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DUBLIN PHYSIOTHERAPY CLINIC 3:
ARTICLES
NEUROLOGICAL
PHYSIOTHERAPY: NEW PERSPECTIVES
INTRODUCTION
Rehabilitation of
neurological conditions requires Specialist Physiotherapy. Historically these
disabling conditions were treated with the aim of regaining function as quickly
as possible at the expense of the affected limbs. One major problem associated
with stroke is excessive muscle stiffness in the affected limbs (known as
spasticity). Using this treatment approach spasticity in the affected limbs was
often increased and movements made more difficult. With time functional loss
and eventual immobility were often the result.
Management of stroke
was originally based on the concept that damage to the brain was irreparable.
Recovery of the affected side was therefore not a consideration. Treatment was
often directed towards strengthening the good side to compensate for the loss
of function on the affected side. No attempt was made to influence spasticity
as a means of facilitating recovery. The 1940's and 1950's saw the development
of new treatment approaches in the management of neurological conditions. This
initiated specialization in Neurological Physiotherapy. Among the numerous
approaches in use today the "Bobath" concept has been shown to be
very beneficial.
The principle of
treatment is to restore 'normal movement'. This involves treating the affected
and unaffected sides to improve normal daily functions. Recent evidence
suggests there is considerable potential for recovery of the brain following a
stroke. This supports the concept that change can occur. Patients have the
ability to learn to move more normally and unwanted spasticity can be
influenced.
Historically it was
thought that following a stroke recovery continued for up to two years post
injury. This time scale is unfounded. Recovery may continue for many years
after a stroke. However rehabilitation in the initial phase post stroke will
have the most significant effect. Indeed many long term strokes (1 year+)
develop problems as time progresses. This may include pain, stiffness,
functional deterioration and often immobility all of which may benefit from
treatment.
Physiotherapy aims to
promote and maximise a person’s independence and quality of life through
rehabilitation, education and support for the individual and their family.
Physical problems associated with a stroke are:
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· Paralysis |
Modern Physiotherapy approaches to those
problems include treatment techniques which relax muscles when tight and
stimulate muscles when weak. The physiotherapist through her handling of
specific bodily parts influences the muscles and guides the patient through a
particular movement e.g. learning to sit, turning in bed or standing up. In
time the patient may learn to carry out a movement with better control and less
assistance. A thorough understanding of normal movements is necessary when
analysing why abnormal movements present in a stroke patient may cause
difficulty with a particular function.
Disability resulting from stroke is variable in
each individual. Research indicates that following a stroke most individuals
regain the ability to walk. However many are slow and may never walk outside.
This means a comprehensive assessment is essential for planning an effective
rehabilitation programme This includes detailed examination of:
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· Body movements |
From this a specific management programme is
devised which may include:
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· An intensive "hands
on" rehabilitation programme |
Goals are set by the therapist and patient/carer
which include functional tasks relevant to lifestyle. Rehabilitation begins on
the day of the stroke. This initially consists of positioning and passive
stretches to maintain muscle and joint range, together with a close liaison
with medical staff. Early mobilisation of the patient is encouraged as soon as
possible when the medical condition allows.
An essential role of the Physiotherapist is to
impart appropriate handling skills to family and carers. This ensures that
continuity carries over into the daily routine. As the ultimate aim of
rehabilitation is for the individual to experience as normal a life as possible
then rehabilitation does not stop at discharge from hospital but continues
after the patient has returned to the community.
A critical stage of personal development is the
initial few weeks following hospital discharge when a person experiments with
their environment e.g. shopping, meeting friends. Many barriers may limit the
disabled person e.g. access to buildings, crowds of people, embarrassment with
their disability. A lack of confidence to tackle such barriers and eventual
avoidance can lead to isolation and depression. The individual may become less
active both physically and socially, reducing the opportunity for further
recovery. Lack of resources and limited out-patient and community stroke
programmes may result in therapy being withdrawn too early. This leaves the
patient feeling abandoned and thinking there is no further chance of recovery.
