Neurology Treatment Techniques

Introduction

A wide range of treatment techniques and approaches from different philisophical backgrounds are utilised in Neurological Rehabilitation. Research to support the different approaches varies hugely, with a wealth of research to support the use of some techniques while other approaches have limited evidence to support its use but rely on ancedotal evidence. This section provides a brief overview of some of the approaches used in Neuro 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" .

Tapping is used to assess reflex activity with a normal response being a brisk muscle contraction. Rood recommended three to five taps over the muscle belly to be facilitated. 

Brushing

Fast brushing, using a battery-operated brush on the skin overlying the muscle, is a therapeutic technique presented originally by Margeret Rood to facilitate movement responses and enhance static holding postural extensors.

There is limited research in terms of the effectiveness of brushing, its long term use, its continued effects or the required rate or duration of brushing or pressure to be applied. 

Cryotherapy - Brief

Ice can be used to facilitae amuscle response.

Passive Stretching - Fast/Quick

Stretch may be applied in a number of ways during neurological rehabilitation to achieve different effects. The types of stretching used include;

1. Fast / Quick
2. Prolonged
3. Maintained
   

When we look at the use of stretch for facilitation we employ a fast/quick stretch. The fast/quick stretch produce a relatively short lived contraction of the agonist muscle and short lived inhibition of the antagonist muscle which facilitates a muscle contraction. It achieves its effect via stimulation of the muscle spindle primary endings which resuts in reflex reflex facilitation of teh muscle via the monosynaptic reflex arc.

Joint Compression

Joint awareness may be improved by joint compression which will lead to enhancing motor control. Receptors in joints and muscles are involved with the awareness of joint position and movment which are stimulated by joint compression. Joint compression can have both facilitatory and inhibitory effects.

Joint Compression of the joint surfaces facilitates posture extensors which are needed to stabilize the body. Compression can be applied slowly to inhibit muscle control or in jerky manner to facilitate muscle control. The application may be manually and/or by using weight bearing postures. 

Joint compression can be achieved in two ways:

Light Compression: Normal body weight being applied through the long axis of the bone which is thought to inhibit (relax) muscle spasticity

Heavy Compression: Compression is greater than that applied by body weight whihch is thought to facilitate cocontraction  at the joint undergoing compression

Vibration

Muscle Vibration

Muscle vibration has been used as a technique to reduce muscle tone and spasticity in individuals with neurological conditions. Vibrations of the muscle are thought to increase corticospinal excitability as well as inhibitory neuronal activity in the antagonistic muscle.

Bishop et al (1974) identified three motor effects achieved through muscle vibration:

1. Sustained contraction of the vibrated muscle via tonic vibration reflex
2. Depression of the otorneurones innervating the antagonistic muscles via recipricol inhibition or antagonistic inhibition
3. Suppression of the monosynaptic stretch reflexes of the vibrated mucel while being vibrated.

Questions still remain as to whether vibration has any sustained effect on the muscle.

Muscle Vibration is generally applied to directly to the chosen muscle or tendon and may be applied in two ways; High and Low Frequency.

High Frequency:

The high frequency vibration is driven from vibratorthat optimally operates at a frequency of 100 - 200 Hz and at amplitude of 1 – 2 mA. This type of vibration produce facilitation of muscle contraction through what is known as tonic vibration reflex. This facilitatory effect sustained for a brief time after application. Therefore it can be used for stimulating muscles whose primary function is one of tonic holding.

Low Frequency:

The low frequency stimulation  occurring between 5 -50 Hz has an inhibitory effect on muscle through its activation of spindle secondary endings and golgi tendon organs.

While Vibration has the potential as a good treatment technique there is still limited eveidence on its effectiveness the therapist must be aware of the pracutions that must be considered when using it as a treatment option which include:

• Generates heat at the point of application
• Can potentially damage skin, particulalry at high amplitude

Whole Body Vibration
Whole body vibration is a relatively new modality which involves the use of vibration through standing on a vibrating platform and has been utilised to improve balance and gait. 

Further studies are needed in the future well-designed trials with bigger sample size to determine the most effective frequency, amplitude and duration of vibration application in the neurorehabilitation.

• Murillo N et al (2014). Focal vibration in neurorehabilitation. Eur J Phys Rehabil Med. Apr;50(2):231-42.

Vestibular Stimulation

The vestibular stimulation technique is a proprioceptive unique sensory system with multi-sensory function. According to the type of stimulus we can use the vestibular system to achieve many treatment alternatives.

• Total body inhibition can be achieved by slow rocking, slow anterior-posterior movement, slow horizontal movement, slow vertical movement and slow linear movement.
• Total body facilitation can be achieved by rolling patterns, a rocking pattern on elbows and extended elbows and crawling.
• Spinning induces tonal responses and causes a strong facilitation of movement through the overflow of impulses to higher centers.
• Facilitation of postural extensors is another effect of vestibular stimulation if it is used by a rapid way anterior-posterior or angular acceleration of the head and body while the child in prone position.
• Inverted position is commonly used now to achieve a total body inhibition, while it may be used to increase to in certain extensors.

