Neurology Treatment Techniques

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Introduction[edit | edit source]

A wide range of treatment techniques and approaches from different philosophical backgrounds are utilized 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 anecdotal evidence. This section provides a brief overview of some of the approaches used in Neuro Rehabilitation.

Facilitation Techniques[edit | edit source]

Facilitation and enhancement of muscle activity to achieve improved motor control are the key tenants to many of the techniques used in neurological rehabilitation, many of which also utilise neuroplasticity. [1]The Rood Approach, theoretically based on the Reflex and Hierarchical Model of Motor Control, developed by Margaret Rood in the 1950s, provides the origin 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 addition to proprioceptive maneuvres 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.[2] [3] 

http://www.slideshare.net/shilpa_prajapati/facilitatory-and-inhibitory-techniques-new

Tapping[edit | edit source]

"Tapping is the use of a light force applied manually over a tendon or muscle belly to facilitate a voluntary contraction" [1].

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. 

[4]

Brushing[edit | edit source]

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. [1]

[5]

Cryotherapy - Brief[edit | edit source]

Ice can be used to facilitate a muscle response, which uses a combination of coolness and pain sensation to produce the desired response.

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Passive Stretching - Fast/Quick[edit | edit source]

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 produces a relatively short-lived contraction of the agonist's 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 results in reflex facilitation of the muscle via the monosynaptic reflex arc.

Cite error: Closing </ref> missing for <ref> tag. The goals of this therapy are muscle relaxation, improving joint motion and reducing pain [6]. This therapy is been used for thousands of years.

For more detailed information about Hydrotherapy read the Physiopedia Page;

www.physio-pedia.com/Category:Hydrotherapy

Proprioception Neuromuscular Facilitation[edit | edit source]

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. [7]

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 stabilisation, which both use isometric contraction.
  3. Finally, learning to relax muscles helps to increase range of motion and decrease spasticity. [8]

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. [9]

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.[10]

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. [10]


Hold Relax: Very similar to the Contract Relax technique. This is utilised 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 utilises the autogenic inhibition, which relaxes a muscle after a sustained contraction has been applied to it for longer than 6 seconds. [10]

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. [10]

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.[10]

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. [10]

Aerobic Exercise[edit | edit source]

There is an increasing range of aerobic exercise options being accessed by people with neurological conditions. These range from aerobic exercise programmes (e.g. overground walking or treadmill training programmes) and an array of sporting and exercise classes to the use of technology (e.g. virtual reality training). These options, supported by the growing body of evidence, present the therapist and patient with the ability to select a programme for an individual, which is timely and can be carried out in an appropriate environment.

Articles

Treadmill Training[edit | edit source]

The incentive to provide a challenging environment, in which there is an opportunity to practise repetitively the missing components of gait, has underpinned another task-specific activity. This involves using a treadmill for gait training and also for improvements in aerobic function. A harness can be used for individuals with significant functional limitations, and this also offers the opportunity to grade the amount of body weight support provided. Therapists help to facilitate alternating stepping and weight-bearing, and as many as three therapists may be required to assist with the complete gait cycle.
Shepherd and Carr (1999) argued that there are three reasons why treadmill training can support gait re-education:

  1. It allows a complete practice of the gait cycle
  2. It provides opportunity  for gaining improvements in speed and endurance
  3. It optimises aerobic fitness

Task -specific training on a treadmill has also been shown to induce expansion of subcortical and cortical locomotion areas in individuals following stroke and spinal cord injury. It can result in an increase in cadence and a shortening of step length as compared to overground walking.

Pilates [edit | edit source]

Pilates is a system of exercises which has evolved from its use with elite dancers to enhance core, shoulder girdle and limb control. It can be both mat based and apparatus based, and is designed to improve physical strength, flexibility, and posture and enhance mental awareness [11]. While pilates is used widely for neuro rehabilitation there is limited research on its effectiveness as part of a rehabilitation for patients with neurological impairment.

