Interventions Used in Neurophysiotherapy

Introduction

An emerging evidence base surrounding the issues of neurological rehabilitation means that the role of the physiotherapist in treating and managing neurological conditions is developing. Current research identifies the importance of task-specific, strength and repetitive training. Alongside this the use of novel interventions, such as functional electrical stimulation (FES) and constraint-induced movement therapy (CiMT) are advocated. (Smith, Watson, & Connell, 2013)

In this article we are going explore some of the interventions that are used in neurophysiotherapy. The interventions discussed here are not exhaustive and this article is not meant to be comprehensive rather, it is meant to briefly explain some of the tools that a neurophysiotherapist uses thus giving the reader a brief overview of how physiotherapy contributes to neurological rehabilitation.

Therapeutic Exercise

Therapeutic exercise is the systematic and planned performance of body movements or exercises which aims to improve and restore physical function. Almost all the approaches/interventions used in neurorehabilitation have their foundations laid on exercise/physical activity.

Exercises can be grouped via the basis of many varied reasons i.e. they can be grouped according to aim and purpose;

Range of motion exercises
Muscle performance exercises
Postural exercise
Balance and coordination exercises
Relaxation exercises
Area specific exercises i.e. breathing exercises, circulatory exercises

Benefits of exercise in neurological rehabilitation include;

Stroke	Benefits of Cardio-respiratory training High grade evidence suggests improvement in; 1. Mobility (increased walking speeds, walking capacities and maximal speed) 2. Improvement in physical fitness Moderate grade evidence suggests it leads to improvement in; 1. Physical function (improved balance) Benefits of Resistance Training Moderate grade evidence suggesting resistance training improves; 1. Muscle strength 2. local muscle endurance 3. power output. Other benefits are; 1. Increase in gait speed and gait endurance 2. Improvement in balance on values measured using the berg balance scale. (Saunders et al., 2020)
Cerebral palsy	Aerobic exercise vs usual care Low grade evidence suggesting that aerobic exercises: Had a better positive moderate effect on Gross motor function compared to usual care Improved the gait speeds (0.09m/s faster than the control group with the usual care. (Ryan, Cassidy, Noorduyn, & O Connell, 2017)
Multiple Sclerosis	Effect of exercise therapy for fatigue in multiple sclerosis Endurance training, mixed training helps; – Reduce fatigue without side events. Heine, et al (2015) Exercise and physical activities leads to; 1. Improved functional outcomes (mobility, muscular strength) 2. Reduced impairment (fatigue) 3. Improved participation (quality of life) Amatya, Khan, & Galea, (2019) Aerobic exercise; Induces Functional and Structural Reorganization of the Central nervous system. (Stellmann et al., 2020)
Parkinson’s disease	Progressive Resistance Exercise Training improved Attention and working memory in non-demented patients with mild-to-moderate Parkinson’s disease. (David et al., 2015) Exercise interventions may reduce falls in people with Parkinson’s (Lai et.al. 2019)
Dementia	Exercise interventions have positive effects on people dementia and cognitive impairment, (Lai et.al. 2019)

Benefits of exercise in neurological rehabilitation

CIMT (constraint-induced movement therapy)

CIMT is an approach proposed by Edward Taub in the 1980s as a means of treating the upper limb following stroke (Smith et al., 2013). It involves three major components (Morris et al 2006):

Repetitive structured Intensive therapy for the affected limb (up to 6hrs)
Restricting the use of the unaffected limb 90% of the waking hours.
Application of the transfer package (behavioral methods to enhance the transfer of gains made in the clinic to the patients’ daily lives.

This approach appears to prevent learned non-use. Restraining the unaffected arm or the application of the transfer package isn’t effective, CIMT is only effective when further training is involved. CIMT is also only a treatment option for patients who have some volitional movement in their paretic upper limb and especially in the extension direction of one or more fingers and/or thumb (Veerbeek & Verheyden, 2018).

The duration of the original CIMT treatment is each working day for 2 or 3 consecutive weeks.

Evidence supporting use of Constraint induced movement therapy:

Results from a systematic review, (Corbetta, Sirtori, Castellini, Moja, & Gatti, 2015), explain that CIMT appeared to be more effective at improving arm movement than active physiotherapy treatments or no treatment.

Another systematic review, (Mcintyre et al., 2012), assessing CIMT for patients 6 months post stroke also concluded that CIMT to improve UE function is an appropriate and beneficial therapy for individuals who have sustained a stroke more than 6 months previously.

Results from a systematic review, (Hoare et al., 2019) assessing the impact of constraint-induced movement therapy in children with unilateral cerebral palsy were:

CIMT compared with a low-dose comparison group (children had 0 to 25 hours of comparison therapy; and the amount of therapy was much lower than the amount of CIMT)

CIMT may improve bimanual ability (that is, using both hands together; low-quality evidence) and unilateral capacity (that is, one-handed ability using the more affected hand; very low-quality evidence) more than low dose. Three studies reported that a small number of children experienced frustration or refused to wear the constraint, or had reversible skin irritations from casting.

CIMT compared with a high-dose comparison group (children had more than 25 hours of bimanual therapy or another form of intensive therapy and the amount was less than CIMT)

CIMT appeared no more effective than a high-dose comparison therapy on bimanual ability (low-quality evidence) or unimanual capacity (very low-quality evidence). Two studies reported that some children experienced frustration from participating in CIMT.

CIMT compared with a dose-matched comparison group (children received the same amount of bimanual therapy as the CIMT group).

