posture assessment in anterior view revealed lt. shoulder drop, rt. side torso shift, lt side pelvic shift, lt hip hike, foot planterflexion & inversion whereas posture assessment in lateral view showed forward head, posterior pelvic tilt and knee hyperextension.

Balance Assessment was done according to Functional Balance Grade: sitting balance (static & dynamic) had grade 2 score and standing balance (static & dynamic) had grade 1 & 0 respectively. Other outcomes measures used were Modified Rankin Scale (Grade 4), Catherine Bergego Scale (Score 17/30), Fugl Meyer Assessment Scale for stroke (UL = 38, LL = 52; total = 90/226). NCCT Head revealed evidence of gliosis noted in right basal ganglia, adjacent fronto-temporo-parietal region with resulting ex-vacuo changes. Mild herniation of brain parenchyma noted at the site of craniectomy defect. Small gliotic focus noted in left basal ganglia region. (20/07/21). Physiotherapy goals were established for the rehabilitation protocol which continued for the duration of 6 weeks (4 times/week). After completion of the rehabilitation, the outcome measures were re-assessed and the prognosis of the patient was reported (**Tables 1** and **2**).

#### **3. Results**

The pre and post assessment score of CBS and FMA have been shown in **Table 3**. After the treatment protocol followed, there was marked improvement in unilateral neglect and sensory-motor recovery following stroke. Overall percentage improvement

#### **PT Goals**

#### **Short term goals**


#### **Table 1.**

*Physiotherapy goals for intervention.*

#### **Long term goals**




#### **Table 2.** *Intervention protocol.*

in FMA score was more for lower extremity (24.44%) than that for upper extremity (11.11%). Percentage improvement for overall FMA score was 14.6%. There was remarkedly more improvement in unilateral neglect (30%) (**Figures 1**–**3**). There was even significant improvement seen in voluntary control grading for synergy pattern, brunnstorm stages, functional balance grade and modified rankin scale as mentioned in **Table 4**.


#### **Table 3.**

*Pre & post score of CBS and FMA along with percentage improvement.*

### **Figure 1.**

*Pre & post score of CBS (percentage improvement 30%).*

**Figure 2.**

*Pre & post score of FMA for UL & LL (percentage improvement 11.1% & 24.44% respectively).*

#### **4. Discussion**

The purpose of this study was to find out the effect of unilateral neglect with basal ganglia bleed in stroke survivors. In this study, a stroke survivor with right BG bleed was administered to a six-week intervention protocol following the episode of stroke that occurred 2 years ago. A complete neurological assessment was carried out including

*Effect of Unilateral Neglect with Basal Ganglia Bleed in Stroke Survivor DOI: http://dx.doi.org/10.5772/intechopen.104383*

#### **Figure 3.**

*Pre & post score of FMA (percentage improvement 14.6%).*


#### **Table 4.**

*Prognosis chart.*

certain outcome measures such as MMSE, Voluntary control grading for synergy pattern, Brunnstorm stages of stroke recovery, Functional balance grading, Modified rankin scale, Catherine begego scale and Fugl meyr assessment of sensory & motion functions.

Unilateral Neglect is a very common perceptual disorder that occurs after stroke. It can be defined as the inability to respond, report or orient to stimuli on contralateral side to brain lesion [5]. It is the inability to understand and integrate stimulus and perception from side of body (body neglect) & environment (spatial neglect) [12]. Left sided unilateral neglect which occurs following the episode of right cerebral stroke is more common than the right sided unilateral neglect which occurs following the episode of left cerebral stroke [13]. The prevalence rate of unilateral neglect is 12–100% in case of right hemisphere stroke whereas in case of left hemisphere stroke the prevalence rate ranges between 0 and 76% [14].

Unilateral neglect is more common in acute as well as sub-acute phase. Left hemisphere stroke causes more severe unilateral neglect as compared right hemisphere stroke [15]. Unilateral neglect is mainly caused by right hemisphere damage resulting from stroke which leads to difficulties in attending to stimuli in the left perceptual hemifield. The brain damage that leads to neglect usually involves infarcts in the inferior parietal lobe, temporo-parietal junction & the superior temporal lobe. Unilateral neglect is most common & severe and it occurs following the episode of right cerebral hemisphere infarct [16]. ULN is of different types. On the basis of behavior that is elicited it is classified into sensory, motor, and representational type and on the basis of abnormal behavior distribution ULN is of personal & spatial type [6].

Unilateral neglect can be assessed by many qualitative as well as quantitative tools such as Behavioral Inattention Test, Cancelation test, Line bisection test, Copying & drawing test, Catherine Bergego Scale etc. [6] Out of these tests, in this study CBS has been used to assess the presence as well as the severity of unilateral neglect in stroke subjects. CBS tool has a high sensitivity in evaluating hemi-neglect, and its inter-researcher reliability was highly reliable as r = 0.93 [17]. Unilateral neglect when compared to the stroke severity results in poor overall recovery. It may involve longer hospitalization period, functional dependency, long term disability in ADLs as well as increased risk of falls [18].

Basal ganglia bleed is most common among all types of intracerebral hemorrhages. Long-standing hypertension is one of the major cause responsible for BG bleed. Cigarette smoking and alcohol consumption further adds on to the risk of developing this stroke. Basal ganglia accounts to most common site of hemorrhagic stroke (50%) [2]. Due to the uncommon nature of BG bleed, stroke cases having lesions confined to globus pallidus, caudate & putamen, only limited number of cases have been reported [19]. Neuropsychological problems such as depression occurs very commonly when there are large lesions in basal ganglia [20].

Balance related issues are most commonly seen in stroke survivors. Issues related to balance are often associated risk of falls and mobility problems. Maintenance of balance involves complex interaction of musculoskeletal and neural systems. Out of these, neural components involve motor system, sensory system and higher level cognitive & perceptual processes. Perception and cognition play a very important role in balance control [8]. Postural imbalance is more prevalent with right hemisphere lesions. Stroke survivors with right hemisphere damage have less ability to ambulate. This is because they have lesser ability to shift weight on the non-paretic leg [8]. Perceptual deficit is one of the contributing factors to balance issues which is more commonly seen in right hemisphere stroke lesions. Inappropriate body perception affects the alignment of the body [8].

Acquiring independence of gait is one of the prime goals in rehabilitation of stroke subjects. Unilateral Neglect leads to poor gait recovery of activity of daily living as well as gait [9, 10]. Unilateral neglect when clubbed with cognitive impairment has a negative impact on independent gait recovery. Thus, this indicates that the unilateral neglect when combined with cognitive impairments is a strong negative predictor for independent gait [11].

Postural instability is the main cause of falls & limited functional independence among the stroke patients. Posture deficits as well as balance deficits is very common. This is because the good limb has to bear a greater proportion of the body weight. The correlations of parameters of balance and gait is utmost important for thorough assessment of stroke subjects as well as for their proper rehabilitation. This is because

#### *Effect of Unilateral Neglect with Basal Ganglia Bleed in Stroke Survivor DOI: http://dx.doi.org/10.5772/intechopen.104383*

a reliable correlation means that resources used to improve balance could also influence gait. As the stroke patient's balance is impaired and can lead to serious consequences like falls. So, if we know the questions related to balance and gait in stroke patients then it would be very important for us to understand these two physical capabilities among the hemiparetic subjects. It is therefore believed that it will lead to a better direction regarding the rehabilitation of these stroke patients.

Basal ganglia bleed patients are prone to have cognitive impairments [19]. According to a study done by Hochstenbach et al. [21], it is stated that striatum of brain receives inputs from mostly all the cortical regions, thalamus, and limbic system thus playing an integrative role in processing the cognitive information processing. Thus, impairment in cognitive domains occurs following BG patients. Such deficits in BG may lead to deficits in other domain. Aphasia and dysarthria type of speech disorders have a prevalence of about 13% of 240 BG bleed cases. This also occurs due to large lesions in basal ganglia. Damasio et al. 1998 explained about speech disorder having reduced fluency in addition to mild defects of repetition, comprehension & dysarthria [20].

Unilateral neglect is also associated with basal ganglia disorders. Visuospatial functions or hemineglect helps to discriminate between stroke patients and healthy subjects [19]. From a global point of view, destruction of the cortex-striata circuits involving the temporal & parietal lobe leads to difficulties with hemispatial analysis, visual organization and even organization of behavior. Damage of striata impairs performance of striata with respect to spatial cues [22]. According to Harris et al., BG bleed patients have problems of mental rotation of the objects into spatial framework thereby leading to problem of perceptual disorders such as unilateral neglect [23]. Coughlan 1979 explained that with regard to lesion laterality, right BG bleed patients have poorer performance in visuospatial domain whereas left BG bleed patients have more problem in language domain [24]. Thus, rehabilitation of BG bleed patients should always include interventional strategies to work cognitive impairments, unilateral neglect in addition to the basic stroke rehabilitation.

#### **5. Conclusion**

This study sheds light upon the effect of unilateral neglect with basal ganglia bleed in stroke survivors. According to the study conducted it was found that perceptual disorders are predominant in right hemisphere lesions. Unilateral neglect being common among the perceptual disorders. Cognitive impairments following the episode of stroke is closely related to such condition depending upon the size of lesion. Neuropsychological dysfunctions such as depression and speech abnormalities such as dysarthria & aphasia are also commonly seen in BG bleed cases. Thus, planning a rehabilitation protocol for such patients should include interventions to work upon unilateral neglect, neuropsychological dysfunctions and speech disorders in addition to improvement in sensory & motor functions for early recovery of stroke survivors. The patient in this study underwent 6 weeks rehabilitation program in the OPD. He was referred to neuro-psychiatrist for medications & counseling for his neuropsychological problems. Referral was also made to speech therapist for his speech problems. He regularly performed home exercise program which was designed by the physical therapist under the supervision of his caregivers. Thus, after following the six-week intervention protocol the patient responded well in terms of sensory-motor recovery and as well showed significant improvement in unilateral neglect.

*Neurorehabilitation and Physical Therapy*

### **Author details**

Ashna Sinha and Meena Gupta\* Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, India

\*Address all correspondence to: mgupta9@amity.edu

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

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[2] Chen S, Zeng L, Hu Z. Progressing haemorrhagic stroke: Categories, causes, mechanisms and managements. Journal of Neurology. 2014;**261**(11):2061-2078

[3] An SJ, Kim TJ, Yoon BW. Epidemiology, risk factors, and clinical features of intracerebral Hemorrhage: An update. Journal of Stroke. 2017;**19**(1):3-10

[4] Karnath HO et al. The subcortical anatomy of human spatial neglect: Putamen, caudate nucleus and pulvinar. Brain. 2002;**125**(2):350-360. DOI: 10.1093/brain/awf032

[5] Talhatu HK et al. Clinical and demographic correlates of unilateral spatial neglect among community dwelling Nigerian stroke survivors. African Journal of Neurological Sciences. 2012;**31**(1)

[6] Plummer P, Morris ME, Dunai J. Assessment of unilateral neglect. Physical Therapy & Rehabilitation Journal. 2003;**83**:732-740

[7] Gammeri R et al. Unilateral spatial neglect after stroke: Current insights. Neuropsychiatric Disease and Treatment. Dovepress journal. 2020;**16**:131-152

[8] Sulay R, Sadhale A. Comparison of balance in sub-acute stroke patients with dominant lobe versus non-dominant lobe involvement of age group 25 to 60 years using balance evaluation system test (BESTest): A pilot study. International Journal of Health Sciences and Research. 2020;**10**(8):2249-9571. ISSN: 2249-957

[9] Di Monaco M, Schintu S, Dotta M, Barba S, Tappero R, Gindri P. Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke. Archives of Physical Medicine and Rehabilitation. 2011;**92**:1250-1256

[10] Paolucci S, Antonucci G, Grasso MG, Pizzamiglio L. The role of unilateral spatial neglect in rehabilitation of right brain damaged ischemic stroke patients: A matched comparison. Archives of Physical Medicine and Rehabilitation. 2001;**82**:743-749

[11] Kimura Y et al. Impact of unilateral spatial neglect with or without cognitive impairments on independent gait recovery in stroke survivors. Journal of Rehabilitation Medicine. 2019;**51**(1): 26-31

[12] O'Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation. Sixth ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2014. pp. 1235-1243

[13] Azouvi P et al. Rehabilitation of unilateral neglect: Evidence-based medicine. Annals of Physical and Rehabilitation Medicine. 2017;**60**:191-197

[14] Bowen A et al. Reasons for variability in the reported rate of occurrence of unilateral spatial neglect after stroke. Stroke. 1999;**30**:1196-1202

[15] Schroder ST et al. Clinical and functional differences between right and left stroke with and without contralateral spatial neglect. Journal of Rehabilitation Medicine. 2020;**52**:jrm0000X

[16] Saevarsson S, Kristjansson A, Hjaltason H. Unilateral neglect: A review of causes, anatomical localization, theories and interventions. PubMed. gov National Library of Medicine. 2009;**95**(1):27-33

[17] Marques CLS et al. Validation of the Catherine Bergego scale in patients with unilateral spatial neglect after stroke. Dementia e Neuropsychologia. 2019;**13**(1):82-88

[18] Gammeri R et al. Unilateral spatial neglect after stroke: Current insights. Neuropsychiatric Disease and Treatment. Dovepress Journal. 2020;**16**:131-152

[19] Su C-Y et al. Neuropsychological impairment after hemorrhagic stroke in basal ganglia. Archives of Clinical Neuropsychology. 2007;**22**:465-474

[20] Bhatia KP, David Marsden C. The behavioural and motor consequences of focal lesions of the basal ganglia in man. Brain. 1994;**117**:859-876

[21] Hochstenbach et al. Congnitive deficits following stroke in basal ganglia. Scopus preview. Clinical Rehabilitation. 1998;**12**(6):514-520

[22] Mijovic-Prelec D, Bentley P, Caviness VS Jr. Selective rotation of egocentric spatial representation following right putaminal hemorrhage. Neuropsychologia. 2004;**42**:1827-1837

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#### **Chapter 6**

## Neurofunctional Intervention Approaches

*Joseph Nshimiyimana, Potien Uwihoreye, Jean Claude Muhigirwa and Theogene Niyonsega*

#### **Abstract**

Neurofunctional approaches play the paramount functions in management of neurological disorders to improve the functional capability after impairments and activity limitations. These interventional approaches aligned with the neuroplasticity theories and all rely on repetition matters to build up engrams for the change of the brain function and activity performance. Affolter approach guides cognitive perceptual interaction through tactile-kinesthetic inputs. Neuromuscular facilitation relays the periphery information to the central nervous system by joint and muscle stimulus by using different techniques such stretching, irradiation, traction and approximation. Neurodevelopmental therapy manages the abnormal movement and postures through hands on facilitation of normal movement and inhibiting abnormal patterns movement. Roods approaches focus on the primitive reflexes through sensory stimuli to the targeted sensory receptors to initiate the appropriate motor pattern development. Brunnstrom approaches build on the synergies to provoke the engagement of the affected limbs. Task-oriented approaches are based on motor learning and involve repeat training with task-oriented activities. It is effective for improvement of the functional performance. It is a training method for encouraging functional movement with an interesting task. And also it improved the dexterity when applied using mixed interventions in hemiplegic.

**Keywords:** neurology, function, approaches, interventions, neurofunctions

#### **1. Introduction**

In 1980s, neurofunctional approaches (NFA) were presented as one of the few intercessions made fundamentally for clients with extreme shortfalls taking after traumatic brain injury (TBI) [1, 2]. Particularly, NFA is intended for clients who were restricted in their capacity to unravel novel issues or generalize abilities from one setting to another [3], and whose lack of insight constrained their capacity to engage within the rehabilitative process [3, 4]. This unit will summarize different approaches utilized as an interventional program for individuals enduring from distinctive neurological disorders.

