¿Qué es INN?


Communication seems to be the most difficult part in our social life - so many possibilities to
misunderstand each other!

Parents and children, partners, working teams, teacher and students, even good friends -
misunderstanding is very common. But is it the message that is wrong?

Communication is complex: the speaker creates an idea in his mind what to say - then he
has to translate this idea into words, these words have to be formed with mouth, tongue, lips
and jaw, using the breath in an adequate way. The listener has to hear the words, to
understand the language, to translate the words into a meaningful content and to react in an
appropriate way.

Therefore, in each of these steps there is a chance to fail, either at the side of the speaker or
at the side of the listener. The clearer the message we produce is, the less doubts about
the content are; the more precisely we choose the words and the tone and the speed, the
more likely it is that my respondent understands what he is supposed to.

At the side of the respondent, the better he listens, the more he asks for clarification if there
is any doubt, before he reacts, the more he knows about the background of the speaker, the
better he will guess the right.

Oliver Sacks described in his book "The man who mistook his wife for a hat" a group of
aphasic people, laughing out loudly when they listened to a speech of a politician - because
his non-verbal expressions were so ridiculous. Some people say that the non-verbal
expression is more important than what we say.

So how is communication with patients?

Some of them have a severe or a partial aphasia. Others are in coma, therefore neither
verbal nor non-verbal interaction is possible. Again others have the ability to speak, but it is
not related to their actions, it seems more to be an assemblage of excuses, diversionary
tactics or like coming from another planet. And last but not least, some are giving us hints
about their feelings and needs, but we do not understand it, because it seems not to fit, we
cannot classify them, because it is not following the traditions of conversation, we are not
expecting something important from them (yes, shame on us, but it is sometimes like this).

Ten points to consider:

1. First of all: Be aware of all these points, and don't go for verbal communication alone!

2. We have to learn to understand all kind of body signs, like turning the head away, starting to move around, tipping with the fingers, wiping both hands - or only of the less involved side (because the other side might not have the ability to be moved), raising and straightening continuously one leg, putting the arm underneath the head...
  All kind of autonomic reactions could as well be seen as body reactions, like sweating, freezing, goose bumps, the suddenly need to go to the toilet, mood changes, and change of the pupils. But all kind of aggressive behavior could as well be an autonomic reaction (just consider a lion would come suddenly through the door into your room, aggression would be the first and perfect reaction to get!). Therefore, if a patient is hitting, don't take it personally, it could be either casual or a defension for this momentary situation.
  In case that there is a comatose person in front of us, additionally we can observe heart rate, blood pressure, oxygen supply on the monitor.
  As you can see, there are many ways to communicate without any word - with people in coma, but as well with any other dialog partner.

3. Listen carefully to what the person is saying when (in which exact moment), and try to figure out why it was just like this. If it was not a common word, any noise is an equivalent.
  Try to decode it, if it was not a fitting word, into what it could have been. like:"I have to scratch my nose.", into: "I feel insecure now and need more help", "I need a brake" ….
  Sometimes the patient suddenly stops continuing an action, or she says: "I don't want to bend down further" - that means, she cannot go further at the moment, rather than she does not want to in general.

4. If the words are clear to understand, but the content seems strange - always believe it.
  Especially, if the sentences are like: "…and then I will fall down the plinth", "Yes, I know, you never have dropped somebody, but there will be a first time in everything", it means that they are full of fear to fall, to loose control - and they are right, they have lost the control over their body and over their life, they need experts to treat them, to support them in daily activities. So put them in a corner, put more heavy pieces of furniture around them, stay very close to them, offer them something to hold on (it usually works with pillows, stuffed close to their body). It is a sign for a completely disturbed body perception, either because they cannot move their body, or because they don't feel it properly, or because there are structural restrictions inside the body - or because they have lost the ability to understand, interpret and solve situations.
  If they say:"This is impossible to do!", "Nobody does it like this" take it serious as well. It means, they have no idea at the moment how to solve the problem, but they are aware that an adult person should be able to. Just help them with the next step, rather by guiding their hands or taking over for them, than telling / speaking / explaining (that would make their momentary failure even more obvious).
  Verbal communication disturbs learning. Non-verbal communication is more clear, you can point out something, show supporting interest. It could be performed with the mimics, but as well with your hands, arms, legs - all sorts of body language. You might have experienced that being in a country with an unfamiliar language.

5. If you decide to speak, better use the words to comment on something than to command.
  Like:" Wow, that was difficult to come into the T-Shirt! But finally you managed.", instead of:  "First put in the right arm, then the left, then the head - no, the left first, no, not like this, that  is wrong!"…Oh, it might be done in a different way than yours, that's fine! And if it is not possible in the chosen way, be aware that each negative feedback is destroying the self confidence.