CIMT appeared no more effective than dose-matched therapy on bimanual ability, unimanual capacity (low-quality evidence) or manual ability (very low-quality evidence). From 15 studies, two children did not tolerate CIMT and three had difficulty getting used to CIMT

Electrotherapy

TENS (Transcutaneous electrical nerve stimulator)

Effect of TENS after stroke

Transcutaneous electrical nerve stimulation can provide additional reduction in chronic post- stroke spasticity, mainly as additional therapy to physical interventions. Especially for low frequency TENS used in the lower extremities (Allein et al., 2018)

There is strong evidence that TENS as an adjunct is effective in reducing lower limb spasticity when applied for more than 30 minutes over nerve or muscle belly in chronic stroke survivors. (Mahmood et al., 2018)

Electrical sensory input can contribute to routine rehabilitation to improve early post-stroke lower-extremity impairment and late motor function, with no change in spasticity. Prolonged periods of sensory stimulation such as TENS combined with activity can have beneficial effects on impairment and function after stroke. (Sharareh, Shuster, & Bishop, 2018)

The results support the use of repeated applications of TENS as an adjunct therapy for improving walking capacity and reducing spasticity in stroke survivors. (Kwong & Ng, 2017)

Effect of TENS in Multiple Sclerosis

Decrease in low back pain scores on the Visual Analogue Scale. However, the decrease in scores was not statistically or clinically significant. (Bhasker Amatya, Young, & Khan, 2018)

Eight hour TENS application (100 Hz and 0.125 ms pulse width) daily led to a significant reduction in muscle spasm. (B Amatya, Khan, L, Demetrios, & Dt, 2013)

TENS in Spinal Cord Injury

TENS was effective in reduction of pain in spinal cord injury when compared to sham treatment. (Harvey, Glinsky, & Bowden, 2016)

Functional Electrical Stimulation (FES)

Functional Electrical Stimulation (FES) uses electrical pulses to stimulate motor neurons or denervated muscle fibers directly to elicit a contraction during a functional activity (Berkelmans, 2008).

Common uses in rehabilitation include:

FES Cycling

FES Cycling 2-3 times per week for 10 weeks in individuals with a spinal cord injury showed increased total cycling power, endurance, lean muscle, and improvements in lower extremity ASIA Impairment Scales Scores for both Motor and Sensory. (Griffin, et al 2009)

FES therapy for upper limb

FES can be used to prevent or reduce shoulder subluxation early after stroke. (Vafadar, Côté, & Archambault, 2015)

FES for foot drop

FES used for foot drop has a positive initial and ongoing effect on gait speed in short walking tests (Miller et al., 2016)

Action Observational Therapy

Action Observation Therapy (AOT) is a top down approach and is grounded in basic neuroscience and the recent discovery of the mirror neuron system (MNS). The mirror neuron system (MNS) is a part of the neural system that is activated when animals or humans execute meaningful actions or observe similar actions performed by others. (Kim, An, & Yoo, 2018)

Comprises of two phases (Buccino, 2013)

Observation phase: during this phase, patient is asked to carefully observe the given video.
Execution phase: during this phase, patient is asked to perform the observed motor task at the best of his/her ability

In a clinical study assessing the effect of group based rehabilitation combining action observation therapy with physiotherapy on freezing of gait in Parkinson’s. (Pelosin et al., 2018) the study found out that Action observation therapy group-based training is feasible and effective on Freezing of gait and motor performance in Parkinson’s disease patients and may be introduced as an adjunctive option in Parkinson’s disease rehabilitation program.

Mirror therapy

Mirror therapy is based on visual stimulation. During mirror therapy, a mirror is placed in the person’s midsagittal plane, thus reflecting the non-paretic side as if it were the affected side. By this setup, movements of the non-paretic limb create the illusion of normal movements of the paretic limb.

The key result from a systematic review investigating mirror therapy after stroke was that at the end of treatment, mirror therapy moderately improved movement of the affected upper and lower limb and the ability to carry out daily activities for people within and also beyond six months after the stroke. Mirror therapy also reduced pain after stroke, but mainly in people with a complex regional pain syndrome. (Thieme et al., 2018)

Virtual reality

Virtual reality (VR) is a computer-based, interactive, multi-sensory simulation environment. It can be categorized into two, immersive and non-immersive. In immersive VR systems, the user feels as though they are actually present in the computer-generated world. Non-immersive VR systems still require the user to interact with the environment but provide a lesser feeling of ‘presence’ within the virtual world. (Smith et al., 2013)

According to (Hornby et al., 2020) virtual reality based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improves walking speed or distance.

Kate E Laver et al., (2017) found evidence that when used alone virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function for post stroke patients. However, virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time).

In reviewing the evidence as to whether virtual reality is effective in improving hand functions for children with cerebral palsy, Rathinam et al., (2018) concluded that the role of virtual reality in improving hand function for children with cerebral palsy is unclear however if used as an addition to treatment, there exist some support.

In people with Parkinson’s Disease, Virtual reality has been found to be effective than other passive interventions improving, stride length, gait speed, balance and activities of daily living.(Triegaardt & Han, 2019)

Robotics

Robotic devices have been developed to assist with labor-intensive walking training that focuses on producing more normal walking patterns after chronic CNS injury. Strong evidence indicates that walking training with robotics compared with walking training alone does not result in greater walking speed or distance in people in the chronic stages following stroke, SCI, and TBI. (Hornby et al., 2020). However, all participants included in these studies were likely able to ambulate without the use of robotic assistance.

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