#### **2. Affolter approach**

The Affolter approach is an innovative perceptual-cognitive approach developed in Switzerland by Felicie Affolter in 1981. Affolter holds the degrees in child psychology, education of normal, deaf, and language disordered children; audiology; and language pathology and speech sciences [5]. She studied with Jean Piaget and uses his interaction model of development as a foundation for her theory. Affolter and Walter Biscofberger have conducted research specifically involving development based on tactile-kinesthetic (T-K) interaction. Affolter theory and treatment approach is designed to give the student food for thought about the process of cognitive-perceptual development and the relationship that exists between T-K input and problem-solving skills in daily life [6]. This practical technique emphasizes evaluation and treatment in realistic situations using functional and age-appropriate activities. It has been successfully used in the treatment of coma recovery; cerebral vascular accident (CVA), TBI, and other neurological deficits including Alzheimer's disease and aging issues, pervasive developmental disorder and autism, and learning disabilities [5]. The Affolter concept challenges the clinician to take a hands-on functional approach in the treatment of T-K perceptual deficits in addition to using the standard evaluations and assessment for visual and auditory perceptual processing. Affolter has developed the treatment technique of nonverbal guiding to facilitate perceptual-cognitive interaction. Therapy is geared toward emphasizing appropriate input through a problem-solving process rather than focusing on the output and successful completion of a product. In using this treatment technique, specific guideline should be carefully followed and continually practiced.

#### **2.1 Assumptions about the treatment framework**

#### *2.1.1 Treating patients in real situations*

A fundamental assumption of treatment is that children with Pervasive Developmental Disorder (PDD) do have the ability to learn, and adults with acquired brain damage can relearn, but they require offer of assistance in doing so [7, 8]. To provide them with the assistance, we must help them organize in the way they search information in a better way, so that interaction improves, and the root can grow [9]. Organizing the seek for data requires identifying sources of data and isolating significant [10], from unessential sources when interacting and participate in activities with a therapist's hand to guide the patient makes a significant change [10, 11]. To achieve this goal, patients need intervention in actual daily life situations, not in artificial environments.

#### *2.1.2 Targeting change in the underlying system*

The work of this therapy does not intend the specific skills as a separate skill or isolated goals of treatment that are separated from the interaction of tasks solving problems in everyday life [12]. If the child cannot eat or participate in play properly, treatment does not pay attention on the same principles [13], that is, enabling nonverbal interactions to occur by enabling the patient to pick up adequate information for interacting with the environment around them [13, 14]. Visual or auditory inputs are not presumed to be of adequate information, rather a tactile perception [15]. The input that is viewed as essential and primary is tactile input [16]. In the absence of tactile information, to help patients, treatment must be designed to get this information [17]. However, to get these inputs are not from the outside environment for

*Neurofunctional Intervention Approaches DOI: http://dx.doi.org/10.5772/intechopen.106604*

participating in everyday life [15, 17]. The kind and quantity of the data available for interaction are regarded as context dependent [18]; the situation demands changes from time to time and specifically with the required information for interaction [18]. Therefore, interacting in the activity is seen in the way of problem-solving event in all its aspects [19], including evaluating the processes, testing and creating in everyday life (for-example; eating spaghetti from the plate, getting toys from bathtub, putting on shoes, and getting a package through the door [20]. The problem to be solved or not will depend on the situation and available information in that situation [21].

#### **3. Proprioceptive neuro-muscular facilitation**

What we know nowadays as proprioceptive neuromuscular help (PNF) started as "proprioceptive assistance" a term created by Dr. Herman Kabat in the early 1940s. In 1954, Dorothy Voss included the word "neuromuscular" to deliver us the presently familiar proprioceptive neuromuscular facilitation, (PNF) [22]. Dr. Kabat's conceptual system for PNF came from his encounter as a neurophysiologist and doctor [23]. The work of Elizabeth Kenney, an Australian nurse who treated polio patients with particular stretching and strengthening exercises, was an early impact on Kabat [24]. Kenny's work was seen as a flight from the typical treatment at the time but needed the establishing of the sound neurophysiological method of reasoning Kabat coordinates Sister Kenney's manual method with Sherrington's disclosure of progressive acceptance, corresponding innervation, and restraint, and the marvel of irradiation [22]. They conclusively stated that PNF is a neurophysiological approach in which impulses from the periphery are facilitated to the central nervous system (CNS) through the stimulation of sensory receptors present in muscles and around the joints by stretch, resistance, traction, approximation, and audiovisual. Many therapists use PNF to help people regain their range of motion after injury or surgery [25]. However, it can also be used by athletes and dancers to improve their flexibility [26].

#### **3.1 Principles of proprioceptive neuromuscular facilitation**

The effectiveness of the PNF principles and procedures based on the integration of the appropriate use of joint and soft tissues mobilization [25]. The core PNF science can be universally utilized in any treatment approach [26], since the foundation is the evaluation and treatment of posture and movement [27]. The utilization of PNF for spinal dysfunction is enhanced by different working knowledge such as arthrokinematics, neurophysiology, and possible pathomechanics of the spine [27].


py, the neck and head are considered first during treatment since they affect the design of the motion in the body [26]. As well the next motor development is the trunk, which has central role of the body alignment [27]. Fine motor skills and extremities are developed following optimal function of the head and neck [26].


#### **4. Rood approach**

Rood's approach is one of the neurophysiological and traditional approach based on hierarchical theories of CNS development [39]. This approach was developed by Margaret Rood in 1940 [40]. The essential concepts of this approach involves the motor patterns development through the sensory stimuli based on primitive reflexes and normal motor development patterns to progress motor performance skills [41, 42]. Rood's approach theories support the activation and de-activation of the receptors by sensory stimulation through facilitation and inhibition techniques [41]. Which of them concerned with the interaction of different factors such somatic,

#### *Neurofunctional Intervention Approaches DOI: http://dx.doi.org/10.5772/intechopen.106604*

psychic and motor behaviors regulations [42]. The roods approach used by different health professionals in handling the motor control problems of patients, resulted from neurological insults [43]. The interventions process of the approach is based on development of the CNS, whereby the motor pattern development facilitated or inhibited for rehabilitation purposes [44–46]. Rood's philosophy focused on establishing typical motor development through building up required motor engrams [47].

#### **4.1 Rood's approach techniques**

The key principles of the Rood approach includes: normalizing tone, sequential developmental of autogenic motor patterns, repetition and purposeful-directed movement [48]. Though Rood's theories started in the 1940s, todays there are few corrections experienced some time recently she passed on, the modification handle has proceeded till presently based on current neuroscientific evidence [41]. Margret Rood during the discovery of this approach, Rood developed stages of motor control: Mobility, stability, controlled mobility, and skill [49]. She further worked on the sequence of motor development during the development of a child under each stage; reciprocal inhibition, [50] innervation/mobility, a reflex governed by spinal and supraspinal centers, subserves a protective function [50], phasic and reciprocal type of movement [50], contraction of agonist and antagonist, co-contraction, [50] c0-innervation/stability, simultaneous agonist and antagonist contraction with antagonist supreme [50], heavy work/controlled mobility [50], Stockmeyer "mobility superimposed on stability", and Creeping [50]. Skill, crawling, walking, reaching, activities requiring the coordinated use of hands [49, 50]. Rood's approach is one of several of the neurophysiological approaches created at that time and is centered upon four fundamental concepts to consider amid treatment: duality, the ontogenetic sequence, manipulation of the autonomic nervous system, and the level of sensitivity of the front horn cell [51, 52]. Following proprioceptive facilitatory techniques are used: heavy joint compression, stretch, intrinsic stretch, secondary ending stretch, stretch pressure, resistance, tapping, vestibular stimulation, inversion, therapeutic vibration and osteopressure [45, 53]. Finally, she developed following spasticity; inhibitory technique: gentle shaking or rocking, slow stroking, slow rolling, light joint compression, tendinous pressure, maintained stretch and rocking in developmental stages [53].

#### **5. Brunnstrom approach**

In 1951, Dr. Thomas Twitchell, a neurologist, published a seminal paper in which he described the longitudinal progression of motor recovery in 121 patients [54]. Twitchell observed that, early in recovery, these people tended to demonstrate stereotypical movement patterns. In addition, he observed that they tended to progress in their motor recovery through a consistent series of stages [54]. Twitchell did not hypothesize why some patients recovered further than others and did not present any recommendations for therapeutic interventions that might influence motor recovery [55]. Signe Brunnstrom, a physical therapist, combined Twitchell's findings with her own clinical observations to develop a treatment approach that was designed to facilitate the progression through the stages of recovery that Twitchell had reported. Brunnstrom's major contributions were:

• Her detailed description of reflexes and associated reactions exhibited by patients with post-stroke hemiplegia


Many of Brunnstrom's contributions remain influential today. The associated reactions and reflexes she described are still recognized as characteristic features of motor behavior in stroke survivors with limited recovery [56]. A major difference is that Brunnstrom advised therapists to use techniques to elicit these pathological responses in an effort to stimulate movement. Today, however, rehabilitation professionals seek to prevent eliciting these responses [46]. The current understanding is that reflexive movements are not precursors to active, functional motor performance. Currently, rehabilitation professionals disagree on whether to consider the limb synergies as primary sequelae of the neurological damage (as Brunnstrom and Twitchell stipulated) that patients develop when they attempt to move in spite of underlying mechanical obstacles, such as immobility at the pelvis or scapular [57]. Those who view the flexor and extensor synergies of the upper limb as maladaptive strategies organize therapeutic interventions to prevent or remove specified "obstacles to movement" that may lead the person to develop inefficient motor strategies. Those who view the synergies as unavoidable motor deficits that precede full recovery of motor function are not concerned when patients move in these stereotypical patterns of movement [57]. There is no controversy, however, about the efficacy of following a therapeutic sequence in which the therapist guides the patient in moving through the six postulated stages of recovery. This paradigm for structuring motor therapy is not supported by current understanding of neuroplasticity and recovery of motor function after stroke.

#### **5.1 Brunnstrom stages of recovery for the affected arm**

According to [58], in their study on a neurophysiological and clinical study of Brunnstrom recovery stages in the upper limb following stroke, outlined the following stages of motor recovery:

Stage I Flaccidity: no voluntary movement, muscle tone, or reflexive responses Stage II Synergies can be elicited reflexively; spasticity is developing Stage III Beginning voluntary movement but only in synergy; spasticity may be significant

Stage IV Spasticity begins to decrease; ability to voluntarily perform movements that deviate slightly from synergy patterns

Stage V Increased control of isolated voluntary movements, independent of synergy patterns

Stage VI Isolated motor control; spasticity is minimal Stage VII Normal speed and coordination of motor function

#### **5.2 Principles of the Brunnstrom approach**

The Brunnstrom approach is based on two key principles: Principle both normal movement which signifies how a healthy individual moves, [59] it requires muscles to work together, following damage to the CNS the muscles will not work as well together [59–61]. During recovery, muscles will start working together better and following damage to the CNS, movement recovery follows a specific sequence [59, 61]. The sequence is:


### **6. Neurodevelopmental therapy/Bobath approach**

Bobath approach which is also known as neurodevelopmental treatment (NDT) [62], is named after a physiotherapist Berta Bobath, and her husband Karl, a neuropsychiatrist proposed it for management of neurological injury impairments [62]. The Bobath approach is defined as client-centered hands on and a problem-solving approach [63]. It is used in management of individuals with abnormal movement and postures resulted from neurological injuries [63, 64]. This approach was first developed for effective management of patients with cerebral palsy manifested by neuro-motor dysfunctions [65–67]. The Bobath concept provided a reference that viewed children with Cerebral Palsy (CP) as having difficulty with postural control and movement against gravity [50]. The Bobath concept provided a reference that viewed children with CP as having difficulty with postural control and movement against gravity [50]. Bobath approach is used in all age group of persons with CNS lesion which resulted into functional dysfunction either movement of postural control. It is referred as both problem-solving approach to the assessment and treatment [68]. This approach underpinned the neurophysiological theories of motor control, motor learning and neural plasticity. This relied on new normal movement patterns and postures learned as a result mastered, and forms cortical representation of repetitive motor patterns. According to [69], the functional movement needs motor, sensory, cognitive, perceptual and biomechanical to be well efficiently produced in individuals with neurological injury. The task learning is influenced by the environmental condition, performance components needed to perform an activity and the evidence showed that neurofacilitation techniques of handling increases sensorimotor in initiation and performing the activity [70].

#### **6.1 Clinical approach of Bobath concept**

#### *6.1.1 Motor control*

Bobath approach concerns with personal factors such as sensory, perception, adaptive behavior and motor control skills of patient [71]. Bobath approach which is task-specific and goal-directed approach, [72] facilitates the optimal motor functions of the individual through the organization of proprioceptive and exteroceptive environments [72]. This client-centered approach focuses on neurological impairments resulted from either UMNL or LMNL to change motor performance [73], through selective activation of cutaneous and muscle receptors [63]. The muscle activation and sensory input to specific task

facilitates complete accomplishment of the task in different contexts and environments, [74] taking into account the perceptual and cognitive demands [74]. It is recommended to be practiced in different real-life situation other than clinical milieu [23].

#### **6.2 Basic principles of Bobath approach/neurodevelopmental treatment**

According to [75], there are six principles of NDT management:


A case scenario of application of Bobath approach in training sitting and standing. They are both main motor function to achieve independent locomotion, to use upper limb and hand [77]. In daily life of individuals these activities of sitting and standing acts as the major in performing other activities including normal movement, locomotion, reaching and grasping [78]. They are a number of different factors which influence the training of sit to stand including seat height, foot positon and upper limb. Seat height, the research evidence considered the length of levers in individuals but the modification and adaption is important respectively the capacity of the patient to optimize progressively the performance of the patients and also grading down or up is considered as the patient is improving the performance capacity [79–81]. Foot position has the impact in sitting to standing positons. During the initiation of the propulsion the heels should be either up or down, even it has limited number of researches and need more discussion [82]. The several studies support the position of the upper limb should be folded across the body. The position facilitated lower limb propulsion [83]. Interlimb neural coupling support the body alignment and proper activity activation as the major the concept of Bobath approach. In addition it releases the workloads of the lower limb [79]. According to [83] the restriction of upper limb in involvement of the body postural transition from sitting to standing remarkably changes the nature of the task. The study conducted [84] mentioned

#### *Neurofunctional Intervention Approaches DOI: http://dx.doi.org/10.5772/intechopen.106604*

four core stages of sitting to stand namely flexion momentum, momentum transfer, extension, and stabilization. Flexion momentum begins with initiation of the movement and ends just before the buttocks lift from the chair (seat off). Momentum transfer begins at seat off and ends at maximal ankle dorsiflexion. Extension phase just after maximal ankle dorsiflexion until cessation of hip extension. Stabilization from when hip extension ceases until all movement has stopped.

As described in **Table 1** there are many factors which have to be taken into consideration when implementing this approach and evaluating its outcome and effectiveness. The mentioned aspect can have an influence in achieving the goal with the patient. Thus when choosing the task, the therapist need to think of multiple varieties in terms of task nature, person capacity and environmental contexts.

During interventions the nature of therapy based on task demands, impairments and environmental contexts as shown in **Table 2**.