  But what is the most important goal for any kind of treatment? To give back the self control and the self confidence and the self responsibility to the person, as it was before.

  Most people don't like to get commands, but prefer to be invited to, to be asked to, to get a choice - and to be challenged. So what about saying: "How many times will you manage to…", or: "How many different ways to do …  will you find?".
  We had a girl in a course, she didn't accept at all the sentence: "May I help you?" - she immediately denied. But with the little change into :"May I?" - she followed easily whatever the therapists intended to do.

6. If the person is not at all following your verbal proposals, an object might give the necessary hint what to do - not only with aphasic people. Even I react faster if I smell the fire and not only hear some person asking me to run away.

7. "The dopey cow fails when I would need it urgently" - a woman said about her hand, speaking about her drop from the toilet. She is really disappointed about it, after 4 months still no active function coming back. But frustration is not helpful at all to calm the system  (=the nervous system, the mind, the frustration matrix or, even better, the 'disability matrix') down - we should stop that process right from the beginning, never ever using or allowing words like "No chance", "Never again", "Who knows", "Maybe once", "It's over", "Accustom yourself to this situation, to the wheelchair, to a one-handed life" - and  substitute it with something like: "Let's see", "Let's try", "Give it a chance", "I'll support you", "You'll manage", "Tomorrow it might be easier", "Let's find another way". The feedback we give always has to be positive and supportive.

8. Some patients are continuously talking, about many different things, during the whole treatment - you'd rather tape their mouth, if allowed. But therefore they cannot concentrate on the task; if the brain is on output-level all the time, nothing can come in. In this case, we have to stop talking at all during the action. Of course we'll have a normal nice conversation before and after, but not during. When you're trying out a new recipe and your little child is incessant asking and talking to you, you'll never get the point, you'll never finish the meal - you have to interrupt and ask for a break or send it away for the moment.

9. Others are very clear in finding abstract explanations. A woman after a stroke could describe perfectly well which subway and which bus you have to take to visit her home - but no clue how to dress herself. A client during a course, when he finally had the T-shirt sitting on the right place after struggling hard, he suddenly said:"Oh, that's my T-shirt!". So during the action no understanding, only at the end it was fully clear for him.
  Therefore never again explain in advance what you intend to do, it might be meaningless and disturb more than help.

  As well, don't announce tasks, like: "I will help you to stand up, and then we'll do some balance training." Horror! Just imagine, I would say first you'll read this text and afterwards you'll have to write an examination about the content - okay, you might say you're used to it, that was your daily experience in school days. But if I would say you have to learn it by heart, otherwise it will have consequences for your salary, your adreanlin would immediately increase, even, if at the end, I would say it's just a joke - you would rather choose not to read the text to avoid the test and the possible failure.
So did my patient - once we were standing (with the help of dorsal plasters at both legs), she said: "My God, if I would have known in advance what you're going to do, I would have stopped you, for sure!" It was the first time after some years sitting in a wheelchair with  MS... After some training she managed to walk with crutches around the plinth  and to do some steps in the open space.

10. Go and learn body language in specific courses, with pantomimes, in a drama school, with actors - whatever. Knowing more about it, you'll have an easier access to people with a disturbed communication, and it will be much easier to handle the relatives: either to encourage them to be a part of the team, or to show them respect but stop interfering attitude.

  What has all this to do with neurodynamics, you might ask? A lot - because a lesion to the
central nervous system gives always confusion to the whole system, nothing is working
regularly and automatically as before. Therefore we have to include into our considerations /
clinical reasoning the thoughts, hopes, fears of the person additional to the body limitations.
And vice verse, if we calm down the system by giving positive feedback and acting
supportively more than emphasizing on problems and limitations, the tension in the system
will decrease as well, which results in smoother and more selective voluntary movements as
well as less development of secondary limitations like spastic patterns, associated reactions,
pain, dislocations, contractures. No person on the intensive care ward suffers from all that...

  I wish you lots of new good ways to communicate with all your patients and friends and family
members and neighbours!