Guidance and encouragement is therefore needed to resume community activities.
Stroke
rehabilitation should therefore take into consideration social and
psychological outcome, as well as physical function when planning a management
programme enabling a person to return to an active lifestyle and not merely an
existence.
PHYSIOTHERAPY AND PARKINSON'S DISEASE
Introduction
Parkinson’s Disease is a movement disorder, which may affect balance, posture and performance in daily activities such as turning in bed, sit to stand, walking and hand dexterity. It may have a major impact on a person’s work, family and leisure activities. However statistics show that referrals to physiotherapy are low and have changed little in the past twenty years, despite the fact that physiotherapy addresses many of the core areas outlined above
How can Physiotherapy Help a Person with
Parkinson’s Disease?
Symptoms a person may experience include some or all of the
following:
· muscle rigidity,
· tremor,
· slowness of movement ,
· fatigue
· balance impairment
which can affect everyday physical activities such as,
moving in bed, hand dexterity, walking, working, and recreation. Over time,
secondary problems may arise such as loss of flexibility, weakness, postural
change, discomfort and pain, further affecting movement and function.
Physiotherapy aims to promote and maximise a person’s independence and quality of life through rehabilitation, education and support for the individual and their family
When Should I See a
Physiotherapist?
Following diagnosis, early
referral to physiotherapy is recommended. The individual has the opportunity to
discuss any concerns or worries relating to the condition and his symptoms.
Early assessment allows the physiotherapist to address current problems and to
identify any potential ones. A treatment program can be devised specifically
for your needs. He/she can give practical advice on physical management of the
condition, aids and adaptations that may help in the home or at work, and can
provide information on services available in the community, including information
on specific support groups.
Early referral also
provides baseline objective levels of performance. Any change in the person's
condition or functional ability can be promptly addressed throughout the course
of the condition.
What Should I Expect on Initial Contact with
the Physiotherapist?
The Physiotherapist
will carry out a comprehensive assessment, which will include a detailed
account of your history relating to diagnosis, history of symptoms, i.e.
stiffness, fatigue, pain and how they affect everyday activities in the home,
at work and social activities. She will ask about current medication and past
medical history. The assessment will also include a physical examination, an
analysis of posture, body movements and performance of functional activities,
e.g. rolling, walking indoors / outdoors, balance activities, and climbing
stairs. From this comprehensive examination, the physiotherapist will discuss
the current findings with you, identify potential problems and decide on the
most appropriate course of action. A rehabilitation programme is then devised
to address your specific needs.
How Long Will I Need to See a Physiotherapist?
This will really depend
on each individual presentation and the findings upon examination. The
physiotherapist may recommend any of the following:
1. A course of treatment, on a one to one basis, perhaps on a
weekly basis for a period of time.
2. A tailor made exercise programme where you would carry out
these exercises at home with the emphasis being on self-regulation. The physiotherapist
may monitor your progress by arranging regular reviews from time to time.
3. Participation in an exercise group. Usually these address
general body movements, flexibility, co-ordination, balance, breathing control
and functional activities.
4. Referral to other services, e.g. consultant, support group,
or other health professionals, e.g. speech therapist, occupational therapist.
It is often the case
that the physiotherapist will recommend one or more of the above, given the
nature of the condition and the changing needs of the person. It is recommended
that your condition and progress are monitored on a regular basis through
regular reviews and intervention as required to achieve your optimal functional
potential.
What does Physiotherapy Treatment Involve?
Treatment is very
dependent one's symptoms. It may be Hands on work, i.e. stretching,
mobilising tissues, massage, or it may consist of various forms of exercise,
addressing posture, balance, flexibility and strength. Usually a combination of
both is needed.
Treatment may also
include teaching of movement strategies. This involves learning new
techniques to perform a functional movement - usually automatic movements (e.g.
turning in bed, standing up, stepping, turning, walking through doorways) which
can become increasingly difficult with this condition.
