Neurological Physiotherapy: A type of physical therapy

Numerous conditions commonly affect the body’s nervous system. A stroke, a traumatic brain injury, or even a neuromuscular disorder, they can result as muscle weakness, imbalance, poor coordination, muscle spasms and tremors, and a loss of function. In the chance the unexpected occurs, it is comforting to know there are therapies designed like neurological physiotherapy to improve these symptoms.  

What is Neurological Physiotherapy?

Consisting of the brain and spinal cord, the role of the central nervous system is to send specialized signals to nerves throughout the body. To do this, the nervous system uses chemical messengers called neurotransmitters which travel by nerve fibers to cells. Many functions like movement, metabolic processes, and emotional regulation are possible.

If the nervous system is damaged, messages fail to reach the appropriate parts of the body. Depending on the affected area, this causes a number of symptoms: loss of movement (i.e. in hands, arms, legs, feet), loss of sensation, muscle weakness, muscle spasms, tremors, ataxia, and pain.  

Neurological physiotherapy rehabilitates the nervous system. With the help of a physiotherapist to implement a personalized exercise and care regimen, neurological physiotherapy forms new brain pathways to restore proper brain signals.

Physiotherapy VS. Physical Therapy 

The terms physiotherapy and physical therapy often lead to confusion. While some argue that physiotherapists are more hands-on than physical therapists and use less exercise-based therapies, their overall meanings are synonymous in most countries. Both serve to assess patients with an injury or illness and through exercise-based techniques, the goal is to educate and promote physical function.

What Conditions Are Treated with Neurological Physiotherapy?

Each of the conditions managed with neurological physiotherapy differs in how they affect the nervous system. However, the impairments of the diagnoses are similar. Physicians recommend neurological physiotherapy for patients suffering from poor balance and coordination, gait issues, vision changes, and those who cannot walk and struggle with self-care/daily living activities.

• Stroke— Blood flow to the brain is restricted during a stroke, causing the death of brain cells. Symptoms manifest from the damaged portion of the brain.
• Traumatic Brain Injury (TBI)—Brain dysfunction resulting from a bump, blow, or sudden jolt to the head.
• Parkinson’s Disease—A neurodegenerative disorder of primarily the dopamine neurons in the brain. The disease affects movement, sleep, and cognition.
• Alzheimer’s Disease—A neurodegenerative disease-causing brain cells to degenerate. The loss of brain cells leads to dementia, which is a decline in memory, thinking, and behavioral skills.
• Spinal Cord Injuries— The spine connects a complex system of nerves to the brain. When a spinal cord injury occurs, force to the vertebrae, ligaments, or discs of the spinal column impedes nerves from communicating with the body. Those with a spinal cord injury lose function below the site of injury. They can experience weakness, loss of strength and sensation, impaired breathing, and loss of bowel or bladder control.
• Multiple Sclerosis (MS)— In MS, the body’s immune system damages the nerves of the central nervous system. The immune system degrades myelin (the protective covering of the nerves). The symptoms vary depending on which nerves are compromised.
• Cerebral Palsy—A disorder characterized by motor disability (i.e. the ability to move and maintain balance and posture) in childhood. People with cerebral palsy cannot control their muscles due to abnormal brain development.
• Charcot-Marie-Tooth Disease (CMT)—CMT is an inherited disorder of the nervous system which causes a progressive loss of muscle tissue from the damage to peripheral nerves. It is also called heredity motor and sensory neuropathy.
• Amyotrophic Lateral Sclerosis (ALS)—A neurodegenerative disease affecting motor neurons. As motor neurons die off, voluntary movement is lost.
• Chronic Pain—Back pain and chronic pain conditions can be primary or secondary to other neurological disorders. The effect on quality of life is a huge reason why patients begin neurological physiotherapy for their chronic pain.

The Goals of Neurological Physiotherapy

Neurological conditions vastly impact a person’s balance, coordination, and ambulation. They are unable to move like they used to before their injury or condition. The inability to walk, transfer positions or even move in bed takes a toll on independence. Regardless of the disorder, lessening the pain of movement is a physiotherapist’s main focus. If walking is unlikely, then getting the patient to move as painlessly as possible with aids is always the goal.

Neurological Physiotherapy: Mobility Aids

The first step in neurological physiotherapy is for the physiotherapist to assess the patient. The physiotherapist evaluates the patient’s condition, carefully observing how they walk, move, bear weight, and respond to stimuli. Through the assessment, they can pinpoint the symptoms interfering with their walking and the assistance they will require. Sometimes, to ensure the task of walking is safe, physiotherapists prescribe assistant devices called mobility aids.