#### **Table 1.**

*Different aspects of the task, person and environment.*


#### **Table 2.**

*Components of therapy setting to be considered.*

#### **7. Constrained induced movement therapy**

Constrained Induced Movement Therapy (CIMT) showed the effective improvement in post-stroke patient improving the motor function of the affected arm [85]. This approach forced the affected arm to involve in task-oriented activities such as Activities of Daily Living (ADLs) [85]. Transcranial magnetic stimulation showed the increase in electrical stimulation on lesioned area from pre-to post Constrained Induced (CI) therapy to patient with stroke. There is expansion of the motor cortex representation of the affected arm. The cortical reorganization remarkably increased in mental imaging of the motor functional activities being repeated by the affected arm [86, 87]. In acute poststroke patients there was a high significance improvement in all scores of Barthel index and functional independence measure (FIM) measures (eating, bathing, grooming and dressing) [88]. The intervention provided is the application of padded mitten on unaffected arm and training an affected arm with UE motor function and ADLs for at least 6 hours/day during 14 days [88]. This is the similar protocol that was first developed by Taub [86, 89] in investigation of the effects of CIMT on humans. However the protocol different from Taub referred to as modified CIMT (mCIMT). CIMT has high effects on affected upper limb of the stroke patients compared to other alternatives treatment or no treatment. This approach of CIMT work in more neurological conditions including spinal cord injury [90], where the study conducted on effects to Unilateral cortical Spinal Tract Injury in adults rat prove that there was growth and synapse formation of CST fibers from the intact side into the denervated spinal cord, synapse formation in the denervated cervical gray matter [90]. Growth and arborization of CST fibers was accompanied by marked behavioral improvements. But not limited to other conditions such as Multiple Sclerosis and cerebral palsy [90–94].

#### **8. Task-oriented approach**

Task-oriented approach found as an important approach in improving the functional outcomes in post-neurological injured persons. There was proved that balance, ADLs, and self-efficacy improved in hemiplegic patients [95, 96]. The provided interventions done in five times a week for four weeks, the session has 30 min, each task is performed three times for 10 min, with a 2-min break between each task [97]. The evaluation tools were modified Barthel index, Berg balance scale, and self-efficacy scale. The results of the Mann-Whitney U test also revealed significant differences in the BBS, MBI, and SES scores before and after training (*p* < 0.01). This approach showed also a remarkable impact in improving the balance and upper body skills in children with cerebral palsy as the study conducted [98–100] proved that all subjects had positive changes in gaining stability of standing and walking. The interventions program provided in two times/ week, 40 min/session during 15 weeks. The outcome of the intervention program is associated with the intelligence of the subjects that should be positive or negative respectively the level of the capacity to follow instructions and cognitive learning ability. The above client-centered task-oriented approach program was used as it is based on motor learning and involves repeat training with task-oriented activities [98].

The client-centered task-oriented approach program in **Table 3** was used, [98] and it is based on motor learning and involves repeat training with task-oriented activities [98]. It is effective for improvement of the functional performance of a child with CP [98]. In addition, it is a training method for encouraging functional movement while providing children with an interesting task [98]. And also it improved


#### **Table 3.**

*Task-oriented activities in children with cerebral palsy.*

the dexterity when applied using mixed interventions in hemiplegic Cerebral palsy patient both bilateral manipulation and unilateral task-oriented activities [101, 102]. This approach preliminary study concluded that it should also be feasible and safe to be applied in persons with multiple sclerosis with moderate mobility impairments [103, 104]. The rigorous systematic review concluded that there is a little significance in improving the upper limb function and hand dexterity in patients with spinal cord injury thus the primary research was recommended for further re-evaluation of the effectiveness of the approach [105].

#### **9. Mirror therapy**

Mirror therapy is a motor imagery process that modulates central mechanisms of motor recovery and neural plasticity. Mirror Therapy (MT) might have an effect on premotor and somatosensory cortex to activate the neurons in facilitating motor functions [106, 107]. MT is implemented by asking the patient to sit in front of the table with mirror and putting the arms both affected and unaffected on different sides of the mirror and during the performing the activities with unaffected arm the patient looks at the mirror to form motor image. With a case scenario which provided a session of 20 min/day, 5 days/week for 4 weeks showed significance in improving motor function of upper extremity [108].

The findings of the clinical stated the good outcome in reducing motor impairments, motor functions and ADLs as they were examined by FIM, Brunnstrom stages of recovery and Fugl-Meyer assessment (FMA) [109–111]. The study combined MT and electronic-mesh-glove found higher significance in normalizing muscle tone, improving hand skills, transfer as they were examined by MAS, box and block test (BBT), Action Research Arm Test (ARAT), and FIM [112]. Both involves in use of sensory stimulation such as kinesthetic inputs and visual illusion. As mentioned before MT activates premotor and somatosensory cortex and MG influence the activation of the sensory motor cortex [113–115]. Thus there is an increase in stimulation of somatosensory inputs which is likely to have remarkable effect of MT on movement control recovery.

#### **10. Interaction of person, occupation, and environment in activity participation after neurological disorder**

#### **10.1 Introduction**

As neurological disorders occur to persons from different professions, the Neurorehabilitation team encounters the challenge of helping clients in returning to a vast variety of occupations. These occupations include the different fields such as business, law, maintenance, office work, terrain work, medicine, housekeeping, accounting, police work, and as well as self-care occupations. Those challenges are grouped into three main aspects; which are person, occupation, and environmental. The quality of a person's experience, with regards to their level of satisfaction and functioning, is the outcome of the fit between the person-environment-occupation transactions [116].

#### **10.2 Changes at person level after neurological disorder**

After neurological disorder occurs to person level; there are changes in sensory and motor function, cognitive components, volition (interest and values), and financial; those changes interfere activity participation in many ways.


work tasks or leisure activities will erode one's feelings of self-efficacy and sense of personal capacity.

#### **10.3 Environment: impact of occupational, social, and physical environment**

Neurological disorders do not only affect person internally but also environment, therefore creating a need to modify environment to support their interests and roles. The MOHO classifies environment into three components: Physical, social, and occupational environment [120]. The physical environment includes both natural and built space where people do their day-to-day activities, changes due to neurological disorders. People who work at home or from home are required to find a supportive space at home or outdoor for participating in day-to-day activities. Occupational environment: According to Black [121], Occupational environment may be defined as the workplace surroundings that encompass the physical and social environment. The social environment can be seen as social relationships, immediate physical surroundings and cultural settings in which people function and interact. The patient with neurological disorders experiences a number of environment barriers, limiting their participation and re-integration after being discharged from hospital. Social environment: The social attitudes define the big part in participation of different areas of engagement such as education, employment, health care and public realm [122]. Negative attitudes towards the persons with disability hinder them from exploring their potentialities like other persons without disability. However, the positive social attitudes enhance the participation in more than one area [122]. Among of them includes home and community based engagement and inclusion, which in turn strengthen self-esteem through sense of belonging [122].

#### **10.4 Applying person-environment-occupation model interventions post neurological disorders**

**Figure 1** shows the extent of congruence in the person-environment-occupation (PEO) relationships is represented by the degree of overlap between the three spheres; the closer the spheres overlap, the greater the degree of harmony or fit [123]. According to PEO, the environment influences both person and occupation but, more importantly it can be easily modified more than person [116]. Thus the fitting between person, occupation and environment depends on the adaptability between those three components respectively the achieving goal of person [116]. Activity, task and occupation are all interrelated as they are the intervention tools used to gain occupational performance.

#### **11. Neuro-functional disorders assessment**

#### **11.1 Introduction**

Functional neurological disorders (FND) are among the most common causes of neurological disability [124]. There is no single factor to consider the cause of FND, but rather a combination of factors interacting together [125]. The etiology of FND is still specifically not known [126]. FND is caused by a complex combination of biological, psychological and social factors on the brain [127]. Referring to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [128], the term

**Figure 1.** *Person-Environment-Occupation(PEO) relationship.*

functional was adopted as the primary definition in the functional neurological symptom disorder [128]. This provides causative neutrality and may also increase patient understanding and acceptance [128]. The first decision in management of FND is the proper diagnosis followed by the explanation of the condition to the patients and care givers. After establishment of the disabling condition, rehabilitation team intervenes for long-term management [129]. Prior to individual follow up, every rehab personnel conduct a thorough assessment to highlight challenges to function and plan accordingly. The intervention plan should also include patient or caregiver involvement. Comorbidities, such as pain or fatigue and psychiatric comorbidities (anxiety, depression, dissociation etc.) should be carefully evaluated, as they need an individualized treatment plan [129].

#### **11.2 Features of functional neurologic disorders**

Motor FND, Suggestive clinical features include sudden onset, disappearance with distraction, increase with attention, and excessive fatigue or demonstration of effort [128]. With motor deficit, the presenting feature of the patients includes but not limited to dysfunctions of body structures in engagement of voluntary and purposeful task [130]. This includes inability to walk and to move the arm [125]. Sensation: sensory impairments in persons with neurological disorders include sensory loss, pain and abnormal sensation such as light touch and vibration [126]. The proprioceptive sensation mighty be also affected whereby the person losses the ability to sense the body part position [130]. Proprioception is tested by asking the patient to close eyes, and position the joint in space and let the patient identify the joint position [131]. A patient with functional proprioception will be able to correctly identify the exact

placement of body part. Axial FND, Functional axial disturbances include disorders of gait and posture such as excessive gait slowness, astasia-abasia and knee buckling [128]. Speech FND, the patients with speech difficulties experiences challenges in verbal response to the incoming request (Broca's aphasia) and understanding instruction (expressive aphasia)[132].

#### **11.3 Areas of assessment for neuro-functional deficits patients**

This is where now practice makes good performance, neurological exam sounds intimidating in the first occasions but the more ones enroll into examination, the more proficient becomes [129]. This is a hands-on patient stage and should not be escaped whenever neurological disorder is suspected.

The neurological exam can be organized into seven categories:


The practitioner approach neurological exam systematically and make sure that there is no area left unevaluated so as to mark the proper prognosis [129]. The preference of assessment approach should be followed to compare the affected part vs normal, distal vs proximal and let vs right mores especially the sensory impairments [129]. Mental Status: The mental status defines the reliability of the rest of neuro-exam. The patient keeps the appropriate eye contact and does not need things repeated, it signifies that he/she can converse. Thus you proceed with medical history and recent event in consistent manner [129]. The mental screening examinations include seven areas, which are attention, orientation, speech fluency, comprehension, verbal response, high cognitive involvement and memory [132]. But the therapist needs to test the status of mood to screening out the presence of psychiatric conditions [132]. This acts screening examination before deciding to proceed with high mental functions. Cranial Nerves: The cranial nerves consist of nerves that exit through foramina in the skull, not necessarily nerves that originate in the brain [131]. Neurologic impaired patients impose difficulties to the prognosis and recovery of the victim [133]. Therefore, cranial nerve screening should be set mandatory [133]. Thus a thorough evaluation should be included in evaluation process. Motor Exam: When assessing motor function among FND patients, it is of the utmost valuable to first distinguish the whether the case is of the upper motor neuron lesion or lower motor neuron lesion [131]. Depending on the strength of the patient, motor evaluation may

incorporate mobility [131]. During motor examination the practitioner is recommended to conduct motor exam to measure fall risk prior to evaluation to minimize the falling incidence [131]. Furthermore, during motor assessments the practitioners observes different aspects of person such as muscle build ups, muscle tone, endurance and movement [134]. As well both equilibrium and non-equilibrium tests should be considered whilst evaluating coordination deficits. In addition, the practitioner has to keep a limb in Position in such a way that there is risk of recruiting other muscles with similar function are kept minimal [135]. Reflexes: Tendon Reflex test is the most objective part of the neurological exam and is the least dependent on cooperation [131]. When test reflexes, the muscle for which tendon to be tested should be put to tension [131] and stress then quickly tap or use the standardized reflex or knee hammer to the tendon to be tested and observe the reaction [131]. The intensity and extent of briskness response has to be analyzed [131]. This should be repeated to the other side and compare against the normal range. Sensation: Both superficial and deep sensation should be tested in all four limbs. Superficial sensation (pain and temperature) this is channeled by unmyelinated and small myelinated nerve fibers through the ascending tract of spinothalamic [136]. Pain sensation can be tested with a safety pin or the broken end of a cotton swab [136]; temperature sensation can be tested with a hot or cold fluid filled test tubes [136], however cool metal object like a tuning fork maybe used as an alternative [136]. Deep sensation which combines pressure, proprioception, and vibration is mediated by large fibers through the dorsal and lateral aspects of the ascending tract [124]. Coordination and Gait Assessment: Incoordination should be noted when patient sits and stands upright, or getting onto the examination table [126]. Gait assessment should not be separated far from coordination among functional neurologic disorder patients [129]. Position of body in space, posture and extremity placement [137] and, speed, steadiness, arm swinging, heel strikes, stance, and heel to toe walking have to be considered in evaluation of gait [137]. While neurologists and other physicians play an important role early on, the treatment of FND, it is typically the purview of allied health professionals, including physical therapist, occupational therapist, speech and language pathologist, art, and recreational therapists to conduct assessment prior to intervention [130].

#### **12. Conclusions**

The neurofunctional interventional approaches imply the significant impact in changing the activity participation of persons with neurological disorder and injury in terms of treating impairments and improving the ability of activity performance after injury. These approaches have been approved by many clinical based evidences and they are mostly contextualized according to the nature of setting, nature of patient and therapist's own experience. Furthermore, among of all those traditional sensorimotor approaches have no remarkable significant difference in effectiveness and efficiency. Thus the therapist chooses the approach according to his/her experience in certain approach, clients conditions and practicing milieu. Besides to that all approaches favor the theories of neuroplasticity and building up required engrams needs repetitions. Apart from that the status of person, task and nature of real working environment have important influence in achieving the goal with the clients with neurological disorder or injury as long as brain insults result in many different areas of impairments such as motor, sensory, cognition and psychosocial issues.

*Neurofunctional Intervention Approaches DOI: http://dx.doi.org/10.5772/intechopen.106604*

#### **Acknowledgements**

NJ: Involved in reviewing articles and wrote about the literature of neurofunctional interventional approaches, involved in organizing and preparing the book chapter and followed up the progress of book chapter. UP: Involved in reviewing the articles and wrote about the literature of neurofunctional interventional approaches. NT: Involved in reviewing the articles and wrote about the literature of interaction of person, occupation, and environment in activity participation after neurological disorder. MJ: Involved in reviewing the articles and wrote about the literature of neurofunctional disorders assessment.

### **Conflict of interest**

None declared.

### **Author details**

Joseph Nshimiyimana1 \*, Potien Uwihoreye2 , Jean Claude Muhigirwa3 and Theogene Niyonsega4

1 Department of Occupational Therapy, Gahini Rehabilitation Center, Kayonza, Rwanda

2 Department of Occupational Therapy, King Faisal Hospital, Kigali, Rwanda

3 Department of Occupational Therapy, Autism Individual Care Center, Kigali, Rwaanda

4 Department of Occupational Therapy, Ndera Neuropsychiatric Hospital/Icyizere Branch, Kigali, Rwanda

\*Address all correspondence to: josephnshimiyimana50@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 7**

## Nutritional Support in Stroke Neurorehabilitation

*Andrés J. Ursa Herguedas and Emilio J. Guzón González*

#### **Abstract**

Acquired brain injury (ABI) due to stroke or cerebrovascular accident (CVA) is a frequent pathology that leaves sequelae, produces great personal and family suffering and has a great economic impact on health systems. Translational research and clinical evidence have revealed the existence of an intestinal dysbiosis in these patients before and after stroke that, ultimately, through the microbiota-gut-brain axis, is capable of producing neuroinflammation, negatively impacting the evolution of stroke and delaying functional recovery in the neurorehabilitation process. Individualized dietary intervention is proposed in order to reverse intestinal dysbiosis until reaching eubiosis and facilitate recovery. For this it would be necessary to have the figure of the nutritionist-dietician in the multidisciplinary team. The objective of this chapter is to report on the importance of nutritional intervention in stroke to obtain better results. Research in this regard must continue as several questions remain unanswered.

**Keywords:** stroke, cerebrovascular accident, gut microbiota, gut dysbiosis, microbiotagut-brain axis, neuroinflammation

#### **1. Introduction**

Stroke or cerebrovascular accident (CVA) is one of the most frequent reasons for urgent neurological care, it is one of the main causes of death and disability in adults and it entails an enormous human and economic cost in developed countries. In recent decades, various advances have been made in the treatment of stroke, such as early medical-surgical care, the creation of stroke units in health centers and rehabilitation treatment. Neurorehabilitation, applied in the different evolutionary stages of stroke, is one of the most decisive interventions when it comes to addressing neurological injuries and their functional repercussions of stroke [1]. Ischemic stroke is responsible for most cerebrovascular accidents, with hemorrhagic stroke being the second most frequent. The annual incidence of stroke in Spain is 156 new cases per 100,000 inhabitants and its prevalence is 500–600 cases per 100,000 inhabitants [2].

