Neurology Treatment Techniques

Introduction

A wide range of treatment techniques and approaches are utilised in Neurological Rehabilitation.

Facilitation

Facilitation and enhancement of muscle activity to achieve improved motor control are the key tenents to many of the techniques used in neurological rehabilitation, many of which also utilise neuroplasticity. The Rood Approach, theoretically based on the Reflex and Hierarchical Model of Motor Control, developed by Margaret Rood in the 1950s, provide the origins for many of the facilitation techniques used today in neurological rehabilitation today. Rood developed a system of therapeutic exercises enhanced by cutaneous stimulation for patients with neuromuscular dysfunctions. In additon to proprioceptive maneuvers such as positioning, joint compression, joint distraction and the general use of reflexes, stretch, and resistance, the greatest emphasis is given on exteroceptive applications such as stroking, brushing, icing, warmth, pressure, and vibration in order to achieve optimal muscular action.  

Tapping

"Tapping is the use of a light force applied manually over a tendonvor muscle belly to facilitate a voluntary contraction" .

Brushing

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Normalisation of Tone & Maintenance Soft Tissue Length

Passive Stretching

• Seriel Casting 
  www.physio-pedia.com/Ponseti_method

Massage

Massage uses pressure to direct venous and lymphatic flow back towards the heart. It is therefore important that the movement is always in this direction so that there is no undue pressure on the closed valves in the veins. These valves prevent backflow of blood by only allowing blood to move in one direction (i.e. toward the heart). As the pressure from the heart pumping subsides and the blood moves back, the valves close and prevent any further back flow.

Massage may also be used to stretch muscle fibres. In this case, the direction is not as important as the strokes are much shorter and therefore pressure in the wrong direction is not significant enough to cause damage.

www.physio-pedia.com/Massage

Physical Activity & Exercise

Hydrotherapy

Hydrotherapy is a definition for exercise in warm water and is a popular treatment for patients with neurologic and musculoskeletal conditions . The goals of this therapy are muscle relaxation, improving joint motion and reducing pain . This therapy is been used for thousands of years. (Level of Evidence A1)

www.physio-pedia.com/Category:Hydrotherapy

Proprioception Neuromuscular Facilitation

Proprioceptive Neuromuscular Facilitation (PNF) is a set of stretching techniques commonly used in clinical environments to enhance both active and passive range of motion in order to improve motor performance and aid rehabilitation. PNF is considered an optimal stretching method when the aim is to increase range of motion, especially as regards short-term changes.

Herman Kabat developed proprioceptive neuromuscular facilitation (PNF) in the 1940s and further developed Dorothy Voss and Margaret Knott. PNF helps to restore normal movement by focusing on the developing sequence of movement and how the agonist and antagonist muscles work together to produce volitional movement. PNF uses reflexive movement as a basis for learning more volitional movement. The idea is that one must be able to roll before he can crawl and crawl before he walks.

PNF focuses on mass movement patterns that are diagonal and resemble functional movement. The body does not work in parts, but instead as a whole. In order to promote these mass movement patterns, PNF uses a multi-sensory approach, incorporating the auditory, visual and tactile systems. PNF allows the patient to understand what normal movement feels like through the use of various senses through use of manual contacts to cue the patient and facilitate movement. 

Primarily, PNF treatment techniques focus on three things:

1. Increase the motor learning of the agonist through repetition of an activity (repeated contractions) and rhythmic initiation.
2. Reverse the motor patterns of the antagonist.
   Two techniques are slow reversal and rhythmic stabilization, which both use isometric contraction.
3. Finally, learning to relax muscles helps to increase range of motion and decrease spasticity. 

Proposed mechanisms underlying the PNF stretching response include Autogenic Inhibition and Reciprocal Inhibition which have traditionally been accepted as the neurophysiological explanations for the range of movement gains that PNF stretching achieves over static and ballistic alternatives. 

The patterns of movement associated with PNF are composed of multijoint, multiplanar, diagonal, and rotational movements of the extremities, trunk & neck. There are 2 pairs of foundational movements for the upper extremities; UE D1 flexion & extension, UE D2 flexion & extension. There are also 2 pairs of foundational movements for the lower extremities; LE D1 flexion & extension, LE D2 flexion & extension. Various PNF stretching techniques based on Kabat’s concept are: Hold Relax, Contract Relax, and Contract Relax Antagonist Contract.

Contract Relax: Passive placement of the restricted muscle into a position of stretch followed by an isotonic contraction of the restricted muscle. After the contraction period the patient is instructed to relax the restricted muscle that was just contracting and activate the opposing muscle to move the limb into a greater position of stretch. Through Golgi tendon organ, the tight muscle is relaxed, and allowed to lengthen. 

Hold Relax: Very similar to the Contract Relax technique. This is utilized when the agonist is too weak to activate properly. The patient's restricted muscle is put in a position of stretch followed by an isometric contraction of the restricted muscle. After the allotted time the restricted muscle is passively moved to a position of greater stretch. This technique utilizes the autogenic inhibition, which relaxes a muscle after a sustained contraction has been applied to it for longer than 6 seconds. 

Contract Relax Agonist, Antagonist Contract: Usually performed by a passive or active stretch of the target muscle(s) to move the limb into a starting position at first, followed by a sub-maximal isometric contraction of the target muscle and finally an active stretch is used to move the limb into a new greater position. This technique uses autogenic and reciprocal inhibition. Reciprocal inhibition is the main cause of the greatest effect of this technique versus the other PNF techniques. 

Rhythmic Initiation: Begins with the therapist moving the patient through the desired movement using passive range of motion, followed by active-assistive, active-resisted range of motion, and finally active range of motion.