There are 4 categories of mobility aids.

• Canes: Canes are handheld stick-like devices suited for postural stability. It is prescribed for patients with moderate mobility impairment to support imbalance.  
• Crutches: Crutches increase base support for patients who cannot use their legs to support their full body weight. A crutch under each arm transfers weight from the legs to the upper body.
• Walkers: Walkers are a walking aid with a frame supported by four points of contact with the ground. It has three enclosed sides with one side open for the patient. Walkers overcome profound balance and stability issues. Some have wheels and seats for further support.
• Wheelchair: Wheelchairs are the most supportive for severe mobility impairment. It consists of a chair with wheels that are either manually operated by the user or power-driven with an electric device.

With the appropriate mobility aid, patients start the exercise components of neurological physiotherapy.

Neurological Physiotherapy: Splinting

Splinting is a neurological physiotherapy treatment in which splints are custom fitted to the patient’s body. When neurological dysfunction is present, muscles contract and the joints become stuck in a bent position. Splinting the hands, fingers, elbows, knees, feet, or ankles preserves the movement in these areas while reducing stiffness. Maintaining a range of motion is necessary to continue progress in therapy.

Neurological Physiotherapy: Walking Education

Functional Electrical Stimulation (FES)

Functional electrical stimulation (FES) stimulates nerves to activate weakened or paralyzed muscles. A small device worn in a cuff above the knee delivers electrical charges through electrodes. As the patient goes to walk, the electrodes signal the nerve responsible for lifting the foot. Functional electrical stimulation is particularly helpful for foot drop—a term that describes difficulty lifting the foot because of muscle or nerve problems in the lower leg.

Neurological Physiotherapy: Motor Sensory Retraining

Patients with damage to the nerves of the central nervous system struggle to feel touch, pain, temperature, and proprioception (the position of the body). The inability to feel sensations influences motor skills. In an attempt to regain motor control, the brain remaps its sensorimotor pathways. Motor sensory retraining is a cognitive-behavioral technique commonly applied in neurological physiotherapy. It is based on altering the brain signals to recognize sensation and to retrain the brain. There are three stages per motor-sensory division.

Motor Stage 1: Motor Discrimination

Motor discrimination is essentially the ability to identify the left from the right direction of an affected body part. The physiotherapist shows the patient photos of the affected area in various positions to increase awareness.

Motor Stage 2: Imagined Movements

Imagined movements are successful because of mirror neurons in the brain. Thinking about performing an action activates mirror neurons. Patients imagine performing activities that typically cause them pain as painless, and associating those activities with positive emotions. No motion is required.

Motor Stage 3: Mirror Therapy

Mirror therapy is similar to imagined movements, except with difficult actions performed using the unaffected body part in front of a full-body mirror. The exercise tricks the brain into believing the affected body part is working normally as the patient sees the unaffected area. Once mirror therapy activities are relatively painless, the physiotherapist guides the patient to movements of the affected limb.

Sensory Stage 1: Localization

The inability to recognize a body part is a frequent complaint in neurological illness. Localization involves generating sensory recognition. For the localization technique, the physiotherapist identifies 6 points in the symptomatic area of the body and numbers each point in rows and columns. Next, the physiotherapist touches the points until the patient can identify the number without seeing.

Sensory Stage 2: Precision

With the 6 points in localization, precision applies the same concept to help the brain recognize what stimulus is touching each point. Stimuli could be a pen, a dull pencil tip, or an object with a cold temperature. The patient must identify what stimulus the physiotherapist is using and where without seeing the number.

Sensory Stage 3: Graphesthesia

Graphesthesia is a more advanced technique to increase sensory awareness of body parts. Without the patient watching, the physiotherapist draws letters or numbers onto the skin in various size, shapes, and orientations. The patient is to identify the drawings.

Neurological Physiotherapy: Deep Breathing and Circulation

Adequate breathing and circulation are imperative for movement. Neurological physiotherapy does focus on breathing and circulation, especially in neurological conditions that affect lung or cardiac function. Deep breathing prepares the body for physical movement and clears the airway of secretions. Patients are instructed to sit or lie in a comfortable position with their hand on their abdomen. They are then to take a deep breath through the nose until the hand on their stomach rises. The chest should not move. Repeat multiple times. By providing the body with sufficient oxygen, the circulatory system can pump it to the limbs for movement.  

Neurological Physiotherapy: Exercise

Exercise is central to the neurological physiotherapy process. Although movement is uncomfortable for individuals with neurological dysfunction, rehabilitation cannot take place without exercise. Deconditioning only worsens movement through muscle wasting. Thus, all exercises and therapeutic techniques in neurological physiotherapy target gait training and balance training.