Occlusion of the middle cerebral artery produces ischemia in the affected territory, followed by an inflammatory and immune response [3]. Neurological deficits are usually present from the first moment.

In various studies on the gut microbiota (GM) in stroke patients, the presence of dysbiosis, altered intestinal permeability, the passage of bacterial lipopolysaccharides through the intestinal barrier into the bloodstream, the maintenance of a systemic low-grade inflammatory state (SLGIS) and neuroinflammation [4].

Given this state of knowledge, we have to find out what is the degree of contribution of SLGIS and neuroinflammation to the establishment of stroke? Can nutritional intervention to achieve intestinal eubiosis contribute to improving stroke prognosis and/or better functional recovery? Translational research and clinical evidence offer us the opportunity to systematically intervene in the stroke neurorehabilitation process with nutritional support in order to reverse the inflammatory state and facilitate the recovery process. To achieve this goal, it would be necessary to include a nutritionist-dietician in the multidisciplinary team that cares for these patients. We cannot forget the application of a holistic approach to the entire neurorehabilitation process, based on clinical and scientific evidence, all within the context of integrative medicine.

#### **2. Reciprocal influence between microbiota, gut and brain**

The intestine and the brain are in constant communication and for this they use different pathways such as endocrine, nervous and immune signaling. The balance between the different symbiotic bacterial species that populate the GM contributes to homeostasis through its participation in various metabolic pathways, the supply of nutrients such as vitamins and short-chain fatty acids (SCFA), stimulating the immune system, facilitating metabolism of substances not digestible by the host, acting on the metabolism of drugs and other xenobiotics, while avoiding colonization by pathogenic species [5].

This exchange of information occurs both via the nerves via neurotransmitters and via the blood (hormones, cytokines, metabolites …). The central nervous system (CNS), the autonomic nervous system (ANS), the enteric nervous system (ENS), the neuroendocrine and neuroimmune systems contribute to this process, forming a fluid exchange network [6, 7].

In murine models, it has been proven that, by stimulating the afferent pathways of the vagus nerve, through the production of metabolites (neurotransmitters, hormones, SCFA) or through interactions with the immune system, GM is capable of modulating brain activity. Similarly, signals are emitted from the CNS that affect the MI [8].

An important pathway by which gut microbes and their metabolites communicate with the CNS involves the cells that make up the gut endocrine system [9]. This communication is mediated by several microbially derived molecules including SCFA, secondary bile acids, and tryptophan metabolites [10]. SCFAs have been implicated as the main signaling molecules that mediate host-microbe communication through enteroendocrine cells (EECs) and enterochromaffin cells (ECCs). SCFAs are generated by the microbial fermentation of resistant starch and non-starch polysaccharides that reach the intestine. These molecules play a role in host energy computation, as well as other functions such as stimulation of local blood flow, fluid and electrolyte absorption, and intestinal mucosal proliferation [11].

SCFAs propagate signals primarily through interaction with EECs, ECCs, and the mucosal immune system. Some cross the intestinal barrier, enter the systemic circulation, and can cross the blood-brain barrier [12]. It has been shown that SCFA production stimulates L cells located in the distal ileum to secrete peptide YY and glucagon-like peptide-1 (GLP-1), which induce satiety and behavioral changes [13]. Among other SCFAs, acetate, butyrate, and propionate modulate GLP-1 expression and secretion via free fatty acid receptor 2 (FFAR2)/G protein-coupled receptor 43 (GPR43) and FFAR3/GPR41 in L cells [13]. Vagal receptors detect gut regulatory peptides, inflammatory molecules, dietary components, and bacterial metabolites and send this information to the CNS [14].

The blood-brain barrier (BBB) regulates the transit of molecules between the circulatory system and the cerebrospinal fluid of the CNS. In murine models, GM can regulate the expression of intestinal cell-to-cell tight junction proteins, including occludin and claudin-5, allowing BBB permeability to be reduced [15]. Systemic immune activation can cause disruptive changes in the BBB and is often modeled using lipopolysaccharides (LPS). Studies evaluating the effects of LPS in vivo on BBB function only showed disruption 60% of the time [16].

#### **3. Relationship between intestinal dysbiosis and neuropsychiatric pathology**

The presence of intestinal dysbiosis can affect the proper functioning of the body and is associated with the development of digestive pathologies, as well as other apparatus and systems such as the immune, metabolic, cardiocirculatory or nervous. In recent years, numerous studies have found links between GM alterations and the most frequent neuropsychiatric disorders such as depression, Alzheimer's disease, Parkinson's disease, autism spectrum disorder, psychosis and demyelinating pathology such as multiple sclerosis [17, 18]. It has been shown that nearly 90% of stroke cases may be related to behavioral factors including poor diet, smoking, and low physical activity, as well as obesity, hypertension, and/or diabetes mellitus. Several studies consider GM as a risk factor for stroke [19].

Under normal conditions, commensal microbes inhabit the outer layer of the colon. The mucus that covers it, rich in glycoproteins, is a source of energy for the microbiota when the amount of fiber in the diet is not sufficient. This circumstance favors the possibility of colonization by pathogenic microorganisms [20]. The inner layer is generally free of bacteria and serves to protect epithelial cells from microbial contact through physical separation and innate immune mechanisms including antimicrobial peptides and adaptive immune mechanisms such as secretory IgA [21].

In murine models it has been shown that stress can cause alterations in the intestinal barrier by directly modulating epithelial permeability and by altering the properties of the intestinal mucosal layer. This fact produces a greater translocation of intestinal microbes or molecules associated with microbes [22]. In these models, it has been shown that the permeability of the jejunum and colon increases in response to either acute or chronic stress [23]. Bacteria, such as Escherichia coli, and their products, as well as bacterial LPS, lead to a pro-inflammatory environment in the gut. Stress-induced changes in the expression of messenger RNA encoding tight junction proteins have also been described in the colon and jejunum [24]. In addition, stress leads to a less protective mucus layer through catecholamine signaling, which alters the composition and size of secreted mucus, as the ANS modulates mucus secretion by intestinal goblet cells, thereby affecting the thickness and quality of the intestinal mucus layer [25].

It is possible that the changes in GM composition observed in murine models of brain injury are the result of altered mucoprotein production and goblet cell population size mediated by increased sympathetic nervous system signaling [26]. Furthermore, epinephrine and norepinephrine have been shown to increase the virulence properties of various enteric pathogens as well as non-pathogenic microbes through stimulation of natural immune sensing mechanisms [27]. Substantial roles for gut microbial regulation of autoimmunity, inflammation, and immune cell trafficking have been identified in mouse models of multiple sclerosis and stroke [28, 29]. Toll-like receptors 3 and 7 recognize viral RNA, and Toll-like receptors 2 and 4 recognize peptidoglycan and LPS. These receptors are expressed in both the murine and human ENS [30].

Under normal conditions, various types of microorganisms and macromolecules manage to cross the intestinal barrier through the M cells, which are part of the lymphoid tissue associated with the intestinal mucosa. This activity allows the constant checking of microorganisms and various molecules [31]. On the other hand, Paneth cells detect bacteria autonomously through the activation of the Toll-like receptor dependent on the MyD88 gene, responsible for the innate immune response to pathogens, which triggers antimicrobial factors and, ultimately, limits the penetration bacteria in host tissue [32]. Microbes and microbial-derived ligands help maintain the tight junctions between cells that are critical for the integrity of the intestinal barrier [33]. All these mechanisms and their alteration for different reasons, make it possible for information to reach the CNS and various types of reactions to occur, such as neuroinflammation and accelerate brain aging, contribute to the genesis of various neuropsychiatric diseases and hinder or delay recovery of ABI.

#### **4. Neuroinflammation in the context of stroke**

Increasing evidence suggests that intestinal inflammation together with the immune response plays an essential role in the pathophysiology of stroke and this may become an important therapeutic target for the treatment of ABI [34]. The different communication pathways between the microbiota, intestine and brain, the increase in intestinal permeability and the passage of molecules through the BBB would make it possible to activate the immune cells of the CNS [35].

The BBB is made up of blood vessels that allow substances to pass into the CNS in a very selective manner to maintain correct homeostasis, guaranteeing correct neural function. The properties of this barrier are due to its architecture and the cells that make it up, the most important being the endothelial cells (EC), which have a great capacity to very selectively regulate the movement of ions, molecules and cells between the blood and the brain. Specific transporters are expressed in these cells that allow a selective passage of substances in both directions. To limit passage of immune cells into the CNS, ECs express very few leukocyte adhesion molecules. The set of all these properties allows the maintenance of cerebral homeostasis in a healthy situation [36].

The inflammatory process during cerebral ischemia involves the participation of glia and microglia, mediating the migration, infiltration, and accumulation of leukocytes to the brain parenchyma during ischemia. In ABI, the expression of cytokines (IL-1β, TNFα, IFNγ) and chemokines such as CCL2 (MCP-1), CCL5 (RANTES) and CXCL1 (GRO-α) has been demonstrated, which precedes the infiltration of leukocytes towards ischemic injury, acting through its receptors CCR2, CCR5 and CXCR2, respectively. Inflammation contributes to tissue injury during the early

#### *Nutritional Support in Stroke Neurorehabilitation DOI: http://dx.doi.org/10.5772/intechopen.106180*

phase of the hypoxic-ischemic response and during the healing process in the late phase of cerebral ischemia. Thus, chemokines exert an inflammatory action against brain damage, although some of them have a neuroprotective effect by inducing the synthesis of growth factors that contribute to brain regeneration based on neuroplasticity, all if the attention process of the patient is carried out in the optimal time and circumstances [37].

The changes in GM in patients who have suffered a stroke have been documented in several studies [38], but it is in murine models that the sequence of events and the repercussions for the evolution and functional recovery of the stroke have been appreciated. In murine models using two types of acute middle cerebral artery occlusion, large stroke lesions were found to cause intestinal dysbiosis, which in turn affected stroke outcome through immune-mediated mechanisms. Reduced species diversity and bacterial overgrowth of Bacteroidetes were identified as hallmarks of post-stroke dysbiosis, which was associated with intestinal barrier dysfunction and reduced intestinal motility following injury progression. The impact of the microbiota on immunity and stroke outcome was transmissible by microbiota transplantation [39].

#### **5. Nutritional intervention in stroke**

The composition of GM is defined by many factors, including the way of being born, the consumption of antibiotics, infection processes, stress, customs, ethnicity, habitat, hygienic habits, genetics and diet among others. Although used infrequently as an intervention specifically targeting GM, diet can have profound, rapid, and reproducible effects on GM structure in humans and animals [40]. Clinical experience and published studies, both in humans and in murine models, invite us to implement the analysis of GM in patients who have suffered a stroke and, in the case of intestinal dysbiosis, to intervene with the modification of the diet until eubiosis is acquired. At this level, there are still some doubts such as the optimal time to start the dietary intervention to act on dysbiosis, that is, in what phase of the stroke would it start? **Table 1** shows the stroke phases, their approximate duration and the units where they are treated according to Murie-Fernández et al. [1].

If we are willing to intervene in stroke patients, it would be convenient to add the figure of the nutritionist-dietician in the team that cares for stroke patients. **Table 2** shows the members of the multidisciplinary team in stroke rehabilitation according to Murie-Fernández et al. [1], to which we include the figure of the degree in human nutrition and dietetics.

A diet adapted to each patient who has suffered a stroke with intestinal dysbiosis, with adequate dietary fiber, the administration of probiotics, symbiotic, etc., could contribute to a better evolution and functional recovery to the current on


**Table 1.**

*Phases of stroke, duration and where it is treated according to Murie-Fernández et al. [1].*


#### **Table 2.**

*Multidisciplinary team in stroke rehabilitation according to Murie-Fernández et al. [1] and completed by A. Ursa and E. Guzón.*

neuroinflammation [41, 42]. More studies are still needed to expand knowledge, clear up doubts and design protocols adaptable to different patients and contexts.

#### **6. Conclusions**

Acute brain injuries such as stroke induce gut dysbiosis and, in turn, changes in GM influence neuroinflammation and thus function in ABI. GM is a key regulator in preparing the neuroinflammatory response to brain injury. These findings highlight the role that GM plays as a therapeutic target to protect brain function after acute brain injury. Dietary intervention in patients with stroke, either by nasogastric tube in case of unconsciousness or orally if there is no alteration of consciousness, would contribute to a better evolution of the stroke and functional recovery. Much remains to be discovered about the specific mechanisms by which GM is involved in the gutbrain axis and in disease development. Current evidence encourages us to continue researching on this topic.

#### **Funding**

This chapter has been funded by the Institute of Integrative Medicine (Valladolid, Spain).

#### **Conflict of interest**

There is no conflict of interest.

*Nutritional Support in Stroke Neurorehabilitation DOI: http://dx.doi.org/10.5772/intechopen.106180*

#### **Abbreviations**


### **Author details**

Andrés J. Ursa Herguedas1,2,3,4,5\* and Emilio J. Guzón González6,7,8,9,10,11,12\*

Institute of Integrative Medicine, Valladolid, Spain

Medicine and Surgery, Complutense University of Madrid, Spain

Junta de Castilla y León, Valladolid, Spain

Rehabilitation and Pain, University of Valladolid, Spain

Clinical Neurophysiology, University of Valladolid, Spain

Human Nutrition and Dietetics, University of Valladolid, Spain

Food Science and Technology, Complutense University of Madrid, Spain

Clinical and Community Nutrition, University of Alicante, Spain

Public Health, Carlos III Health Institute in Madrid, Spain

Health Sciences, Doctoral School of the University of Valladolid, Spain

Food and Nutrition Research Team (ALINUT), University of Alicante, Spain

Miguel de Cervantes European University, Valladolid, Spain

\*Address all correspondence to: ajursa@educa.jcyl.es and guzonemilio@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Nutritional Support in Stroke Neurorehabilitation DOI: http://dx.doi.org/10.5772/intechopen.106180*

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#### *Neurorehabilitation and Physical Therapy*

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#### **Chapter 8**

## Mild Cognitive Impairment: An Overview

*Biraj Bhattarai and Hema Nagaraj*

#### **Abstract**

Heterogeneity of symptoms within and among mild cognitive impairment (MCI) individuals often makes it challenging to document cases clinically. Number of diagnostic criteria have been proposed in recent decades. MOCA and MMSE are two tests useful for the assessment of MCI, besides the neuroimaging studies with MRI and PET scan, have provided promising results in the early diagnosis of MCI. Lifestyle changes and cognitive training have been found to be more effective in the treatment of individuals with MCI.

**Keywords:** cognitive impairment, amnestic, non-amnestic, MoCA, MMSE, cognitive training

#### **1. Introduction**

#### **1.1 Cognitive decline in aging**

Changes in brain morphology resulting from normal aging have been documented in neuroimaging studies. The results show that there are alterations in white matter integrity, white matter hyper-intensities, and reduced hippocampal volumes [1–3].

Cognitive decline is a common phenomenon associated with normal aging and is getting a lot of attention among clinicians. Some of the earlier labels such as "benign senescent forgetfulness," [4] "age-associated memory impairment" (AAMI) [5], "ageassociated cognitive decline" (AACD) [6], and "age-related cognitive decline" [7] are frequently used to describe the deterioration in cognition.

The decline in cognitive performance with aging is due to several cognitive processes, including a reduction in processing speed, working memory capacity, and loss of sensory input. This thereby results in deficits in encoding, storing, and retrieving information, but cognitive capability remains unaffected [8, 9]. The problems are mainly noted while retrieving information from the long-term and short-term memory store, where the retrieval of information is slower in the former, and the amount of information that can be stored decreases in the latter [9].

