Neurological Physiotherapy – exciting times ahead
Feature article PhysioTimes James McLoughlin, Vol 3, Issue 6, May 2012
The history of Neurological Physiotherapy stems from the simple discovery that people with neurological disease or injury benefit from physical rehabilitation. A number of NeuroPhysiotherapy approaches emerged in various places around the world throughout the 20th century, each with their own rationale and strategies that could be used to encourage recovery of movement and function in patients with Central Nervous System (CNS) injury or disease. Concepts developed by Karl and Berta Bobath, Margaret Rood, Signe Brunnstrom and later Carr & Shepherd have formed the foundation of the majority of clinical practice today. While these approaches and concepts grew in popularity, key discoveries in neuroscience in the areas of neuroplasticity and motor learning were also starting to gain momentum. By the 1990’s it was becoming abundantly clear that the human central nervous system had a remarkable ability to reorganize itself, and therefore it was possible that training approaches could potentially be used to enhance the rehabilitation of conditions such as Stroke and Cerebral Palsy. This was in contradiction to the previous theories that maintained that a damaged human CNS was static, lifeless and unable to repair, and that physiotherapy was only having local effect strengthening muscles.
Research into the evidence for neurorehabilitation began to accelerate, and many physiotherapists teamed up with neuroscientists to investigate both clinical and neurophysiological measures of neurological recovery. Positron Emission Tomography (PET), Functional Magnetic Resonance Imaging (fMRI) and Transcranial Magnetic Stimulation (TMS) were some of the investigative tools that were able to give clues about CNS recovery.
Passionate debate regarding the superiority of different approaches still exists today, however it is likely that all strategies play an important role, particularly when considering the diverse range of neurological impairments and disorders that challenge the Neurological Physiotherapist. Goal setting, motor relearning, task specificity and exercise are fundamental to all approaches within Neurological Physiotherapy. Ideally therapists should strive to integrate many client-centered approaches that are preferable based on sound evidence. While our understanding of the human nervous system has improved dramatically, we still have a great deal to learn about motor control in normal and patient groups. It is hoped that neuroscientific tools such as fMRI and TMS may assist in our understanding of CNS recovery and hopefully enhance our clinical reasoning process. These methods may discover biomarkers that help us to predict clinical outcome. It is possible that type of research may even assist in deciding which patients will respond to high dose therapy and informing us about what rehabilitation techniques are likely to maximize recovery in individual patients. It may even lead to new treatment techniques and protocols that we are yet to experience. There is certainly increasing interest in what dose of therapy is needed to make a clinically meaningful difference. Cardiovascular exercise capacity in people with neurological impairments is also critical in relation to improving long term outcomes regarding community ambulation and overall health. Research that examines these aspects may assist in designing more cost efficient service delivery models.
Technology and innovation in the area of neurorehabilitation is expanding rapidly. Body weight support treadmill training (BWSTT), upper and lower limb robotics and virtual reality devices have created much excitement over the past decade. Many centres around the world have started adopting these technologies as part of routine clinical practice. However, we must be careful not to get too carried away with pushing to use these technologies at the expense of more practical and effective approaches that have evolved over time. Gait retraining with robotics and BWSTT is a classic example where research evidence does not support the initial excitement and temptation to change practice.
Physiotherapists working in the area of neurology are now faced with an extraordinary amount of information that needs to be considered when designing a rehabilitation program. The Evidence Base research is expanding rapidly, although understandably only the more clearly defined approaches to physiotherapy such as BWSTT and Constraint Induced Movement Therapy (CIMT) have been researched in larger well controlled trials. Task Orientated methods such as CIMT for the upper limb have been shown to be very effective, particularly for those patients who already show some recovery of distal wrist and hand movement. The challenge still remains to characterize and measure aspects of human movement and motor recovery and more clear evidence is required regarding rehabilitation methods for patients with more severe movement impairments and additional cognitive deficits. Movement laboratories and mobile technologies such as motion sensors have an enormous potential in allowing us to differentiate functional and motor recovery as well as measuring the real world activity and participation levels in our patients. In additional to movement recovery, sensory retraining is has also been effective strategy that can enhance neuroplastic change stroke patients.
Specialization appears to be an inevitable part of physiotherapy practice, and the area of neurology is no exception. Physiotherapists with an interest in neurological rehabilitation need the time to study many neurological conditions such as Stroke, Multiple Sclerosis, and Parkinson’s Disease. Neurological Physiotherapists need to be able assess both musculoskeletal disorders as well as various forms of movement disorders such as spasticity, dystonia and ataxia. Cognitive, perceptual and neuropsychological factors also directly influence rehabilitation outcomes therefore a Neurological Physiotherapist must utilize this knowledge when designing optimal rehabilitation programs. A greater knowledge and respect of the roles other professionals such as medical practitioners, occupational therapists and orthotists is essential in order to enable effective multidisciplinary and interdisciplinary rehabilitation. Extended Scope roles for Neurological Therapists in the area of Spasticity management is also beginning to emerge, with options for additional training in supplementary prescription in the UK leading to Physiotherapists injecting Botulinum Toxin for focal spasticity.
The Masters in Clinical Rehabilitation at Flinders University in South Australia now has a new educational stream in Neurological Physiotherapy. This gives physiotherapists the opportunity to learn advanced up to date knowledge of neurological conditions in an inter-professional environment alongside medical practitioners, nurses, occupational Therapists and Speech Therapists. Following this, the program then focuses on the key discipline specific aspects of advance practice in NeuroPhysiotherapy covering topics that include clinical neuroscience, motor relearning, exercise prescription and treatment approaches. University programs that incorporate both inter-professional and discipline specific training have a number of advantages. Not only do they provide a broader scope of knowledge base, but also encourage more effective interdisciplinary teamwork and research.
It is difficult to predict the next chapter for Neurological Physiotherapy. Clinical and Neuroscientific research is expanding rapidly, and advances in technology such as Telerehabilitation, motion analysis, robotics and functional electrical stimulation will no doubt influence our practice in coming years. The evolution of formal post-graduate education that critically examines these areas of advanced practice will hopefully assist in steering our profession in the right direction. These are certainly exciting times for physiotherapists embarking on a career in Neurological Physiotherapy!
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Bachelor Applied Science (Physiotherapy)
Masters of Clinical Neuroscience (Distinction)
PhD Candidate UNSW
James is Principal of James McLoughlin NeuroPhysiotherapy, a private practice in Adelaide that focuses on Neurological & Vestibular rehabilitation. James is also Senior Lecturer at Flinders University in Clinical Rehabilitation and coordinator of the new specialist streams in Neurological Physiotherapy and Neurological Occupational Therapy.