Gait Training

Gait refers to aspects of walking. For successful walking or “gait,” one must be able to support their body weight, propel their body in an intended direction, have control of balance, keep a steady locomotor rhythm, and attain the flexibility to adapt movement to the environment. Neurological physiotherapy optimizes walking performance. Gait training increases muscle strength, endurance and speed, counteracts maladaptive changes to limb tissues, and teaches the patient to voluntarily elicit muscle movements.

Experts recommend the following adaptations for neurological patients to re-train their gait: short or increased stride width, decreased speed, or support of the body via the hands (Carr, 2003). Neurological physiotherapy has patients practice the activity of walking.

Treadmill

Treadmill training is the primary approach for gait re-training. The advantage of a treadmill is that patients can repetitively walk under controlled conditions with the guidance of a professional. For patients with extremely limited mobility, a harness system lends body weight support while walking on the treadmill. Studies do reveal downfalls to treadmill training (Eng, 2007). On a treadmill, patients are not exposed to the same visual flow of stimuli as they are when walking. They also cannot complete a range of gait variations such as starting and stopping, turning or going from sitting to standing.  

Mobility Tasks

Patients with neurological dysfunction exhibit rehabilitation progress through intensive mobility training tasks. These programs are comprised of circuits of walking activities (i.e. stepping over obstacles, walking backward), functional tasks, and an aerobic component. For example, patients repetitively rise from a chair or go up-and-down on a stair stepper for the functional tasks. The aerobic component can include walking or riding a stationary bike at moderate intensity. The circuit setup provides a more comprehensive workout than the treadmill alone. Mobility task programs are incremented to challenge the patient to reach new goals.

Balance Training

Balance issues are the leading cause of injury in patients with neurological dysfunction. Whether from dizziness, vestibular disorders, or age-related imbalance, they feel unsteady during movement. Neurological physiotherapy applies exercises to combat loss of balance. This reduces falls, improve joint proprioception, and decrease overactive muscles.   

Balance training consists of exercises such as balancing with one foot off of the floor, tandem walking, walking while turning head, and walking forward and backward while staring at an image. Variety can be added to the exercises by altering the terrain, dynamics, or using different bases of support.

Hydrotherapy

Hydrotherapy is a combination of therapy in neurological physiotherapy that allows patients to complete activities in the pool more easily than on land. Neurological patients benefit from hydrotherapy because the buoyancy of the water facilitates movement by decreases the amount of weight the body has to support. The warm water decreases stiffness, relaxes tense muscles, and provides resistance for strengthening exercises. Physiotherapists accommodate hydrotherapy according to the patient’s needs. If they cannot swim, the patient can remain seated in a chair while in the water or have assistance from floats.

Neurological Physiotherapy: Stretching

Proprioceptive Neuromuscular Facilitation (PNF) is the predominant form of stretching in neurological physiotherapy. PNF is thought to increase flexibility and range of motion by stretching and contracting targeted muscle groups. Patients can perform almost any stretch using the below PNF techniques.

1. Hold-relax: Put a muscle in a stretched position and hold for a few seconds. Next, contract the muscle without moving. The reflex is triggered by pushing against the stretch. Relax the muscles while exhaling.

2. Contract-relax (isotonic stretching): Like the hold-relax technique, put a muscle in a stretched position. Instead of contracting the muscle without moving, contract it while moving.

3. Hold-relax-contract: Actively push against a stretch instead of relaxing.

Stretching before and after exercise is important to enhance muscular function, lessen the chance of injury, and reduce pain and stiffness.

Finding a Neurological Physiotherapist

Finding a neurological physiotherapist might seem challenging. After all, patients themselves are unsure where to begin to connect with the professional who will become such an integral component to their care team. The specialist treating the underlying neurological disorder typically has the best recommendations, as they are aware of the details of the condition. However, the American Physical Therapy Association website has a directory that generates a list of neurological physiotherapists by location. Reach out to the potential options. Ask questions to learn if they specialize in the treated diagnosis or if they have like patients. By staying proactive, patients are closer to managing their condition.

References

Eng, J. J., & Tang, P. F. (2007). Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence. Expert review of neurotherapeutics, 7(10), 1417–1436. doi:10.1586/14737175.7.10.1417

Cheyanne Perry

Cheyanne is currently studying psychology at North Greenville University. As an avid patient advocate living with Ehlers Danlos Syndrome, she is interested in the biological processes that connect physical illness and mental health. In her spare time, she enjoys immersing herself in a good book, creating for her Etsy shop, or writing for her own blog.