Slow reversals: This technique is based on Sherrington's principle of successive induction, i.e. that immediately after the flexor reflex is elicited the excitability of the extensor reflex is increased.This technique is used to strengthen and buildup endurance of weaker muscles and develop co-ordination and establish the normal reversal of antagonistic muscles in the performance of movement. 

• Westwater-Wood S, Adams N, Kerry R (2010): The use of proprioceptive neuromuscular facilitation in physiotherapy practice Physical Therapy Reviews Vol.15 No.1,p23-27
• Hindle, Kayla B. et al. (2012). Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function. Journal of Human Kinetics 31;105–113. PMC.
• GD, Victoria et Al (2013). The PNF (Proprioception Neuromuscular Facilitation) Stretching Technique – A Brief Review. Science, Movement and Health, Vol. XIII, ISSUE 2 supplement, 2013 September 2013, 13 (2), 623-628
• Proprioceptive Neuromuscular Facilitation - http://www.slideshare.net/AartiSareen/proprioceptive-neuromuscular-facilitation-16081045

Exercise Prescription

• www.physio-pedia.com/index.php/Closed_Chain_Exercise

Pilates 

Pilates is a system of exercises using special apparatus, designed to improve physical strength, flexibility, and posture and enhance mental awareness .

www.physio-pedia.com/Pilates

Constraint Induced Movement Therapy

The term Constraint-Induced Movement Therapy (CIMT) describes a package of interventions designed to decrease the impact of a stroke on the upper-limb (UL) function of some stroke survivors . It is a behavioural approach to neurorehabilitation based on "Learned- Nonuse"  . 

CIMT is typically performed for individuals following a Cerebrovascular Cccident as between 30-66% will experience some functional loss in their impaired limb . Furthermore, CIMT has also been performed for individuals with Cerebral Palsy, Traumatic Brain Injury and Multiple Sclerosis. The aim of CIMT is to improve and increase the use of the more affected extremity while restricting the use of the less affected arm.
The three major components of CIMT include ;

1. Repetitive, structured, practice intensive therapy in the more affected arm
2. Restraint of the less affected arm
3. Application of a package of behavioural techniques that transfers gains from the clinical setting to the real world (i.e. making it functional)

For more detailed information about CIMT read the Physiopedia Page; 

www.physio-pedia.com/Constraint_Induced_Movement_Therapy

Articles:

• Revisiting Constraint-Induced Movement Therapy: Are We Too Smitten With the Mitten? Is All Nonuse “Learned”? and Other Quandaries

Virtual Reality

• www.physio-pedia.com/The_effectiveness_of_gaming_technology_in_neurological_rehabilitation
• www.physio-pedia.com/The_emerging_role_of_Microsoft_Kinect_in_physiotherapy_rehabilitation_for_stroke_patients

Electrotherapy

Transcutaneous Electrical Nerve Stimulation

Transcutaneous Electrical Nerve Stimulation (TENS) is a method of electrical stimulation which primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the opioid system. The different methods of applying TENS relate to these different physiological mechanisms. The effectiveness of TENS varies with the clinical pain being treated, but research would suggest that when used ‘well’ it provides significantly greater pain relief than a placebo intervention. There is an extensive research base for TENS in both the clinical and laboratory settings and whilst this summary does not provide a full review of the literature, the key papers are referenced. It is worth noting that the term TENS could represent the use of ANY electrical stimulation using skin surface electrodes which has the intention of stimulating nerves. In the clinical context, it is most commonly assumed to refer to the use of electrical stimulation with the specific intention of providing symptomatic pain relief. If you do a literature search on the term TENS, do not be surprised if you come across a whole lot of ‘other’ types of stimulation which technically fall into this grouping.

For more detailed information about TENS read the Physiopedia Page;

www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS)

Electrical Stimulation of Muscle

• www.physio-pedia.com/Electrical_Stimulation_-_Its_role_in_upper_limb_recovery_post-stroke

Biofeedback

Biofeedback is the technique of using equipment to reveal to human beings some of their internal physiological events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals . The ultimate purpose is that the patient gets to know his own body signs and that he can control them consciously. In first place using biofeedback equipment, afterwards even without .

Further, neuromuscular training or biofeedback therapy is an instrument-based learning process that is based on “operant conditioning” techniques. The governing principal is that any behavior-be it a complex maneuver such as eating or a simple task such as muscle contraction-when reinforced its likelihood of being repeated and perfected increases several fold . 

For more detailed information about Biofeedback read the Physiopedia Page;

www.physio-pedia.com/Biofeedback

Other

Acupuncture

Acupuncture forms part of traditional Chinese medicine (TCM). This ancient system of medicine dates back as far as 1000 years BC and is based on a holistic concept of treatment which regards ill health as a manifestation of imbalance in the body’s energy. Re-establishing a correct balance is the aim of TCM. Energy is referred to as Qi, (pronounced chee) and is described in terms of Yin energy - quiet and calm and Yang energy - vigorous and exciting. They are complementary opposites and in health exist in a dynamic but balanced state in the body. Practitioners of TCM believe that stimulating certain Acupuncture points on the body can help to restore the balance between Yin and Yang that becomes disturbed in illness.

For more detailed information about Acupuncture and the contraindications for use read the Physiopedia Page;

www.physio-pedia.com/Acupuncture

www.physio-pedia.com/Acupuncture_contraindications

String Wrapping

• String Wrapping versus Massage for Reducing Digital Volume.
  Flowers KR1. Phys Ther. 1988 Jan;68 (1):57-9.

Recent Related Research (Pubmed)

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