Vestibular stimulation is not widely used in neurological rehabilitation. The management of vestibular dysfunction is recognised as a specialist area within physiotherapy.

• Lena Schmidt et al (2013). Galvanic Vestibular Stimulation Improves Arm Position Sense in Spatial Neglect : A Sham-Stimulation-Controlled Study. Neurorehabil Neural Repair published online 11 February 2013 DOI: 10.1177/1545968312474117

Normalisation of Tone & Maintenance Soft Tissue Length

Passive Stretching

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

Neutral Warmth

It is one of the most common methods used to inhibit postural tone and muscle activity. Neutral warmth acts through stimulating the thermo receptors and activating of parasympathetic responses. Usually 10-20 minutes are sufficient period to produce effect. The application may be by wrapping body part with towels, hot packs, tepid baths and air splints.

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

ES is an assistive technology that can be used to aid the recovery of upper limb after stroke. It uses electrical current to stimulate muscle contraction via electrodes, facilitating movement of a weakened or paralysed limb. It has been used since the mid 1960’s, traditionally to aid mobility through addressing dropped-foot, however, more recently it has been considered as a promising treatment modality for upper-limb recovery . ES has also been used in the treatment of other upper motor neuron impairments including people with Cerebral Palsy, Parkinson’s Disease, Multiple Sclerosis and spinal cord injury .
Several uses and benefits have been investigated regarding ES use in stroke upper limb recovery. These include strengthening weak muscles, increasing range of motion, reducing spasticity, improving motor control, reducing shoulder subluxation, reducing pain associated with shoulder subluxation and spasticity, improving sensory and proprioceptive awareness, and improving effects of botulinum toxin for management of spasticity  . Neuroplasticity is a key concept underpinning stroke recovery and it is the ability of the brain to adapt and form new neuroconnections . By forming these new synapses, motor-skills can be relearned and concepts of sensory-motor learning are founded on this premise . Following stroke there is evidence that the brain has a period of hyper-excitability within the first weeks after stroke  and it is hypothesised that by affert stimulation central reorganisation can be enhanced by stimulation through movement which ES may be able to facilitate . Additionally there is large predictive probability (90%) of return of upper limb function decided within the first 5 weeks, indicating a critical window for influencing recovery. Evidence supporting use of ES is not conclusive   . 

For more detailed information about Electrical Stimulation of Muscle, specifically in relation to its use in  recovery of Upper LImb function post stroke you can complete the the Physiopedia developed by final year physiotherapy students from Queen Margaret University.

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

Orthotics

The focus on function in neurorehabilitation neces- sarily means complex interventions are used to address body structure, activity, participation and environmental issues that may arise. Orthotics, like any tool used in the treatment of a complex and chronic condition, can target all levels of health at once. It may be an intervention designed to change body structures, or an intervention to support and stabilize unresponsive mus- cles so an activity can be performed, or an adjunct to enable participation in a life role such as work . According to Leonard et al (1989)  an orthosis is a device that, when applied correctly to an appropriate external surface of the body will achieve one of more of the following:

• Relief of Pain
• Immobilisation of Musculoskeletal Segments
• Reduced Axial Loading
• Prevention or Correction of Deformity
• Imprived Function

Orthoses are made from various types of materials including thermoplastics, carbon fibre, metals, elastic, EVA, fabric or a combination of similar materials. Some designs may be purchased at a local retailer; others are more specific and require a prescription from a physician, who will fit the orthosis according to the patient's requirements. Over-the-counter braces are basic and available in multiple sizes. They are generally slid on or strapped on with Velcro, and are held tightly in place. One of the purposes of these braces is injury protection.
In relation to Neurological Rehabilitation, Orthoses are used predominantly to improve function and to prevent and/or correct deformity. When using orthotics to improve function the orthotic should assist the patient to meet specific funational objective e.g. improve walking. 

For more detailed information about the design and fitting of Cutom Orthotic Devices read the Physiopedia Page;

www.physio-pedia.com/Orthotics

• S, Tyson et al (2013). Effects of an Ankle-Foot Orthosis on Balance and Walking After Stroke: A Systematic Review and Pooled Meta-Analysis. Archives of Physical Medicine and Rehabilitation;94:1377-85
• Natasha Lannin (2011). Orthotics in Neurorehabilitation. NeuroRehabilitation 28, 15–16
• Houlden, Henry, Paul Charlton, and Dishpan Singh (2007). Neurology and Orthopedics. Journal of Neurology, Neurosurgery, and Psychiatry 78.3: 224–232. PMC.

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, also referred to as Compressive Centripetal Wrapping, was first promoted by Flowers  for the control of local oedema and is very usefulewhen swelling is restricting functional improvment in the hand. It is applied through firm and continuous wrapping of the swollen limb, from distal to proximal with a 1-2mm diameter string. A loop is made as the wrapping is applied and it is the removal of the wrapping by pulling on the free end of the loop immediatley after the wrapping is completed which produceds reduction of swelling. 

String Wrapping versus Massage for Reducing Digital Volume.

Flowers KR. Phys Ther. 1988 Jan;68 (1):57-9.

Recent Related Research (Pubmed)

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