For more detailed information about Pilates read the Physiopedia Page;

www.physio-pedia.com/Pilates

Tai Chi[edit | edit source]

is an internal Chinese martial art practiced for both its defence training and its health benefits. Though originally conceived as a martial art, it is also typically practiced for a variety of other personal reasons: competitive wrestling in the format of pushing hands (tui shou), demonstration competitions, and achieving greater longevity. Built upon the mind–body connection, Tai Chi combines physical movement, meditation and breathing to induce relaxation and tranquility of the mind, and it improves balance, postural control, movement coordination, strength and flexibility. In the past decade, a substantial number of studies and reviews have been conducted in the field of the clinical use of Tai Chi. Recently, the significant effects of Tai Chi for fibromyalgia and Parkinson’s disease rehabilitation have been confirmed, and related studies published in the New England Journal of Medicine have brought great attention to and general agreement on the clinical effects of Tai Chi.

Constraint-Induced Movement Therapy[edit | edit source]

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 [12]. It is a behavioural approach to neurorehabilitation based on "Learned-Nonuse". [13]

CIMT is typically performed for individuals following a Cerebrovascular Accident as between 30-66% will experience some functional loss in their impaired limb [14]. 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 [12];

  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

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Robotics[edit | edit source]

Over the past decade, rehabilitation hospitals have begun to incorporate robotics technologies into the daily treatment schedule of many patients. These interventions hold greater promise than simply replicating traditional therapy because they allow therapists an unprecedented ability to specify and monitor movement features such as speed, direction, amplitude, and joint coordination patterns and to introduce controlled perturbations into therapy.
Rehabilitation robotics is a field of research dedicated to understanding and augmenting rehabilitation through the application of robotic devices. Rehabilitation robotics includes development of robotic devices tailored for assisting different sensorimotor functions (e.g. arm, hand, leg, ankle, development of different schemes of assisting therapeutic training, and assessment of sensorimotor performance (ability to move) of patient; here, robots are used mainly as therapy aids instead of assistive devices. Rehabilitation using robotics is generally well tolerated by patients, and has been found to be an effective adjunct to therapy in individuals suffering from motor impairments, especially due to stroke.

With greater development of robotics within the field of neurorehabilitation it is now becoming a real alternative method for enhancing both upper limb and lower limb function in patients with movement disorders. It is still a relatively new and emerging area of physiotherapy with limited research to support its use.

More information on the Physiopedia page for Robotic Rehabilition of the Lower Extremity 


Articles

Presentations

International Industry Society in Advanced Rehabilitation Technology (http://www.iisartonline.org/home/). The education slide pools provided by IISART provide an overview of basic as well as specific information on new technologies in neurorehabilitation.

Virtual Reality[edit | edit source]

Advances in virtual reality technology mean that devices using computer and gaming technology, such as the Nintendo Wii ®, are now found in many people’s homes. The potential of these types of adjuncts to maximize task-orientated practice and increase energy expenditure are beginning to be explored. The use of games using the Nintendo Wii ®, for example, has shown to increase energy expenditure in a group of asymptomatic participants (Graves et al., 2007; Lanningham-Forster et al., 2009). Research in individuals with neurological disorders, such as cerebral palsy, is beginning to emerge (Deutsch et al., 2008).

For more detailed information about the emerging role and effectiveness of virtual reality in neurorehabilitation read the Physiopedia Page;

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

Articles:

Electrotherapy[edit | edit source]

Transcutaneous Electrical Nerve Stimulation[edit | edit source]

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[edit | edit source]

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 1960s, traditionally to aid mobility through addressing dropped-foot, however, more recently it has been considered as a promising treatment modality for upper-limb recovery [15]. 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 [16].
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 [17] [18]. Neuroplasticity is a key concept underpinning stroke recovery and it is the ability of the brain to adapt and form new neuro-connections [19]. By forming these new synapses, motor-skills can be relearned and concepts of sensory-motor learning are founded on this premise [20]. Following stroke, there is evidence that the brain has a period of hyper-excitability within the first weeks after stroke [21] and it is hypothesized that by afferent stimulation central reorganization can be enhanced by stimulation through movement which ES may be able to facilitate [22]. 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 [15] [23] [24]. 

