Neurological Physiotherapy Exercises and Techniques

 Neurological Physiotherapy

Neurological physiotherapy is the treatment of patients who have a neurological disorder. Neurological disorders are those affecting the brain, spinal cord, and nerves, such as stroke, MS, and Parkinson's disease. Treatment in neurological conditions is typically based upon exercises to restore motor function through attempting to overcome motor deficits and improve motor patterns. To achieve this aim various theoretical frameworks have been promoted, each based upon inferences drawn from basic and clinical science research.

Some of the common conditions that are treated by neurological physiotherapy are:

• Epilepsy and Seizures
• Alzheimer’s and other dementias
• Strokes
• Migraine and other headaches
• Multiple sclerosis
• Parkinson’s disease
• Neurological infections
• Brain tumors
• Amyotrophic Lateral Sclerosis (ALS)
• Ataxia.
• Bell's Palsy
• Cerebral Aneurysm.
• Epilepsy
• Acute Spinal Cord Injury
• Traumatic conditions of the nervous system such as head injuries and disorders caused by malnutrition.

Benefits

Physiotherapy treatment will help:

• Make movements easier to achieve that are precise and goal-directed
• Retrain normal patterns of movement
• Improve ability with everyday activities
• Increase muscle strength
• Increase range of movement
• Improve gross or fine motor skills
• Improve posture
• Increase balance
• Lengthen tight muscles to help decrease spasticity and reduce contractures
• Increase fitness levels and endurance
• Help problems with breathing
• Reduce the risk of chest infections
• Reduce the risk of falling
• Reduce stress and anxiety
• Relieve pain
• Increase independence
• Achieve maximum potential

Equipment used in Neurological Physiotherapy

The kind of equipment used will depend on your current symptoms, your housing circumstances, your lifestyle, and your goals. Neurological physiotherapists often use equipment to teach you how to do things more safely and effectively and to promote independence with everyday tasks. Neurological physiotherapists also work closely with occupational therapists who can provide additional equipment for you if necessary. Commonly recommended aids and adaptations include:

• Walking sticks
• Crutches
• Zimmer frames
• Gutter frames
• Three-wheeled walkers
• Four-wheeled walkers
• Wheelchairs
• Seating systems
• Pressure relief cushions
• Access ramps
• Bath seats
• Shower seats
• Perching stools
• Kitchen equipment /accessories
• Cups/beakers for easy drinking/swallowing
• Grab rails
• Hoists/slings
• Transfer boards/belts
• Leg lifters
• Bed levers
• Toilet seat raises
• Toilet frames
• Adapted toilets

Treatment Exercises

Some treatment exercises are used, often incorporating a selection of the following as appropriate:

• Stretching
• Strengthening
• Balance re-education
• Gait re-education
• Joint mobilization
• Electrical stimulation
• Postural exercise
• Spasticity management
• Advice/Education on lifestyle, fatigue management, and exercise

Treatment Techniques

Facilitation Techniques

Facilitation and enhancement of muscle activity to achieve improved motor control are the key tenants of many of the techniques used in neurological rehabilitation, many of which also utilize neuroplasticity. 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. Rood developed a system of therapeutic exercises enhanced by cutaneous stimulation for patients with neuromuscular dysfunctions. In addition to proprioceptive maneuvers such as positioning, joint compression, joint distraction, and the general use of reflexes, stretch, and resistance, the greatest emphasis is given to exteroceptive applications such as stroking, brushing, icing, warmth, pressure, and vibration to achieve optimal muscular action.

Tapping

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

Tapping is used to assessing 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 facilitate a muscle response, which uses a combination of coolness and pain sensation to produce the desired response.

Passive Stretching - Fast/Quick

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

Fast / Quick

Prolonged

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.