During the aging process, the onset of dementia has been widely reported. Recently, the label "mild cognitive impairment (MCI)" has been used to signify the intermediate condition between dementia and normal aging [10]. Cases presenting with the following signs and symptoms such as (i) informant-corroborated history of memory symptoms, (ii) impairment in memory when measured objectively

(usually <1.5 standard deviations on a verbal memory test), (iii) spared general cognition, (iv) activities of daily living (ADL) well preserved, and (v) no dementia are recommended to use this label [11]. Recent criteria proposed include the following cognitive domains for diagnosing MCI, and four subgroups made are of (1) only memory deficit; (2) memory deficit along with deficits in other cognitive domains; (3) deficit in the non-memory domain; and (4) non-memory domain deficit along with deficits in other cognitive domains [12, 13]. Evidence suggests that cognitive decline in MCI has no adverse effects on the activities of daily living in contrast to dementia, and this is consistent with the definition of "mild neurocognitive decline"(NCD) from DSM-V [14]. Cognitive decline was studied in individuals with Alzheimer's disease (AD), mild cognitive impairment (MCI), and normal cognition for 11 years, and it was concluded that the cognitive capacity in the normal group declined at a slower extent than in the MCI group and that of the MCI group declined at slower extent than the group with Alzheimer's disease [15]. Studies report that all cases diagnosed as MCI do not progress to dementia [12, 13].

There is substantial evidence that neuropathological alterations occur several years before the clinical manifestation of Alzheimer's disease (AD) [16, 17] and that subtle cognitive abnormalities persist up to 9 years before a dementia diagnosis [18].

As a result of these findings, researchers have coined the term moderate cognitive impairment (MCI), which was coined by Flicker, Ferris, and Reisberg [19]. MCI is defined by Petersen and colleagues [16] as a transitional, preclinical state characterized by intermediate symptomatology between cognitive changes associated with healthy aging and the more pathological alterations associated with Alzheimer's disease [20].

Memory complaints (confirmed by an informant), objective evidence of memory impairment (for age and education level), generally intact overall cognitive function, essentially preserved activities of daily living, and the absence of dementia are all clinical criteria for diagnosing MCI, according to the American Academy of Neurology [21]. Separate subgroups of MCI have been found more recently [12] based on the element of cognition that is most impacted. Memory loss is the most significant symptom of amnestic MCI (a-MCI). In longitudinal studies, this kind of MCI is the most frequent and is most likely to be related to conversion to AD.

**Figure 1** depicts current perspectives on the shift from healthy cognitive aging to amnestic MCI and Alzheimer's disease. Single non-memory domain MCI (sd-MCI) is another subtype of MCI that is characterized by significant abnormalities in linguistic skills, executive function, or visuospatial function [12]. Finally, multiple domain MCI (MD-MCI) is characterized by the involvement of multiple cognitive domains and can occur with or without memory problems (MD-MCI + a). According to epidemiologic research, persons diagnosed with MCI are substantially more likely to develop AD or dementia within 5 years than those without MCI. In one study, 56% of amnestic MCI individuals and 50% of non-amnestic MCI participants transitioned to Alzheimer's disease or dementia within 4 years [22].

**Table 1** summarizes the four widely recognized subtypes of MCI. Generally, a case of MCI is classified in one of the following four subtypes as per four essential characteristics, (1) Complaints of cognitive problems; (2) Memory impairment; (3) Impaired or spared functional ability, and (4) Presence or absence of dementia. Within MCI, amnestic versus non-amnestic MCI is classified based on memory impairment. Suppose an individual is objectively confirmed to have memory-related issues. In that case, it is classified within amnestic types, and if s/he has issues related to other domains of cognition rather than memory, then it is confirmed to be

#### *Mild Cognitive Impairment: An Overview DOI: http://dx.doi.org/10.5772/intechopen.106192*

#### **Figure 1.**

*Current perspectives on the shift from healthy cognitive aging to amnestic MCI and Alzheimer's disease.*


#### **Table 1.**

*Four widely recognized subtypes of mild cognitive impairment (MCI).*

non-amnestic. Further, if a single aspect of cognitive function is affected, it is termed a single domain, and if two or more elements are involved, it is confirmed to be multiple domains.

#### **1.2 MCI—signs and symptoms**

There are three main types of trajectories seen in cognitive decline, which are (1) Stable pattern, observed for the impaired language skills; (2) Gradual pattern, noted for immediate recall, inhibition, and visuospatial skills; (3) Stable period followed by accelerated decline pattern, seen in delayed recall, visuospatial memory, and working memory skill [23]. It has been reported that episodic and working memory are the domains that are affected to a greater extent among MCI individuals and present with the fastest decline in those individuals who progress to other groups like dementia. These studies have consistently found that memory deficits are the major deficits reported by individuals with MCI or their caregivers [24].

Individuals with MCI exhibit a wide range of difficulties in multiple areas of cognitive functioning, such as attention, memory (primary and secondary), visuospatial ability, and language and executive functioning [6]. MCI has been considered a "syndrome" due to the presence of a cluster of symptoms centered around major neuropsychological manifestations, such as (i) complaints of noticeable cognitive decline, (ii) memory deficit observable on tests, and (iii) spared activities of daily living except mild deficit in instrumental activities of daily living [25, 26]. Evidence suggests individual with MCI usually presents with the complaint of a certain decline in normal cognitive functioning. Evidence shows that mood variations are a good predictor of MCI [26–28]. An important diagnostic variable is the presence of preserved activities of daily living. However, it is observed that the instrumental activities of daily living are much more affected than the ADLs [26]. For example, an auto-driver with MCI might face more difficulty executing his skill/or job effectively.

Regarding the diagnosis of MCI, there is a considerable amount of debate going on. Previous literature has reported that the condition of MCI is characterized solely by memory impairment. Further studies, however, supported that MCI could be an impairment in the non-memory domain alone or a condition with multiple cognitive components (executive function, memory, language, etc.) being affected simultaneously [10, 12]. Research suggests that MCI generally develops into an Alzheimer's disease (AD) type of dementia. However, contradictory studies also support that MCI is reversible or could develop into non-AD type dementia [10, 29]. Therefore, to bring uniformity to the diagnosis of MCI, the international working group on MCI has given modified criteria for diagnosis, suggesting any cognitive impairment that fails to meet the diagnostic criteria of dementia is categorized as MCI [10].

#### **2. MCI assessment**

According to Petersen et al. [30], the clinician can use the progression criteria as per the description provided in the flowchart for an easy understanding of the procedure used for making a diagnosis for MCI. The same is depicted in **Figure 2** [31]. The clinician is thus faced with the challenge of evaluating this symptom, given that the patient appears with a cognitive concern. It is vital to obtain a patient's history and confirm it with someone who is familiar with the patient. It is critical that the patient, the patient's informant, or the physician expresses some level of cognitive concern. The cognitive concern is important since it reflects a change in the person's performance. MCI is not meant to reflect a person's low cognitive function for the rest of their life; rather, it is meant to show a shift in this specific person's cognitive function. As a result, the clinical history is vital in the absence of formal longitudinal

**Figure 2.**

*Flowchart for clinical evaluation and diagnosis of cases with MCI.*

cognitive data on an individual. The clinician should emphasize the types of cognitive changes the patient has experienced. If the primary concern is memory loss, the clinician should focus on recent forgetfulness occurrences (approximately in the last 6 months to a year). In cases of forgetfulness involving current events, appointments, visits by friends, or conversations, the physician should be particularly interested. If the patient begins to repeat themself, this indicates that impairments are emerging. Again, the clinician should evaluate for changes in that person's memory or cognitive performance [32].

The clinician should investigate the extent of the cognitive impairment. The question is whether the issue is solely about memory or does it also involve other cognitive areas like attention and concentration. Patients frequently identify cognitive alterations in the memory domain when, in reality, they may be referring to attention or language issues. It is essential to define the breadth of the cognitive shift. The clinician will need to conduct a mental status examination and explore the various cognitive domains at this time. If schedule allows, a mental status assessment using an instrument like the Montreal Cognitive Assessment (MoCA) or the Short Test of Mental Status can be useful, but the clinician should be aware that these screening instruments are insufficient to make the diagnosis; however, they can be useful in isolating domains of impairment and advising the clinician on additional assessments like neuroimaging and for amyloid imaging (MRI, PET scan, etc.,) and a CSF study [33, 34]. Neuropsychological testing can be beneficial if the key question with the patient is how to differentiate between the patient's symptoms and the changes in cognitive function that occur with normal aging. The neuropsychologist can examine whether the level of cognitive function is acceptable for the patient's age, gender, and education by describing the profile of cognitive function. If the clinician does not have access to this information, they must make the best assessment of function possible.

Test materials such as the Montreal Cognitive Assessment (MoCA) [34] and the Mini-Mental State Examination (MMSE) [35] are typically used to assess patients with cognitive impairment. According to Nasreddine et al. [34], the sensitivity of MMSE to detect MCI was only 18%, whereas the sensitivity of MoCA to detect MCI was 90% [34, 36]. The specificity of both tests was reported to be good. The poor sensitivity for the MMSE to see conditions of MCI was attributed to the poor scoring, and any score greater than 26 was considered normal, within which the scores of persons with MCI are just above average [37]. Hence, it can be concluded that the condition of MCI can be detected successfully using the MoCA.

Both MMSE and MoCA are primarily used for screening, and the time of administration required is 5–10 min. Subtle differences exist between the two. Longer delayed recall time and fewer trial learning stimuli are present in MoCA, giving more challenges to the patient. Executive and complex language abilities (abstraction) are not assessed in MMSE but in MoCA. This increases the complexity of the tasks of MoCA when compared to MMSE. Studies report that the attention tasks in MoCA, such as the digit span, sustained attention, and the serial 7 calculation task helped to discriminate between AD versus the normal and MCI group as all the three tasks were affected in the AD group but were preserved in MCI group. AD and MCI groups also demonstrated impairment in sentence repetition, and delayed recall was found to be the most impaired task in the MCI group [34].

With reference to the functional performance, a patient with MCI should suggest that the patient's daily function is mostly retained. However, the history of being assessed for any cognitive decline. For example, the patient may be inefficient at particular tasks and take longer to do them, but he or she will eventually be able to complete them without assistance. This form of evaluation satisfies the criteria retained for cognitive function requirements. This can be a very subjective judgment. Therefore, having a trustworthy informant on hand can help. However, if the individual continues to operate daily, such as driving, paying bills, and filing taxes, and appears normal to the casual observer, a function is often kept. Finally, the patient does not meet the criteria for dementia based on all of these factors. The person's cognitive deficits are not severe enough to interfere with daily activities. As a result, an essential condition for dementia is not met.

The clinician should then decide whether the patient has had a change in cognition, whether there is objective evidence of this, whether a function is generally intact, and whether or not the patient meets dementia criteria. Suppose MCI is considered to be a valid diagnosis. In that case, the clinician must then assess whether memory is a significant element of the cognitive impairment and if so, the amnestic MCI arms would be appropriate. The non-amnestic arm of the diagnosis, on the other hand, would apply if the person is experiencing cognitive loss, but their memory is generally intact.

Following the determination mentioned above of the clinical syndrome, the clinician must then discover the cause or etiology of the syndrome. **Figure 2** depicts potential explanations for various clinical symptoms with degenerative, vascular, psychiatric, or medical etiologies and can aid in determining the next steps in the diagnostic process. A degenerative disease is a plausible possibility if the onset of the disorder has been slow and gradual. A vascular contribution must also be evaluated if the patient has a history of vascular risk factors and has had cerebral ischemia episodes. Furthermore, some mental diseases, such as major depression or generalized anxiety disorder, might have cognitive components. As a result, cognition may be compromised in the early stages of these disorders. Other medical conditions, such as

uncompensated heart failure, poorly controlled diabetes mellitus, or chronic obstructive pulmonary disease, must always be considered factors of cognitive impairment by the clinician. Some of these medical comorbidities are curable, and their drugs may also lead to clinical syndrome [32].

#### **2.1 MCI pathogenesis and outcomes**

An amyloid-b deposition is linked to dementia caused by decades of proteinopathy, such as Alzheimer's disease caused due to extraneuronal neuritic plaques and intracellularly neurofibrillary tangles. They are characterized as tauopathy for progressive supranuclear palsy, corticobasal degeneration, frontotemporal lobar degeneration, and synucleinopathy for Lewy body dementia and Parkinson's disease dementia. However, there are also significant aspects in the pathophysiology of dementia that can be modified, including a sedentary lifestyle, low nutritional status, social or environmental influences, and hereditary factors [38].

MCI can be caused by a variety of factors, including systemic disorders. Differential outcomes are caused by neurological diseases, drugs, and psychological disorders [39]. There are just a handful of possible outcomes of MCI—stabilization, progression, or reversion to normal aging. There is a unique presentation of metabolic disorders in older persons. Basic investigations are recommended, and when clinically necessary, neuroimaging is used. Reversible reasons are uncommon, with most cases occurring in surgical and depressive patients [32, 40–42].

If the clinician considers a degenerative condition the most likely cause, then the clinical symptoms can help identify an underlying diagnosis. If the patient has a typical amnestic condition with MCI and is in the right age range, Alzheimer's disease (AD) is a possible diagnosis. However, suppose the patient is having trouble with attention, concentration, and visuospatial difficulties. In that case, a form of dementia with Lewy body should be considered. If the person has behavioral changes, inappropriate behavior, apathy, lack of insight, and impaired attention and concentration, frontotemporal lobar degeneration should be considered. In fact, Alzheimer's disease, the most frequent degenerative disease of old age, can manifest itself in unusual ways involving attention, focus, and language [12, 32].

The clinician may be able to make a fair assumption about the nature of the condition based on the history and examination. Additional testing, such as an MRI scan, fluorodeoxyglucose positron emission tomography (FDG-PET) or positron emission tomography (PET) for amyloid imaging, and a CSF study, may be considered at this time. These additional tests may aid in determining the underlying cause of the clinical symptoms. While the US Food and Drug Administration (FDA) has not yet approved any pharmaceutical therapy for MCI caused by Alzheimer's disease, lifestyle changes and cognitive and behavioral therapies may be beneficial. Counseling patients about their expectations is also crucial. Medical comorbidities, such as sleep disorders like sleep apnea, should be investigated, as previously stated because some have curative components [12, 30, 32, 43].

#### **3. MCI treatments**

The FDA, the European Medicines Agency, and the Pharmaceuticals and Medical Devices Agency in Japan have not approved any pharmacological treatments for MCI. There have been numerous randomized control trials in the MCI spectrum, but none has been successful in slowing the progression of MCI to AD dementia [44–47]. The Alzheimer's Disease Cooperative Study tested donepezil with high-dose vitamin E in amnestic MCI as one of the earliest trials [32]. This study found that donepezil could delay the rate of advancement in all patients with amnestic MCI for the first year of the trial and perhaps for up to 2 years in those with amnestic MCI. They were positive for the APOE4 isoform. However, because the study was only supposed to last 36 months, no treatments were shown to be helpful at that point, and the trial was deemed a failure. Other studies employing cholinesterase inhibitors, which have been used to treat Alzheimer's disease dementia, have also failed [32, 44, 45].

Only a few research looked at the effects of over-the-counter (OTC) intervention on clinical MCI caused to Alzheimer's disease, according to a systematic review [37]. There are no studies that compare placebo to omega-3 fatty acids, soy, folic acid, B vitamin (folic acid plus B12), B vitamin (folic acid plus B6, B12), vitamin D plus calcium, vitamin E, vitamin C, or b-carotene in terms of MCI prevention. There was insufficient evidence to conclude the benefits of Ginkgo biloba, and a clinical trial found that multivitamins had no effect. In general, there is little evidence that OTC vitamins protect the brain [48].

There is research with reference to changes in lifestyle and non-pharmacologic therapy like aerobic exercise may be useful in slowing the progression of MCI to Dementia [49]. However, a 2010 state-of-the-science report from the National Institutes of Health (NIH) found no effective therapies for dementia progression [32]. However, recent evidence suggests that lifestyle adjustments may have some efficacy, which needs further investigation.