SOME HISTORY ABOUT INN (Integration of Neurodynamics into Neurorehabilitation):

It all began in the middle of the nineties last century, when the leader of a huge rehabilitation centre in Germany asked Gisela Rolf MA to create a new type of course for the colleagues working in this center.
Gisela was a senior teacher in the Maitland Concept, a teacher of Bobath and,  being the first person to invite therapists from all over the world to the study center in Bad Ragaz, Switzerland, she knew David Butler and his ideas, amongst many other concepts.
So she created a two weeks course based on these mentioned concepts, influenced additional from her studies of psychology, and offered it first in Germany, then in Denmark and Austria to physiotherapists, and a 5 days course for occupational therapists.
I was engaged at that time as a clinical consulter / supervisor in this rehabilitation center, called Therapiezentrum Burgau, and wanted to spend with her one day - she denied: one day wouldn't be ever enough to understand her reasoning and her explanations.
I had to make up my mind - being a Bobath Instructor since some years yet - and decided to do a re-start or re-modelling of my thoughts by starting an assistance with her. It took me some years to completely understand that way of thinking and reasoning, and it still continues - I doubt whether it will ever stop! It opened my horizon, and I allow myself since then to skip boundaries and to stop "believing" well-accepted theories. It all could be seen different as well…
We had some years together, me being first an assistant, later  a co-teacher, and since she stopped working as a physiotherapist  in 2003 I am continuing the work she has started - being more convinced every day that it was worth starting this project. The basics are still the same, the practical part is changing, according to new aspects gained during patient treatments, questions of students during the courses and new theories in neurophysiology, in pain management, in motor control / motor learning and in understanding of neuropathies.
Therefore I started to give the course a new title some years ago: it is not at all only neurodynamics that is being taught on the course, but a highly entangled system of structural differentiation techniques for joints, muscles, nerves, connective tissues etc., combined with awareness of beliefs, fears, hopes and wishes of the client and the therapist, the social circumstances, and the interaction between these items.

Good success with using INN!


La idea de que el sistema nervioso periférico puede ser la causa subyacente de dolor se ha desarrollado enormemente desde la utilización de los test neurodinámicos estandarizados por parte de los fisioterapeutas dedicados al tratamiento de pacientes con problemas neuroortopédicos, como Maitland, Elvey, Butler y Shacklock.
Este planteamiento abrió puertas para interpretar y tratar lo que hasta entonces eran síndromes dolorosos sin explicación.
El manejo del dolor ha dado un gran paso adelante descrito en el libro de Butler y Moseley “Explain Pain”. El dolor crónico provoca cambios a nivel cerebral, la llamada centralización, así como a nivel de las sinapsis. Podríamos concluir que el dolor crónico da lugar a cambios en todo el sistema nervioso.

Pero, ¿que ocurre cuando hay una lesion directamente en el sistema nervioso central?. El cerebro no siente dolor por sí mismo, por lo tanto no nos encontraremos en principio con ningún síndrome doloroso. El sistema nervioso periférico no tendrá lesiones directas, por lo que no nos encontraremos con atrofia muscular. Las investigaciones se están basando en el propio cerebro y las vías aferentes y eferentes del sistema nervioso central.

Butler describe posiciones “out of tension” (fuera de tension), Shacklock "unloading-postures" (posiciones sin carga en el SNP), ambos con el objetivo de disminuir el dolor, tanto de una manera automática como pasando por un proceso de aprendizaje con ese objetivo.

Si consideramos las posiciones finales de los test neurodinámicos como la maxima elongación y “desenrrollamiento” de los nervios periféricos, en pacientes con una lesión en el SNC como un ictus, TCE, sangrados o hipoxia, observamos lo contrario, la posición de relajación total. Cualquier patrón espástico se puede relacionar directamente con un test neurodinámico específico.

Después de una lesión en el sistema nervioso, éste necesita descansar, ni que se estire ni que se tire de él, menos movimiento, en definitiva. Este mecanismo es válido tanto para un nervio periférico como para una lesión central.

Esto hace aflorar la idea de que los patrones espásticos deben ser interpretados como patrones de “descarga total” o “ total relajación”, lo que nos lleva a una interesantísima nueva idea de cómo se llegan a desarrollar los patrones espásticos, cómo evitarlos y cómo tratarlos. Además ayuda a explicar por qué luchando contra estos patrones con medicación o estiramientos no se alcanza el éxito deseado, y sin embargo la actividad motora controlada, la actividad muscular selectiva y el aprendizaje a la hora de utilizar el lado más afecto (con la forma y el manejo del terapeuta) ayuda a “relajar el sistema”, siendo éste el aspecto más importante a tener en cuenta en ese sistema nervioso alterado que ha sobrevivido a una agresión hacia él mismo.

Nora Kern, Munich 2011

1 comentario:

  1. Hola, soy una estudiante de fisioterapia, mi trabajo de final de grado, trata sobre INN en pacientes con ictus, busco evidencia cientifia y no encuentro nada. Me recomiendas algún articulo para saber un poco mas.
    Muchas GRACIAS