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 movement 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 a jerky manner to facilitate muscle control. The application may be done 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 which is thought to facilitate co-contraction 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:

• Sustained contraction of the vibrated muscle via tonic vibration reflex
• Depression of the other neurons innervating the antagonistic muscles via reciprocal inhibition or antagonistic inhibition
• Suppression of the monosynaptic stretch reflexes of the vibrated muscle while being vibrated.
• Questions remain as to whether vibration has any sustained effect on the muscle.
• Muscle Vibration is generally applied 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 by a vibrator that optimally operates at a frequency of 100 - 200 Hz and an amplitude of 1 – 2 mA. This type of vibration produces facilitation of muscle contraction through what is known as tonic vibration reflex. This facilitatory effect is sustained for a brief time after application. Therefore, it can be used for stimulating muscles whose primary function is 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 evidence of its effectiveness the therapist must be aware of the precautions that must be considered when using it as a treatment option which include:

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

Whole Body Vibration

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

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

Vestibular Stimulation

The vestibular stimulation technique is a proprioceptive unique sensory system with a 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 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 rapidly with anterior-posterior or angular acceleration of the head and body while the cis health d in the prone position.

The inverted position is commonly used now to achieve total body inhibition, while it may be used to increase certain extensors.

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

Normalization of Tone & Maintenance Soft Tissue Length

Passive Stretching - Slow

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

Fast / Quick

Prolonged

Maintained

The presence of increased tone can ultimately lead to joint contracture and changes in muscle length. When we look at the use of stretch to normalize tone and maintain soft tissue length, we employ a slow, prolonged stretch to maintain or prevent loss of range of motion. While the effects are not entirely clear the prolonged stretch produces inhibition of muscle responses which may help in reducing hypertonus, e.g., Bobath's neuro-developmental technique, inhibitory splinting, and casting technique. It appears these influences both neural components of muscle, via the Golgi Tendon Organs and Muscle Spindles, and the structural components in the long term, via the number and length of sarcomeres.

Muscle immobilized position = Loss of Sarcomeres and Increased Stiffness related to increasing connective tissue

Muscle immobilized lengthened position = Increase Sarcomeres

Studies in Mice show that a stretch of 30 mins daily will prevent the loss of sarcomeres in the connective tissue of an immobilized muscle, although the timescale in humans may not relate directly.

Passive stretching may be achieved through several methods which include:

Manual Stretching

Prolonged manual stretch may be applied manually, using the effect of body weight and gravity, or mechanically, using a machine or splints. Stretch should provide sufficient force to overcome hypertonicity and passively lengthen the muscle. Unlikely to provide sufficient stretch to cause a change in a joint that already has a contracture.

Weight Bearing

Weight-bearing has been reported to reduce contracture in the lower limb using Tilt-tables and standing frames through a prolonged stretch. Angles are key to ends ensuring knees remain extended during the prolonged stretch as the force exerted on the knee can be quite high. Some research also challenges the assumption of the benefits of prolonged standing.

Splinting

“Splints and casts are external devices designed to apply, distribute, or remove forces to or from the body in a controlled manner to perform one or both basic functions of control of body motion and alteration or prevention in the shape of body tissue. Splinting can be used to produce low-force, long long-duration things although there is a dearth of evidence to support this. A wide range of splints has been used to influence swelling, resting posture, spasticity, and active and passive ROM.

Serial Casting

Serial casting is a common technique that is used and most effective in managing spasticity-related contracture. Serial casting is a specialized technique to provide an increased range of joint motion. The process involves a joint or joints that are tight and are immobilized with a semi-rigid, well-padded cast. Serial casting involves repeated applications of casts, typically every one to two weeks as a range of motion is restored.

The duration of a stretch to reduce both spasticity and prevent contracture are not yet clear from the research and requires further research to determine the most appropriate technique and duration to produce the required effect.

Positioning

Patients should be given individualized positioning and early mobilization management plans as soon as possible after a neurological impairment to prevent complications and regain function. It is based on reducing the effects of gravity on alpha motor neurons and consequently inhibiting muscle tone. Relaxation achieved by this technique is not permanent and unless motor learning or central program adaptation is actualized it is reversible. Hence, modifications in several systems are required for this treatment to be effective. The effects of muscle tone on autogenic inhibition, reciprocal innervation, labyrinthic or somatosensory effects, and cerebellar regulation can be affected. It should be kept in mind that active participation of the patient is required for the changes in the CNS to occur and motor learning to take place