There was insufficient data to conclude the effect of a multi-component physical intervention that included flexibility, strength, balance, endurance, and aerobic training. No studies compared attention control to aerobic training, strength training, physical activity plus diet, physical activity plus protein supplement, or physical activity, diet, and cognitive training [37]. Even though single-component physical activity programs had negative results, a multidomain intervention appeared to improve cognitive function in older people with normal cognition. It is advised that clinicians encourage their patients to participate in clinical practice because the advantages can help avoid or manage other chronic conditions [50].

With reference to cognitive training, according to a systematic review, there is no clinical research on the protective impact of cognitive training in persons with normal cognitive function from developing MCI [37, 48]. Training in specific domains, such as reasoning, executive function/attention/processing speed, and memory, improved cognitive performance in the trained domains. As a result, there is inadequate evidence of cognitive training in people with the normal cognitive ability to prevent or delay cognitive decline [48].

#### **4. Conclusion**

In clinical practice and research, MCI has become an important topic. MCI established boundaries for this intermediate stage, focusing on earlier detection of incipient forms of cognitive impairments. Several randomized controlled studies for the MCI subtype caused by Alzheimer's disease are currently underway, and doctors should be aware of these research prospects for their patients. The cognitive abnormalities may be reversible once treatable etiologies of MCI (such as those caused *Mild Cognitive Impairment: An Overview DOI: http://dx.doi.org/10.5772/intechopen.106192*

by psychiatric illnesses, drugs, or medical comorbidities) are recognized. The development of biomarkers should give clinicians new tools for detecting and possibly treating MCI.

#### **Conflict of interest**

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the book chapter.

#### **Funding**

There is no funding by any agency for the manuscript.

#### **Author details**

Biraj Bhattarai1 \* and Hema Nagaraj2

1 Speech Language Pathologist Grade I, All India Institute of Speech and Hearing, Mysore, Karnataka, India

2 Assistant Professor, Department of Speech-Language Sciences, All India Institute of Speech and Hearing, Mysore, Karnataka, India

\*Address all correspondence to: birajbhattarai29@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 9**

## Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the Spectrum of Autism

*Elzbieta Trylinska-Tekielska, Dorota Pietraszewska, Iwona Stanisawska and Ada Holak*

#### **Abstract**

In recent years, the autism spectrum in children has been increasingly recognized. Parental awareness and the knowledge of health professionals are critical to the early diagnosis of autistic disorders. The autism spectrum disorder (ASD) is a complex neurodevelopmental disorder. The diagnosis of autism spectrum disorders is made on the basis of observation of behavior in three areas: social interaction, communication, and behavioral rigidity. The most common diagnosis is in children around 2–5 years of age, but the autism spectrum can be diagnosed at any age, also in adulthood. As the spectrum of autism varies, symptoms of autism may differ slightly from person to person. In order to exclude the presence of ASD in a child or adult, it is necessary to diagnose with the use of various tools, in which both a psychologist-diagnostician and a psychiatrist are involved. After diagnosis, the next important step is to include therapeutic and rehabilitation activities aimed at improving the functioning of the individual in disturbed areas. Lack of proper rehabilitation may lead to profound functional disturbances at a later age.

**Keywords:** spectrum autism, diagnosis, symptoms, methods of rehabilitation, therapy

#### **1. Introduction**

The word autism comes from the Greek autós, which means "alone." The concept was introduced into psychiatry in 1911 by the Swiss psychiatrist Eugen Bleuler for the inability to maintain relations with the environment. The first description of a person with autism was made in 1943 by psychiatrist Leo Kanner. Autism spectrum disorders (ASDs) are characterized by disturbances in the ability to communicate feelings and build interpersonal relationships, impoverishment and stereotypical behavior, and difficulties in integrating sensory impressions. According to the ICD 11 classification in force in Poland since 2022, there is a wider diagnosis of autism spectrum disorders,

which combines the categories of childhood autism, atypical autism, and Asperger syndrome described earlier in ICD-10 into one main category of Autism Spectrum Disorder (ASD) included in the chapter on neurodevelopmental disorders. ASD is described in seven different variants listed as follows:

6A02 Autism Spectrum Disorder 6A02.0 Autism spectrum disorder without intellectual development disorder and with mild or no functional language impairment 6A02.1 Autism spectrum disorder with mental development disorder and mild or no functional language impairment 6A02.2 Autism spectrum disorder without impaired intellectual development and with impaired functional language 6A02.3 Autism spectrum disorder with impaired intellectual development and functional disorders 6A02.4 Autism spectrum disorder without intellectual development disorder and lack of functional language 6A02.5 Autism spectrum disorder with impaired intellectual development and lack of functional language 6A02.Y Other specified autism spectrum disorders 6A02.Z Autism spectrum disorder, unspecified [1]

Most people with ASD exhibit features that impair functioning in three areas: communication, social, and behavioral (the so-called autism spectrum triad). The triad of disorders distinguished by Wing and Gould [2] is reflected in the current DSM V classification, which lists the following symptoms important in the diagnosis of ASD:


An important element added to the diagnostic criteria in DSM-5 is the inclusion of disturbances within the sensory profile.

Symptoms of autism are most often seen in early childhood, but may not be fully manifested until social expectations exceed the child's limited abilities. It should be emphasized that autism is not a mental illness. It has been assumed that the underlying causes are errors in neurological development, i.e., abnormalities in the formation of the central nervous system, starting in the prenatal age.

For proper therapy, it is also important to determine the severity of symptoms and their impact on the daily functioning of people with ASD:

L1 —patient and family require support —problems mainly relate to social relations,

L2 —requires significant support —communication problems with people, L3 —requires very significant support —incapable of verbal and nonverbal communication [3].

*Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

#### **2. Diagnosing ASD**

Autism spectrum disorders are multifactorial disorders, and its exact causes are not fully understood. Due to the very different manifestation of symptoms, diagnosing autism spectrum disorders is a complex process, consisting of several stages and requiring the cooperation of a team of specialists. The word "spectrum" means that each person with autism is different, and each person with autism manifests itself in a different set of characteristics and their severity. Despite the neurobiological basis of autism spectrum disorders, there are still no biological indicators that would allow them to be used in everyday clinical diagnosis [4]. The diagnosis of ASD remains a clinical diagnosis, based on the observation and assessment of the patient's behavior and cognitive functions. The disorder long-term affects a person's ability to take care of himself, participate in society. The diagnosis of ASD also affects other family members of a person with ASD [5, 6].

Although there is no single conclusive test or biological marker for ASD detection, there are many screening and diagnostic tools that can be used in the examination of children with suspected neurodevelopmental disorders [4].

#### **2.1 Diagnostic tools**

#### *2.1.1 CHAT*

Screening tools available include "first-level" tests that can be used during your primary care physician visit, including the Checklist for Autism in Toddlers (CHAT; parental assessment/physician observation; examination of children between 18 and 24 months of age) [4]. This tool is intended for testing 18-month-old children during pediatric follow-up visits, although it can also be used for older children—up to 24 and even 36 months of age. This tool consists of two parts: nine questions asked to parents and five short clinical trials. CHAT has a consistent and fairly well-documented theoretical basis. CHAT is recommended to pediatricians in Great Britain by National Autistic Society. One of the versions of CHAT is M-CHAT (Modified-CHAT) intended for testing children aged 16–30 months [7]. This questionnaire contains 23 questions (nine were taken directly from CHAT) and is completed by the parents. Another variation of CHAT is Q-CHAT (Quantitative CHecklist for Autism in Toddlers) intended for the study of children aged 18–24 months. In the questionnaire, the parent assesses the frequency of a given behavior or the severity of the problem on a five-point scale (not a dichotomous one, unlike M-CHAT) [8].

In Western countries and the United States, autism is the most frequently used interviewing tool Diagnostic Interview–Revised (ADI-R). The Polish version has been available recently thanks to Dr. Izabela Chojnicka, who is the author of the Polish language version [9].

#### *2.1.2 ADI-R*

It is a diagnostic tool used to conduct an interview. Its publisher is Western Psychological Services. Initially, it was used for research purposes. It is now a "*Comprehensive, standardized, and partially structured interview that is conducted with parents or guardians people with ASD"* [9].

During its development, the currently applicable diagnostic criteria ICD-10 and DSM-IV-TR were taken into account. It is recommended for children from 24 months of mental age. It consists of 93 items grouped into the following headings:

Introduction and introductory questions – a section consisting of six items concerning the family situation, the process of education and treatment, diagnosis. Early development – a section of seven items concerning the onset of symptoms of milestones in development and purity training.

Acquisition and loss of skills, including language skills – section consisting of 20 items.

Language and functioning of communication – a department consisting of 21 items.

Social development and fun – a department consisting of 17 items.

Behaviors and interests – section consisting of 13 items.

General behavior – a section of 14 items.

Final comments – a section consisting of three items concerning incl. Impressions of the interviewer [9].

The interview lasts from 1.5 to 4 hours depending on the age of the child. The individual items refer to both the previous behavior and the current behavior. The interview also includes questions about the presence of some symptoms typical of other pervasive development disorders, some questions about behaviors that are less important in the diagnosis of the autism spectrum but show the specificity of development of many children. The questionnaire also includes questions about the family or previous diagnoses and the course of any previous therapy. The scoring is nine levels, each question is assessed, and the diagnosis is made on the basis of an algorithm.

ADI-R interview may differ from the clinical diagnosis, but it is a very helpful tool in making a diagnosis, and it helps to gather a large amount of information.

*"When reading Western scientific publications, especially in the field of autism spectrum biology, there are no studies in which the diagnosis of the respondents would not be made on the basis of ADI-R and ADOS-G" [9].*

#### **2.2 Behavior observation scales**

#### *2.2.1 ADOS*

It is a tool for direct observation of behavior. It is standardized and consists of four protocols differing in terms of age and stage of speech development. It is most often used with the ADI-R. This tool consists of a number of experimental situations in which the observer is also a participant.

#### *2.2.2 CARS*

This scale is useful for the observation of children from 0 to 16 years of age; however, it should be noted that its effectiveness is greater for children from 2 years of age. It includes 15 areas of behavioral behavior, information comes from parents or other people staying with the child. The CARS scale is commonly used for treatment planning and assessment of progress [10].

*Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

#### *2.2.3 PEP-R*

PEP-R is a useful and popular tool for the functional diagnosis of a child. It is used in designing the therapy of a child with developmental problems. Thanks to the PEP-R test, it is possible to assess the educational needs of the child and determine the baseline level for therapy.

The PEP-R test consists of two parts: the developmental scale and the behavioral scale.

The scale of development allows for the assessment of the child's functioning in the following areas:

Limitation, perception, fine and gross motor skills, eye-hand coordination, cognitive activities, and communication. It consists of 131 tasks in total.

The behavior scale is designed to identify responses and behaviors. The degree of disorders and the areas in which these disorders appear are assessed. The behavior scale consists of 42 tasks divided into four areas: networking and emotional reactions, play and interest in objects, reactions to stimuli, and speech [10–12].

#### **3. The multifactorial basis of autism spectrum disorders**

The autism spectrum is much more than diagnostic criteria. So the difference between defining autism spectrum disorder (ASD) and developmental pattern (ASC) is analogous to the difference between negative and positive definitions of health. In the first case, we focus on deficits and looking for therapeutic measures to help mask them. In the second case, we focus on the resources of the individual, resulting from its proper development pattern, and we look for ways to strengthen it. According to Baron-Cohen, there are currently four narratives describing the autism spectrum: disorder, disability, difference, and disease. However, it was the terms "otherness" and "disability" that he indicated as fully compatible with the concept of neurodiversity understood as nature's strategy aimed at ensuring the scope of the human species (human minds) with a variety of challenges inherent in different environments (Baron-Cohen 2020: 138). Thus, this position can be considered more akin to the treatment of the autism spectrum as a developmental pattern than as a disorder. It is worth quoting at this point the opinion of one of the Polish researchers: "The spectrum of autism is a borderline category in many respects, blurred and unclear, ephemeral and changeable, and thus constantly revealing its arbitrariness and more social than biological construction" [5].

The state of knowledge about autism does not give unequivocal answers as to the causes of this disorder. The development of neurobiology and neuroimaging prompted many researchers to seek answers to the question of where does autism come from in neurological areas. Intensive efforts are underway to elucidate the neurobiology of autism. The combination of neuroanatomical abnormalities revealed in children's brain MRI studies with abnormalities in neuropsychic development and autistic symptoms seems to be of particular interest. Significant links were found between autism spectrum disorders and the presence of certain biomarkers. For example, functional resonance in children with autism shows that human facial image processing takes place in a different area than in healthy people; autistic people look at human faces, paying attention to the mouth area, not the eye area. In his works, Tuchmann [13] showed that various types of EEG abnormalities often occur in the group of ASD patients. About 20% of ASD patients in basal resting EEG display show epileptic activity mainly in

the form of focal lesions (spikes). EEG tests performed during sleep show even more seizure disorders in children with ASD*.* The EEG test is a method that can be used to assess the work of the brain in children with autism. However, there are no typical EEG patterns that would be unambiguous and specific to an ASD image.

Another hypothesis that contributes to the search for the causes of ASD is the theory of mirror neurons. The broken mirror hypothesis assumes that there is abnormal mirror cell activity in the brain of autistic people. Mirror cells are responsible for the mental mapping of motor activities, emotions, and sensory experiences observed in other people. In people with autism spectrum disorders, decreased activity of these cells in the area of the inferior frontal gyrus may explain the inability to understand the intentions of other people, in the insula and anterior part of the cingulate gyrus difficulties in understanding emotional states, and in the angular gyrus—language disorders [14]. Oberman et al. [15], by monitoring mi waves in the EEG record, proved that in people with the autism spectrum, the activity of mirror neurons in the premotor cortex is reduced. These waves are attenuated by the discharges of motor neurons when making conscious body movements and by discharging mirror neurons when observing these movements in others. In children on the autism spectrum, muwave suppression is not observed when observing the movements of other people, which confirms the low activity of mirror neurons [16].

It seems interesting to analyze the relationship between symptoms of autism and possible dysfunctions in various regions of the brain. It is known that the centers located in different lobes of the cerebral cortex are responsible for higher mental functions. The temporal lobe is responsible for speech, remembering, verbal memory, object recognition, musical hearing and sound sensation, and smell analysis. Damage to the temporal lobes results in impaired hearing, speech understanding and sound perception, impaired selective attention to auditory and visual stimuli, problems with recognizing and describing the seen objects, and difficulties in recognizing the face (prosopagnosia). Functional disorders in the left hemisphere impede the ordering and categorization of verbal information and are responsible for difficulties in understanding speech (Wernicke's aphasia). On the other hand damage to the right hemisphere can cause speech orthosis. Centers in the temporal lobe are responsible for problems related to recall, disorders of sexual behavior, and control of aggressive behavior. Speech abnormalities of various degrees are evident in people suffering from autism spectrum disorders. They are of various dimensions and quality, ranging from a complete lack of speech understanding, through speech that is exclusively echolalia and does not serve the communicative function, through semi-communicative speech, poor to almost normal active speech, characterized by impaired prosody, intonation and a weak pragmatic meaning of language. What is typical in the picture of autistic disorders is also frequent aggressive and auto-aggressive behaviors, which are an expression of the dysfunction of the right temporal lobe. Therefore, in people suffering from autism, dysfunctions of the frontal and prefrontal areas are typical, which is manifested in the presented symptoms: stereotypical behavior and interests, disturbed social interactions, lack of understanding and socioemotional reciprocity. An important function is also played by the limbic lobe, which is responsible not only for the analysis of olfactory sensations and pain, but also for controlling negative emotions, focusing attention, memory, and learning. The manifestation of dysfunction in this area of the brain in people on the autism spectrum is hyperactivity, psychomotor restlessness, severe attention and memory disorders, loss of control over emotions, as well as disorders in the area of sensory integration (hypersensitivity or hypersensitivity to pain, touch, sounds) [17].