For more detailed information about Electrical Stimulation of Muscle, specifically in relation to its use in the recovery of Upper Limb function post-stroke, you can complete 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[edit | edit source]

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 [25]. 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 [26].
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 behaviour - be it a complex manoeuvre such as eating or a simple task such as muscle contraction-when reinforced its likelihood of being repeated and perfected increases several fold [27]. 

For more detailed information about Biofeedback read the Physiopedia Page;

www.physio-pedia.com/Biofeedback

Other[edit | edit source]

Orthotics[edit | edit source]

The focus on function in neurorehabilitation necessarily 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 stabilise unresponsive muscles so an activity can be performed, or an adjunct to enable participation in a life role such as work [28]. According to Leonard et al (1989) [29] 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
  • Reduce Axial Loading
  • Prevention or Correction of Deformity
  • Improved 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 functional objective e.g. improve walking. [30]

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

www.physio-pedia.com/Orthotics

Acupuncture[edit | edit source]

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[edit | edit source]

String Wrapping, also referred to as Compressive Centripetal Wrapping, was first promoted by Flowers [31] for the control of local oedema and is very useful when swelling is restricting functional improvement 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 immediately after the wrapping is completed which produces reduction of swelling. [32]

String Wrapping versus Massage for Reducing Digital Volume.