Positioning is used widely to prevent the development of contracture in neurological conditions and to discourage unwanted reflex activity. After a neurological impairment, muscles can be affected in various ways, causing pain, spasticity, and problems with speed and range of motion. One way to minimize these effects is to properly support, position, and align the body. Proper positioning can be useful to minimize or prevent pain and stiffness that are commonly present post-impairment. It can also regain movement that was lost, or limit future problems with movement. In addition, proper positioning has been shown to increase awareness and protection of the weaker side of the body. Some common positions recommended following a stroke:

Positioning while lying on your back:

Pillows are placed behind the shoulder, head, weaker arm, and hip. The feet are placed in a neutral position.

Positioning while lying on the weaker side:

When lying on the weaker side, one or two pillows are placed under the head, the weaker shoulder is positioned comfortably on a pillow, the stronger leg is forward on one or two pillows, and the weaker leg is straight out. Pillows are also placed in the back and front of the body.

Positioning while lying on the stronger side:

One or two pillows are placed under the head, while the weaker shoulder is placed forward with the weaker arm supported by pillows. The weaker leg is placed toward the back of the pillows.

Positioning while sitting up:

The individual is seated at the center of the chair or wheelchair, their arms placed forward onto pillows on their lap or a tablet placed flat on the floor or footrest that seems bent directly above the feet.

Positioning while sitting in bed:

Sitting up in bed is recommended for short periods only as it is better to sit in a chair as soon as possible. The individual will sit upright, well supported by pillows. Arms are placed on pillows on either side of the body and legs are extended comfortably.

Positioning during transfers: 

During transfers to a chair or from a chair to another chair, positioning the weaker shoulder and upper arm is important. The weaker arm should always be supported during transfers, and it is important that most pulls can cause pain in your shoulder that will be difficult to eliminate once created. For getting out of bed, it may be useful to install a bar beside your bed bottled you can hold onto with your stronger arm to help push yourself up to the standing position.

Positioning while standing and walking:

• While standing up and moving around, slings and supports are used for positioning weaker arms.
• Bed Positioning for Optimum Patient Safety and Comfort Carolinas Rehabilitation

Neutral Warmth

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

Cryotherapy - Prolonged

Efferent and afferent neurotransmission is reduced through prolonged use of ice, which is effective for the reduction of spasticity. To achieve this, the muscle spindles need to be cooled requiring that ice is applied until there is no longer an excessive reflex response to stretching. Effects can last from 1-2 hours providing video a window of opportunity to work on stretches or exercises that may provide a more long-lasting effect. The most common method of prolonged icing that is used is local immersion, which is particularly useful in reducing hand flexor tone.

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 the 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 backflow.

Massage may also be used to stretch muscle fibers. 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.

Physical Activity and Exercise

Hydrotherapy

Water immersion can enhance the retreater’s messianically impaired individuals with both therapeutic, psychological, and social benefits. Hydrotherapy is the term used 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 joints m, options, and reducing pain. This therapy has been used for thousands of years.

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 to improve motor performance and aid rehabilitation. PNF is considered an optimal stretching method when the aim is to increase the 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. To promote these mass movement patterns, PNF uses a multi-sensory approach, incorporating auditory, visual, and tactile systems. PNF allows the patient to understand what normal movement feels like using various through the e of manual contacts to cue the patient and facilitate movement.

Primarily, PNF treatment techniques focus on three things:

• Increase the motor learning of the agonist through repetition of an activity (repeated contractions) and rhythmic initiation.
• Reverse the motor patterns of the antagonist.
• Two techniques are slow reversal and rhythm stabilization, both of which use an isometric contraction.

Finally, learning to relax muscles helps to increase the 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 multi-joint, 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 and UE D2 flexion & extension. There are also 2 pairs of foundational movements for the lower extremities: LE D1 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 the 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 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 move me using a passive range of motion, followed by an active-assistive, active-resisted range of motion, and finally an 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 building up the endurance of weaker muscles and develop coordination and establish the normal reversal of antagonistic muscles in the performance of the movement.