#### *Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

F. Warren, director of the National Association for Children and Adults with Autism in the United States, describes the symptoms of autism spectrum disorder in this way, making the far-reaching thesis that autism is caused by damage to the brain. "The symptoms of autism are caused by damage to the brain and include: disturbances and delays in mastering the habits of daily living, social and language habits …. These children have an abnormal reaction. This applies to both individual senses and the entire group. This applies to sight, hearing, touch, pain, sense of balance, taste, smell, and also to body posture … Speech and linguistic development are delayed or completely absent in these children. There may also be specific thinking abilities. In speech, we observe an incorrect accent, a limited understanding of concepts, the use of words in such a way that they are not associated with things that mean (…) abnormal ways of contacting people, objects and situations (…) they do not react properly to adults as well as peers. They also do not use objects and toys in the usual way (…). Autism occurs as a single disorder or in combination with others that damage the functions of the brain: viral infections, metabolic disorders or epilepsy" [18].

#### **4. The nutritional aspect of the autism spectrum**

Etiopathogenesis of these disorders is multifactorial, and both predispositions are important genetic, factors environmental-like and factors related to answer layout immune system and functioning cable alimentary [19, 20]. With spectrum disorder autism, gastrointestinal symptoms often coexist. It is suspected that children with autism spectrum disorders may suffer from improper digestion of gluten proteins and casein, leading to the formation of peptides that may act as endogenous opioids (including milk caso–morphin- and gluten-based gliadomorphins), influencing the functioning of the central system nervous [21, 22]. Gastrointestinal symptoms in children with ASD may also be caused by hypochloridia and decreased secretion of gastric acid, less activity of amylolytic enzymes, intestinal disaccharidases, and inflammation of the esophagus, stomach or intestines. In this case, children with ASD suffer from autoimmune diseases and diseases, including celiac disease [23]. Increased permeability of the intestinal mucosa and imbalance of the intestinal microflora are also more frequent in patients with autism spectrum disorders occurrence increased permeability membranes mucous bowels and imbalance of the intestinal microflora [24, 25]. Research conducted in 2018, which drew attention to the importance of dietary ingredients and their impact on the somatic behavior of children with ASD, clearly documented positive changes in groups subjected to specific diets.

In children with ASD before the elimination diet, the parents more often observed gastrointestinal symptoms, especially flatulence, abdominal pain and diarrhea (p≤0.05) (**Table 1**), more often than in children who did not undergo dietary modification (**Table 1**). Most children experience these symptoms they gave way after introduction diets elimination [19, 26]. They write about the advantages and disadvantages of nutritional treatment of the autism spectrum disorder (based on their research) and emphasize that in some cases GFCF (gluten-free, casein-free) diets - ketogenic, low-phenol, low-oxalate may even cause the disappearance of disorders, symptoms characteristic of ASD. Parents of these children observe the beneficial effects: children sleep better, learn faster, blood results improve, rashes disappear. Perseverance behavior is also reduced. [27] Among ASD patients, deficiencies of vitamins B, C, K, and D3 and elements—calcium, potassium, and iron—are common. Deficiency of these ingredients may negatively affect the functioning of the neurological system.


#### **Table 1.**

*Gastrointestinal tract symptoms in children with autism spectrum disorders in the past and at present (%).*

Adequate supply of omega-3 fatty acids and probiotics may have a positive effect on the condition of patients with ASD [28].

#### **5. Relation of the therapist —the parent of a child from the autism spectrum**

The assumptions of working with ASD people say, first of all, about establishing a good relationship with this person. A very important element in building such a relationship is creating a safe space in which we will work with a person with ASD, developing a way of communication and supporting the family of a person with ASD.

One of the most important elements of the development of a child with autism apart from family adaptation—is properly selected and continued specialist and home therapy. A specialist or a group of specialists should work with the child, who will first of all give the correct diagnosis and repeat it, tracking the child's development and adjusting the therapy to the changes in the child's behavior and its health. It is very important that parents have a full understanding of current and changing techniques regarding the care, care and development of an autism spectrum child in everyday life. At this stage, the exchange of experiences between parents and mutual support both in sharing their perceptions and experiences, as well as the need to obtain help is very important. [29].

Cooperation in the parent-therapist relationship allows parents to participate in the child's therapy and get to know them better, notice characteristic behaviors or progress that they do not notice in the home environment. The best results are achieved when the therapy starts in early childhood, when the child receives the most stimuli, develops the fastest, and the parents are strongly involved in cooperation to obtain the best results. Parents' participation in the child's therapy combines the specialist's experience with parental care, which brings the best results [30].

Pisula illustrates this on the example of the TEACCH model, in which it was assumed that parents learn how to cooperate with a child from therapists, and therapists get to know the child through the prism of the parent. It is a model of mutual support in everyday functioning. The better prepared the parents are, the better the results are achieved by working with the child at home, which has a positive effect

#### *Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

not only on the child, but also on the whole family. Parents finally take control of the situation and stop being helpless about the behavior of their autistic child [30].

The best results are to stick to a few basic rules, starting with the fact that it should be remembered that the family has the greatest influence on the child's development and that it is the basis for his progress and should spend the most time on exercise, maintaining routine, rhythm, noting behavior changes. Certainly, a specialist or a group of specialists who exchange information and observations with parents on an ongoing basis should work with an autistic child. It is important to adjust the family's capabilities and resources, to pay attention to how to cope with their situation, and to establish solid relationships with other families operating under similar circumstances.

In addition to the great role of the parent, it should be remembered that it is the specialist's task to get to know the child and the conditions of his family, its strengths and weaknesses, and strive to cooperate with the child's parents, enabling its development to the fullest extent. Developing a relationship with the parents is as important a goal for the therapist as the work with the child itself. Thanks to this, the therapist inspires confidence in parents, which has a positive effect on the proposals of various solutions on his part. Otherwise, with a poor relationship with the parents, they may react negatively to his methods [31].

#### **6. Therapeutic methods and techniques**

Autism is a way of human development different from the typical one, manifested by differences in the way of communication, establishing relationships, expressing emotions, learning, and a diverse pattern of behavior. Each person with autism is an individual, and the abovementioned features may be of varying intensity. Autism accompanies a person throughout his life. After 6 years of analyzes, the NAC (National Autism Center) report was published, summarizing the research on the therapy of children, adolescents, and adults with autism. Its main goal is to select those forms of therapy that are most effective based on reliable scientific evidence. 2015 NAC report prepared as a result of the analysis of 361 scientific studies on methods of therapy for people with ASD. The report divided the treatments used into three groups: established (scientifically proven with strong and abundant evidence for their effectiveness), promising (there is evidence for the effectiveness of the method, but too little research is conducted), and undefined (very little or no evidence of a positive effect of the method). The established therapeutic methods are: behavioral methods, cognitive-behavioral interventions, modeling, natural teaching models, social skills training, activity plans. The group of promising therapies includes: alternative and supportive communication, relationship therapy, desensitization training, rehabilitation, massage, language training (resource and understanding), interventions based on new technology, therapies based on Theory of Mind Training, PECS, and music therapy. The group of undetermined therapies includes auditory training, the method of facilitated communication, gluten-free and casein-free diets, sensory integration, and additionally zootherapies or electroconvulsive therapies.

#### **6.1 Physiotherapy**

Each child diagnosed with an autism spectrum disorder or other related pervasive development disorder also has its own individual range of problems and dysfunctions. Their degree of intensity is also varied, which results in an absolute need for

individualization of therapy. The therapeutic program must take into account the personality of the patient, as well as his current abilities and needs. It is important that the working methods used do not eliminate each other, but work complementary and synergistically, only then can they effectively activate the child's development. The current tendencies in the world's leading autism spectrum therapy centers dictate the broadly understood complexity of the actions of specialized institutions on children affected by the autism spectrum. This means that institutions that deal with the treatment of pervasive disorders should create and implement comprehensive rehabilitation programs, which should be arranged in the field of rehabilitation, therapy, vocational and general education, and social care. Not only every child needs therapeutic support, but also his family (siblings, parents, grandparents, and other people) who have close contact with the child.

The impacts of specialized institutions on patients with the autism spectrum can be divided into:


In short, it can be said that medical interactions are primarily aimed at eliminating or minimizing the causes of disturbed CNS activity, as well as at improving the

#### *Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

somatic state of the patient. Psychological support is needed to assess the level of a child's functioning in various areas, to set directions for further influence, and to monitor the progress made. The work of psychologists in autism spectrum therapy is also used in a very important field, which is improving educational competences and counteracting the effects of chronic stress, as well as social exclusion of families who care for children with autism spectrum disorders.

Educational activities are aimed at modifying the child's behavior, which will make it possible to obtain the effect of the student's and therapist's work, acquire the ability to carry out orders, eliminate undesirable disruptive, self-destructive, and aggressive behaviors. This impact zone is also aimed at assimilating the child with educational skills and knowledge necessary for the implementation of compulsory schooling, introducing a general improvement program, and consolidating all acquired skills. Communication interactions are the basis for building the little patient's independence and the possibility of finding his own place in society, as well as the ability to communicate with him, if not verbally, then with the use of alternative methods of communication. Activities in the social sphere should provide care for the child as well as assistance and advice in dealing with official matters, as well as provide social support to the patient's family.

The last group of interactions that should be applied by a facility that specializes in autism spectrum therapy is supportive treatment and physiotherapy. This type of activities is aimed at stimulating development in individual spheres of functioning, improving the tasks of individual senses, their compatibility and integration.

Social integration through therapeutic contact with the animal world and peers as well as occupational therapy also finds its place here. The interaction group based on supportive therapy is an appropriate field for physiotherapists to work with autistic children. In the autism spectrum therapy, the following are used among the physiotherapy departments: manual therapy, hydrotherapy, therapeutic massage, physical therapy, and ergotherapy.

#### **6.2 Neurorehabilitation**

It is an important type of individual therapy aimed at intensifying the level of concentration of attention, similar to quantitative indicators in terms of the ratio of beta waves to theta, as well as SMR to theta, as well as in quantitative indicators for functional tests. Neurorehabilitation can be divided into two types of impact:


Research shows that systematic EEG biofeedback training can be an effective form of therapy for autistic children in the areas of verbal, physical, and social communication. Scientific research also shows improved speech, balance, understanding, and facial expressions in children with autism. The trainings also turned out to be helpful in reducing sensory sensitivity and in improving the response to changes in

the environment. Trainings should be conducted at least once a week. Greater and definitely faster effects of the therapy are obtained by training two or three times a week. The minimum number of trainings to achieve the goal and consolidate the achieved effects of the therapy is about 20 sessions. [33].

#### **6.3 Sensory integration (SI)**

Sensory integration is the stimulation of the neurological process so that it organizes the sensations flowing from the body so that they can be used for purposeful action. Sensory integration disorders consist in incorrect processing of stimuli within the sensory, vestibular, visual, auditory, olfactory, and taste systems. The function of the analyzers is correct. They are clinically manifested by increased or decreased sensitivity to stimuli, abnormal levels of attention, poor motor coordination, delayed speech development, and behavioral difficulties. Thanks to AI therapy, the child's brain, after collecting information from all senses, leads to their recognition, segregation, interpretation, and integration with information already possessed in order to be able to prepare an answer in the form of an appropriate motor reaction. The basis for working with this method consists of three basic sensory systems: the surface/tactile sensing system (whose receptors are located on the skin and are responsible for the reception of tactile, pain, and thermal stimuli), the deep/ proprioceptive sensing system (with receptors receiving stimuli coming from tendons and muscles), and the vestibular/vestibular system (in which the receptors are located in the inner ear and receive impulses that inform us about the position of the head in relation to the force of gravity). Therapy based on loose and liquid materials—in children with the autism spectrum, it aims to overcome the resistance which, due to their hypersensitivity in the area of superficial sensation, does not want to touch anything, which is wet, rough, slippery, warm, cold, etc., different structure, temperature, texture, or liquidity. Working in the darkroom, it is a method aimed at increasing the level of concentration of attention. Classes are conducted in a darkened room.

Working with an autistic child takes place in three stages:


#### **6.4 Auditory training**

Auditory training using the Tomatis method—it is audio-psycho-linguistic stimulation carried out with the help of a device called the electronic ear. They make up her sessions, which consist in listening to appropriately configured sound material through special headphones, as well as additional consultations together with an audio-psycho-phonological assessment. Through appropriate training, this method allows to achieve good results when the child's listening process is disturbed, i.e., processing and analyzing auditory stimuli through the nervous system. And in the case of hearing disorders, it does not apply, i.e., when the sound reception is incorrect due to organic hearing damage.

*Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

#### **6.5 Movement-based therapeutic interventions**

Relaxation—it is used during the occurrence of excessive muscle tension or strong psychomotor agitation often occurring in children with the autism spectrum. The most commonly used relaxation techniques are:


Therapy using the Knill method—it is a therapy in the form of a session, which is always accompanied by similar rituals (preparing props, adopting similar positions, starting exercises when certain music is turned on, etc.). These types of classes allow you to establish contact with the child, develop its activity in time and space, teach the acquisition of planning and foresight skills, as well as develop hearing and motor coordination.

Sherborne Developmental Movement Method is a system of movement games and exercises, the main task of which is to develop the emotional and social sphere in a child, as well as to develop awareness of himself and other people. Groups of exercises thanks to which you can solve specific problems occurring in people with developmental disorders:


There is no competition-inducing exercise. Children are praised and encouraged to be active. By gaining self-confidence, children are more likely to participate in other forms of therapy [15].

Dennison's method also known as The Brain Gym is a set of exercises aimed at integrating the cerebral hemispheres in order to work more effectively. Dennison's method is teaching with activating methods to turn on the natural mechanisms of mind and body integration through specially organized movements. Through the use of exercise, all parts of the brain turn on and work together to improve each chosen skill. It is a method that improves the effectiveness of learning, communication, creativity, and work efficiency. A very important factor in using this form in working with an autistic person is learning how to relax, relieve tension, and cope with stress.

The method of a good start aims to improve and improve the interaction of motor and psyche in a child through correction as well as compensation of disturbed functions. This method has various aspects, both prophylactic and therapeutic, as well as an equally important diagnostic aspect that allows assessing the type, causes, and depth of dysfunction in a given patient. Scheme of therapeutic work with this method begins with introductory classes, then basic classes (motor, motor-auditory and motor-auditory-visual), and final classes (they are calming, relaxing).

Therapy according to Masgutova's program consists in organizing neurosensory conditions for the proper functioning of schemas that are components of the reflex wheel, and they include the sensory organ, then the processing of the sensoryproprioceptive stimulus, and the motor organ. The techniques of this therapy are focused on re-patterning procedures, i.e., coordinating new relationships between the components of the reflex wheel. The results of reflex integration influence their maturation and the structure of planned and controlled movement. Their task is to improve the functioning of the sensor, motor coordination, and quality of movement. They improve the communication skills, concentration of attention as well as spatial organization.

#### **6.6 Structured improvement**

It is a group of activities included in the strictly defined framework of their course. They consist in providing the environment of a child with ASD with permanent structures: physical (including establishing permanent places to play, eat, move, didactic tasks, eliminate disruptive stimuli, no sudden radical changes); visual (visibility of materials and teaching aids, the use of clear, unambiguous pictures, symbols, visual organization of activities and tasks, day plan); visual marking of areas in the room with symbols, pictograms; structures in the form of fixed rules, rules and a fixed schema, e.g., daily schedule.