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

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 M, Stokes & E, Stack. Physical Management for Neurological Conditions. Edinburgh: Churchill Livingstone, 2011.
  2. ↑ Alison Baily Metcalfe, Nigel Lawes. A modern interpretation of the Rood Approach. Physical Therapy Reviews; Vol. 3, Iss. 4, 1998
  3. ↑ Eisenberg MG. 1995. Dictionary of Rehabilitation. New York: Springer Publishing Company. p. 375
  4. ↑ Tapping sotahouston Available from:https://www.youtube.com/watch?time_continue=4&v=4b2UiVTlNLw accessed on 31/05/19.
  5. ↑ Fast Brushing Heather Watson-Fournier Available from https://www.youtube.com/watch?v=0B23ngwLcGc accessed on 31/05/19.
  6. ↑ Eversden L, Maggs F, Nightingale P, Jobanputra P. A pragmatic randomized controlled trial of hydrotherapy and land exercises on overall well being and quality of life in rheumatoid arthritis. BMC Musculoskeletal Disorders 2007;Vol.8:23
  7. ↑ PMNC
  8. ↑ EL, Stroup and J, Snodgrass. The Motor Control Model. Treatment Applications and Research Considerations. Vol. 21, Issue 3, P.48
  9. ↑ 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.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 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
  11. ↑ Oxford Dictionaries, Definition of Pilates in English. Available from: http://oxforddictionaries.com/definition/english/Pilates (accessed 20 Mar 2016).
  12. ↑ 12.0 12.1 Morris DM, Taub E, Mark VW. Constraint-induced movement therapy: characterising the intervention protocol. Eura Medicophys. 2006;42(3):257–68
  13. ↑ Taub, E.,Uswatte, G. Constraint-induced movement therapy: answers and questions after two decades of research. 2006 NeuroRehabilitation, 21(2), 93-95.
  14. ↑ Kwakkel, G., Kollen, B. J.,Wagenaar, R. C. Therapy impact on functional recovery in stroke rehabilitation: a critical review of the literature. 1999 Physiotherapy, 85(7), 377-391.
  15. ↑ 15.0 15.1 Scottish Stroke AHP Forum. Use of Electrical Stimulation Following Stoke: A Consensus Statement. http://www.chss.org.uk/documents/2014/10/electrical-stimulation-consensus-statement-ssahpf-pdf.pdf (accessed 5 March 2016).
  16. ↑ Odstock Medical. Who Can Benefit from FES? http://www.odstockmedical.com/who-can-benefit-fes (accessed 5 March 2016).
  17. ↑ Scottish Intercollegiate Guidelines Network. SIGN 118 Management of Patients with stroke: Rehabilitation, Prevention and Management of Complications and Discharge Planning. A national clinical guideline. http://www.sign.ac.uk/pdf/sign118.pdf (accessed 24 January 2016).
  18. ↑ Foley N, Mehta S, Jutai J, Staines E, Teasell R. Upper Extremity Interventions. http://www.ebrsr.com/sites/default/files/module-10-upper-extremity_final_16ed.pdf (accessed 8 January 2016).
  19. ↑ Van Wijck F, McBean D, The brain-behaviour relationship: an introduction. In: Applied Neuroscience for the Allied Health Professions. Edinburgh: Churchill Livingstone/Elsevier, 2013. P33-52.
  20. ↑ Schmidt R, Lee T. Motor control and learning : a behavioural emphasis. Champaign, IL : Human Kinetics, 2011.
  21. ↑ Butefisch CM, Netz J, Wessling M, Seitz RJ, Homberg V. Remote changes in cortical excitability after stroke. Brain 2003; 126 (2): 470-81. http://brain.oxfordjournals.org/content/126/2/470 (accessed 11 January 2016).
  22. ↑ Meilink A, Hemmen B, Seelen H, Kwakkel G. Impact of EMG-triggered neuromuscular stimulation of the wrist and finger extensors of the paretic hand after stroke: a systematic review of the literature. Clinical Rehabilitation 2008; 22: 291-305. http://cre.sagepub.com/content/22/4/291.long (accessed 11 January 2016).
  23. ↑ Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke (Review). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010820.pub2/abstract (accessed 8 January 2016).
  24. ↑ Howlett OA, Lannin, NA, Ada, L, Mckinstry, C. Functional Electrical Stimulation Improves Activity After Stroke: A Systematic Review With Meta-Analysis. Archives of Physical Medicine and Rehabilitation 2015; 96 (5):1-9. http://www.archives-pmr.org/article/S0003-9993(15)00044-1/abstract (accessed 8 January 2016).
  25. ↑ Basmajian J. (1989), Biofeedback: Principles and Practices for Clinicians, Williams and Wilkins (level 4)
  26. ↑ Biofeedback Vereniging Nederland (2012), Wat is biofeedback?, geraadpleegd op 1/05/2013, (level 4), http://www.biofeedbackvereniging.nl/index.html
  27. ↑ Satish S.C. Rao, DYSSYNERGIC DEFECATION and BIOFEEDBACK THERAPY, Gastroenterology Clinics of North America, Volume 37, Issue 3, Pages 569-586, September 2009 (level 2A)fckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575098/
  28. ↑ Natasha Lannin (2011). Orthotics in Neurorehabilitation. NeuroRehabilitation 28, 15–16
  29. ↑ Leonard et al (1989). Prosthetics, Orthotics and Assistive Devices 1. General Concepts. Arch. Pays. Med. Rehab. 70, S195-S201
  30. ↑ Houlden, Henry, Paul Charlton, and Dishpan Singh (2007). Neurology and Orthopedics. Journal of Neurology, Neurosurgery, and Psychiatry 78.3: 224–232. PMC.
  31. ↑ Flowers KR (2006). String Wrapping versus Massage for Reducing Digital Volume. Phys Ther. 1988 Jan;68 (1):57-9.
  32. ↑ Davies (2000).Steps to Follow: The Comprehensive Treatment of Patienst with Hemiplegia. Springer-Verlag, Berlin


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