Aerobic Exercise

There is an increasing range of aerobic exercise options being accessed by people with neurological conditions. These range from aerobic exercise programs (e.g. overground walking or treadmill training programs) 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 program for an individual, which is timely and can be carried out in an appropriate environment.

Treadmill Training

The incentive to provide a challenging environment, in which there is an opportunity to practice repetitively the missing components of gait, has underpinned another task-specific activity. This involves using a treadmill for gait training and 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:

It allows a complete practice of the gait cycle

It provides an opportunity for gaining improvements in speed and endurance optimizers aerobic fitness

Task-specific optimizes eons 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

Pilates is a system of exercises that 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. While Pilates is used widely for neurorehabilitation there is limited research on its effectiveness as part of rehabilitation for patients with neurological impairment.

Tai Chi

Tai Chi is an internal Chinese martial art practiced for both independence training and its health benefits defense 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 mind-body connection, Tai Chi combines rhyming embodiment, 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 on 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

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 behavioral approach to neurorehabilitation based on "Learned-Nonuse".

CIMT is typically performed for individuals following a Cerebrovascular Accident 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:

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

Robotics

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 the 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 the patient; here, robots are used mainly as therapy aids instead of assistive devices. Rehabilitation using robotics is generally well tolerated by patients and is 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.

Virtual Reality

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 is beginning to be explored. The use of games using the Nintendo Wii ®, for example, has been 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). However, a Systematic Review and Meta-Analysis of Randomized Controlled Trial analyzing virtual reality's effectiveness to improve functional performance in patients with Spinal Cord Injury (SCI) showed inconclusive outcomes suggesting that virtual reality may not be more effective than conventional physical therapy in improving functional performance in patients with SCI. A recent systematic review and meta-analysis also show limited evidence of virtual reality interventions in upper limb motor function recovery after SCI compared to conventional physical therapy.

Electrotherapy

Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) is a method of electrical stimulation that 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 mostly 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 that technically fall into this grouping.

Electrical Stimulation of Muscle

Electrical Muscle Stimulation (ES) is an assistive technology that can be used to aid the recovery of the upper limb after a stroke. It uses an electrical current to stimulate muscle contraction via electrodes, facilitating the movement of a weakened or paralyzed limb. It has been used since the mid-1960s, traditionally to aid mobility by addressing dropped-foot, however, more recently it has been considered 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.

A randomized control trial carried out on critically ill traumatic brain injury (TBI) patients suggests positive outcomes with neuromuscular electrical stimulation (NMES). This study showed no significant reduction in muscle thickness of the Tibialis Anterior and Rectus Femoris muscle when NMES was applied for fourteen consecutive days as compared to the control group who received only conventional physiotherapy.

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 the brain can adapt and form new neuro-connections. By forming these new synapses, motor skills are relearned, and concepts of sensory-motor learning are founded on this premise. Following a stroke, there is evidence that the brain has a period of hyper-excitability within the first weeks after stroke and it is hypothesized that by afferent stimulation central reorganization can be enhanced by stimulation through a movement that ES may be able to facilitate. Additionally, there is a 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 the use of ES is not conclusive.

For more detailed information about the Electrical Stimulation of Muscle, the specification only about its use in the recovery of Upper Limb function post-stroke, you can complete the

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 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 body signs and that he can control them consciously. In the first place using biofeedback equipment, afterward even without.

Further, neuromuscular training or biofeedback therapy is an instrument-based learning process that is based on “operant conditioning” techniques. The governing principle 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 folds.

Other

Orthotics

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 cultures, an intervention to stabilized stabilize unresponsive so 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:

• Mobilization of Musculoskeletal Segments
• Reduce Axial Loading
• Prevention or Correction of Deformity
• Improved Function

Orthoses are made from various types of materials including thermoplastic fiber carbon fiber, 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 concerning 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 objectives e.g. improving walking.

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 that regards ill health as a manifestation of an 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 in the body can help to restore the balance between Yin and Yang that becomes disturbed in illness. When choosing acupuncture as a means of treatment it is important to be aware of the contraindications.

String Wrapping

String Wrapping, also referred to as Compressive Centripetal Wrapping, was first promoted by Flowers for the control of low demand 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 rea duction of swelling.