#### **6.7 Relationship-based therapy**

The Relationship Development Intervention (RDI) method is based on work with children performed by parents at home. It consists in providing parents with tools to effectively teach their child the skills that make up dynamic intelligence and increase his motivation to work. It focuses on changing what characterizes autism, i.e., thinking

#### *Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

stiffness, reluctance to change, lack of motivation, inability to see someone else's perspective, difficulties in communication. The RDI program was based on working on five basic skills, typical of the so-called dynamic intelligence, necessary for normal functioning in life, which are also the five basic deficits found in people with autism. These are:


#### **7. Manual techniques (cranial therapy and microkinesitherapy)**

They consist in the use of forms of minimal pressure on the patient's body in specific places in order to relieve the remaining tensions and muscle or fascial blockages. In autistic children, the most important thing is to eliminate blockages that are located in the bones of the skull and the entire hyoid system (muscles of the neck, collarbones, skull base, palate, temporomandibular joint).

#### **8. Ergotherapy**

Ergotherapy is recognized as one of the branches of physiotherapy and is based mainly on medical, psychological, social, and craft knowledge. It is used in the case of movement, sensory, nerve conduction, and mental disorders in patients of all ages, including older children. Its aim is to restore or acquire mobility, overcome difficulties in performing self-service activities, as well as other activities of everyday life. The consequence of ergotherapy should be for the child to obtain the greatest possible independence, independence, and life activity. Among the ergotherapeutic forms of work used in the treatment of patients affected by the autism spectrum, it is worth mentioning: occupational therapy, creative therapy, art therapy, music therapy, culinary therapy, psychodrama, rock climbing, or therapeutic and recreational tourism.

#### **9. TEACCH**

The origins of the TEACCH program go back to the 1970s. Eric Schopler's research resulted in the creation of an unusual, for those times, program of work with autistic

people. This program differed from previous methods of work by recognizing the role of the parent as a co-therapist, full involvement of parents in the therapy, which was a stark contrast to the earlier attitude of blaming them for the autism spectrum of the child. The TEACCH program was also a structured program as opposed to the widely used play therapy.

The most important assumption of the TEACCH program is the individualization of the therapy program for each child and the broadly understood cooperation between professional therapists and parents. Parents are treated as an invaluable source of knowledge about their children, they are treated on an equal footing with therapists, the parent and the therapist learn from each other by creating a therapeutic team. Parents bring dedication, commitment, motivation, knowledge of the child to the team, and professionals bring knowledge about professional techniques. PEP-R tools are used to individualize therapy.

The TEACCH program is a comprehensive program, it includes various types of therapy for autistic children, it uses, for example, behavioral therapy or sensory integration and many other programs that will prove effective for a given child. The diagnosis of the TEACCH program is divided into several stages. The first is the initial diagnosis, which is based on the individual assessment of the child by PEP-R, CARS, or AAPEP. With the help of these tools, the predisposition, skills, and potential of the child are established. The obtained results are supplemented with an environmental interview. Then the whole family is included in the program of meetings at the center, which aims to work with both the child and the parent. The child therapist works with the child, learns about its strengths and weaknesses, determines the initial therapy plan, while the family counselor looks after the parents, helps them find their way around the situation, helps them understand the nature of the impairment, and learns from it about the child. Then the therapy program is jointly established. Once this program is approved by the parents, the therapist arranges the exercises to be performed at home.

#### **10. Option method**

The option method was developed by a Kaufman couple through experiences with their own autistic child. They were looking for a therapy for their son before an official diagnosis was made. They knew that the earlier the therapy started, the greater the possibilities and chances for the child. They also realized that leaving their son in their own world without trying to understand and help them may result in the deepening of autistic behaviors, the consolidation of autistic patterns, and the resulting emotional problems. Barry Kaufman became interested in the Option Method derived from the Attitude of Options, that is, "To love someone and be happy with him" [35].

This method consisted in revising one's own beliefs, which made a person unhappy. She assumed that you can choose your own beliefs, which affects your feelings and behavior. The starting point for therapy is therefore work with parents, its aim is to teach the parent to accept the child, understand his behavior, and the parent also learns educational techniques. The next stage of therapy is joining the child's activity, imitating his behavior in order to show him that he is next to a presence full of love and approval and that he wants to make contact in a way that is possible for the child. The next stage is motivating the child to want to make contact, to want to go *Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

beyond the rigid framework of their behavior. At this stage, it is all the time important to imitate the child and constant presence, stimulate the child with himself, with his closeness, try to establish contact through various types of clever tricks, such as making the child meet with the eyes of the parent. Making eye contact is very important for the child to it acquired awareness of the existence of parents, acquired knowledge about parents so that it could learn through limitation. Eye contact is essential for significant progress to be made.

#### **11. Behavioral interventions**

Applied Behavior Analysis (ABA) is a scientific approach to understanding different behaviors. It uses many years of experience, numerous studies, theories, and principles of behavior understood very broadly [36]. SAZ is based on causal (also known as instrumental) conditioning. Behavioral interventions use, inter alia, proactive strategies, i.e., various techniques related to manipulating the stimuli that precede the behavior. The most frequently used of them are: adapting the program to the child's abilities, interweaving difficult and easy tasks, presenting tasks at the right pace, allowing the child to make a choice, adjusting the environment to be the optimal place for learning, and using various types of prompts [36]. Behavior-related interventions are also included in this category, and reinforcement is of particular importance here. Reinforcement can be positive or negative. Positive reinforcement occurs when, after a child becomes involved in a behavior, he or she receives the desired stimulus. It is important to take care of the variety of reinforcements and to individualize them so as not to become saturated with them. These can be the child's favorite treats, the therapist's attention, attractive toys, or pleasant activity with the therapist. The second type of reinforcement, negative reinforcement, occurs when the child's involvement in a given behavior causes the unwanted stimulus to be withdrawn. A particular type of enhancement is differential enhancement, where desired behaviors are enhanced and undesirable behaviors are suppressed. This results in the reduction of many undesirable behaviors of the child and teaching functional and desired responses in a given situation.

#### **12. Modeling**

Modeling is an effective way to teach a child how to do something by showing him or her. Children can learn a lot by observing and imitating the behavior of their parents, siblings, peers, and teachers. We distinguish between two types of modeling: "live" and video-modeling. The first type is that the therapist (model) presents a certain behavior to imitate and the child repeats it. It is important that the behavior to be imitated is well described and that each of the modelers presents it to the child in the same way. During modeling, the child should be focused in order to be able to observe the model's behavior well. In the final stage, a method of withdrawing modeling should be developed so that the learned behavior occurs spontaneously and in appropriate situations without the participation of the model. The second type, video modeling, is where a certain behavior is prerecorded and the child imitates the behavior observed in the video [37].

#### **13. Methods of supporting communication**

Various forms of assisted communication are used in autistic children. The term *Alternative and Supportive Methods of Communication* (AAC) groups methods that enable people with speech disabilities to communicate with their environment.

#### **13.1 Makaton**

The Makaton method is one of many alternative communication tools. It uses signs, i.e., gestures and symbols. Gestures and symbols can be used along with speech, then they have an auxiliary function, reinforcing the message, or in the case of lack of speech they constitute an independent method of communication. Graphic symbols are used with Makaton's gestures. They are black and white, simple pictures that accurately reflect the concepts they represent. The basic vocabulary includes 450 symbols and approximately 7,000,000 supplementary symbols. Each country has its own set of graphic symbols. The Makaton program was originally developed in the United Kingdom by Margaret Walker, a speech therapist and psychiatrist. The Polish version of Makaton was developed by Bogusława Kaczmarek. The changes included both gestures and graphic symbols. The basic vocabulary is 350 words very similar in all countries in Europe, in addition, in Poland, 100 words characteristic of our culture or customs. It is also emphasized that the applied therapeutic methods are carried out under additional aggravating conditions of Covid-19 [38].

Makaton Program users can be children and adults with different communication disorders profiles. The use of the language of symbols and gestures does not pose a threat to the development of speech as speech is used together with symbols or gestures whenever possible, and when it develops on a level sufficient for communication, the language of signs and symbols is discontinued [39].

#### **13.2 Therapeutic process in the event of a pandemic**

The first case of the SARS-CoV-2 virus in Poland was recorded on March 4, 2020, and less than a week later, the World Health Organization granted COVID-19 pandemic status, which resulted in changes in the functioning of families around the world. People with autism as people with disabilities were included in the group at high risk of contracting the virus. A number of changes concerned not only education, but also care and rehabilitation [40].

When on March 11, the work of educational system institutions was limited, it was also associated with the closure of educational and upbringing institutions, special schools, as well as specialized training and revalidation and upbringing centers [41]. Even in the first half of March, some support centers were also closed, and the children had to stay at home, without specialist care, which certainly made it difficult functioning of the family and initiated the growing problems of parents [40]. Due to the fact that families with children were locked at home, it was extremely important that the child continued to develop properly and make progress despite the lack of treatment with a specialist. One of the examples of replacing sensory therapy is sensory-motor games that stimulate the senses and reduce irritability in a child:

1. creating a harp from a box of chocolates and recipe rubber bands—the child chooses the number of rubber bands on his own and puts them on the boxes, then he can pluck them like strings while humming his favorite songs, while the parent can help "tune the strings" by stretching or loosening the rubber bands in order to spend others sounds, this game affects touch, sight, and hearing,


These sensory games not only help children to cope with stress and isolation, but can also be used at home as an addition to sensory therapy classes [41]. An important aspect is to create an environment for the child to facilitate sensory processing. For a child with autism, the highest priority is a safe environment that makes it easier for them to focus. Parents should adapt the environment in which the child is to be with other household members on a continuous basis to his needs. The level of the child's arousal depends on his environment. Any loud sounds should be eliminated by introducing soft background music, providing subdued colors and natural lighting, as well as organizing each room and clearly defining the passages. The apartment should be warm, but not too hot, and the smells should be subdued and controlled (no use or limitation of perfumes, disinfectants, cleaning products) [41].

Kashman and Mora created in their essay a sensory cheat sheet for the sense of touch, proprioceptive, and vestibular. And so, the sense of touch is best influenced by loose products such as rice or dry beans, modeling clay, or a massage with a balm. The sense of proprioception is influenced by e.g., walking, even in place, stomping, placing food cans (with a load). On the other hand, races, jumping on the floor or playing with a scarf are good examples of games that affect the vestibular sense [28].

Karen Simmons, based on a short sentence spoken by her friend: "Fear may be the most destructive and harmful virus known to mankind." SARS-CoV-2 virus. These are:


These so-called positive attitudes principles were intended to help, in these extremely difficult times, especially for parents to remain calm and pass it on to a child with autism spectrum disorder [41].

#### **14. Discussion**

Progress in research on the autism spectrum and its genesis results in more and more forms of development support therapy. However, since the causes of the autism spectrum disorder have not been clearly identified, there is no "cure" for the disorder. Educational, behavioral, and rehabilitation influences play the most important role in the treatment of autism. Therapy should be comprehensive and carried out in specialized centers. The nervous system is so plastic that when properly stimulated, it can make up for many deficits. The sooner a child is cared for, the better the results. Currently, there are many forms of therapy available to improve the functioning of an autistic child. Autism is not a fully curable disorder, but with the use of appropriate therapeutic programs, some people are able to achieve such an improvement that they can function independently.

Children with autism spectrum disorder (ASD) are less likely to participate in physical activity than their age-related peers, and it has been suggested that physical therapists (PT) have the potential to facilitate their participation. Currently, no study has investigated the potential role of PT in increasing participation in physical activity (PA). The purpose of this qualitative study was to investigate the experiences of PT and the outlook for working with children with ASD and to explore potential directions in which PT could potentially increase PA. Methods: Ten pediatric PTs in Canada were interviewed and the data analyzed by thematic analysis. Results: Three themes were identified: the role of PT, perceived lack of expertise, trust and training, and structural and systemic barriers. The accounts emphasize the social and institutional complexity and limitations of PT's potential promotion of PA in children with ASD. Participants supported primarily a consultative role whereby

#### *Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

physical therapists can educate themselves and collaborate with parents, teachers, and social service providers to improve gross motor development and individualize PA needs. Conclusions: These results indicate how PT may be involved in enhancing PA in children with ASD [7].

Stasolla, Boccasini, and Perilli (2017) presented a literature review on assistive technology-based programs supporting the adaptive behavior of children with autism spectrum disorders that are broadly understood and designed to bridge the gap between human/individual abilities and/or skills and requests for environment. In particular, AT builds a link that enables people with ASD to gain independence and self-determination. By using the AT configuration, individuals with ASD may be able to achieve an active role, positive participation, beneficial occupation, and/or performance of functional daily activities. Moreover, they could be enabled to improve their social image, attractiveness, and status, while reducing the burden on families and carers. In short, people with ASD would cope positively with their environment. At least two functional goals can be achieved through an AT-based intervention, namely (a) evaluation and (b) recovery. In the case of the autism spectrum, El Kaliouby and Robinson (2007, p. 3) indicated that assistive technologies can be "divided into two broad categories," i.e. therapeutic and prosthetic, with therapeutic technologies aimed at helping people cope with disabilities or specific deficiencies through curricula and interventions [42].

The review of the abovementioned methods of therapy for people with ASD shows that there is no one method that would cover all the needs of a child with ASD and his family. It seems appropriate to select therapies and working methods in accordance with the child's needs and based on his strengths.

The latest research (not published: E.Trylinska-Tekielska The sense of empathy and the sense of stress in the group of parents of children from the autism spectrum in the pandemic period, 2022) shows that the personality traits of the closest relatives are a very important rehabilitation factor for children from the autism spectrum disorder. The child's caregivers show the greater stress they experience, certainly a very important factor in preparing the child to function in society. It is also important that the society understands and respects the child's needs from the autism spectrum.

#### **15. Conclusion**

The assessment of the social functioning of a person with an autism spectrum disorder is in contradiction with the dominant image of the autism spectrum as an ailment that disrupts functioning in the social sphere.

Most people believe that an autistic person is capable of making friends, working professionally, and living independently; the general public believes that a person with ASD is able to start a family. At the same time, the dominant opinion is that a child with spectrum autism is not able to cope in an ordinary school.

Behind this contradiction may be the belief that autism is a predominantly childhood condition, out of which to some extent "outgrows," and an adult on the spectrum copes better in society than a child.

The problems of families of children with the autism spectrum have remained unchanged for years: it is primarily the lack of professional help in childcare, social exclusion, lack of emotional support, lack of knowledge about the autism spectrum, and lack of funds for living.

A specialist or a group of specialists should work with the child, who will first of all give the correct diagnosis and repeat it, tracking the child's development and adjusting the therapy to the changes in the child's behavior and its health condition.

People with the autism spectrum disorder during the pandemic reported experiencing higher than usual anxiety, nervousness, and tension, as well as anger.

A very small group of people on the autism spectrum have benefited from therapeutic support for the pandemic; most people did not receive any form of therapy.

Due to the fact that families with children were locked at home, it was extremely important that the child continued to develop properly and make progress despite the lack of treatment with a specialist.

The entire burden of carrying out therapy rested with families. The crumbs of autism reside in each of us.

### **Author details**

Elzbieta Trylinska-Tekielska\*, Dorota Pietraszewska, Iwona Stanisawska and Ada Holak College of Rehabilitation, Warsaw, Poland

\*Address all correspondence to: etek@poczta.onet.pl

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Methods of Treating Autism: Holistic Approach to the Rehabilitation of People with the… DOI: http://dx.doi.org/10.5772/intechopen.105435*

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## *Edited by Hideki Nakano*

Neurorehabilitation (neuroscience-based rehabilitation) is a medical approach that utilizes the brain's plasticity to help patients recover from nervous system injury. Remarkable progress has been made in this field, thus attracting increased attention from the scientific community. The concept of neurorehabilitation is widely accepted in physical therapy, and evaluation and treatment based on this concept are currently being practiced. This book provides a comprehensive overview of neurorehabilitation with chapters on motor imagery, repetitive peripheral magnetic stimulation, virtual reality, neurofunctional interventional approaches, and much more.

Published in London, UK © 2023 IntechOpen © DaryaDanik / iStock

Neurorehabilitation and Physical Therapy

Neurorehabilitation

and Physical Therapy

*Edited by Hideki Nakano*