If pain is a problem
then an assessment of the particular area of your body may be needed to
identify the faulty tissues - joint, muscle, nerve or ligaments. In PD, common
areas of pain are the neck and lower back. Your postural habits, body movements
and daily activities are also assessed. Treatment may include manual therapy
for the appropriate structures, exercise, and advice regarding posture and
movement.
What Type of Physiotherapy Treatment is Best?
In the last few years a
professional body in England has reviewed the evidence in relation to
best-practice treatment for Parkinson’s disease. The findings suggest that
further research is needed!
However studies they did
look at showed that exercises such as stretching, strengthening, balance
re-education, breathing control, relaxation and aerobic exercise i.e. cycling,
walking can all have a positive effect on a person’s well being and help to
promote functional independence. It has also been suggested that exercise is
most effective whilst maintaining an optimal drug regime. Some studies looked
at carrying out exercise classes over a certain period of time. Many programmes
included exercises for improving strength and flexibility in the head and neck,
trunk and limbs together with exercises for balance, posture, speech and
breathing control, relaxation, and walking re-education.
What was highlighted
was the difficulty a person might have of continuing with these exercises once
the class was completed. To promote compliance it was suggested that regular
home visits together with top-up programmes were needed.
What are the Benefits of Individual Therapy and
Group Therapy?
To have a clear
understanding of the person’s problems, a comprehensive assessment on a one to
one basis with the physiotherapist is essential. Most people like to have
individual treatment with a physiotherapist where they can discuss their
personal problems privately and where personal needs are addressed and progress
is monitored closely through personal supervision. A structured class has the
advantage of providing motivation, social contact, camaraderie and it can be
fun.
What are the Benefits of Exercise?
There are many benefits
of exercise.
Exercise:
·Maintains
flexibility.
·Improves
balance.
·Increases
muscle strength.
·Improves
general functioning.
·Improves
fitness and stamina.
·Provides a
sense of achievement and empowerment
·Reduces stress
and anxiety
·And most
importantly it can be enjoyable.
Exercise will not
change the course of the condition, but it may promote your level of wellbeing
and quality of life and help counteract the effects of the symptoms.
Movement Patterns
The basal ganglia is
involved in complex automatic movement patterns. As mentioned, in Parkinson’s
disease a person may have difficulty performing such automatic movements as
rolling, walking, or sit to stand. To execute the movement, sequence cues may
link components of the movement.
There are four possible
cues:
1. Visual cues - eyesight
2. Auditory cues hearing
3. Proprioceptive cues – feeling the movement
4. Internal cues – memorising the movement, mental rehearsal.
If we take an example
of freezing when walking, we may help overcome the freezing either by use of:
1. Visual cues – place a stick in the ground
2. Auditory cues – count one - two or use a metronome
3. Proprioceptive cues – heel tap to initiate the next step
4. Internal cues – or cognitive thoughts.
Thinking of the
sequence of the movement we want to perform prior to carrying it out may help.
Research has shown that
there is greater improvement in performance, over a longer period of time, if
movement strategies are incorporated into the rehabilitation program, as
compared to when they are not. They also suggest that these compensatory
movement strategies should be performed at peak medication dose.
The Role of Carers in Rehabilitation
Involvement of carers
is vital, as they can provide much information relating to problems faced at
home. The physiotherapist can give practical advice on the most effective ways
to stretch, and how to assist with movements such as transfers and walking.
How Can I Access a Physiotherapist?
A person can access
community and outpatient physiotherapy services in Ireland through referral
from a GP, Consultant e.g. Neurologist, Geriatrician or Physician.
Alternatively an individual can refer himself to a private physiotherapist,
preferably one who specialises in the treatment of Neurological conditions.
Some physiotherapists
will provide private treatment at home as well as in a clinic. The advantage of
seeing a physiotherapist in hospital / clinic is the available space and the
accessibility to various pieces of equipment. When treating in the home the
physiotherapist has the opportunity to understand the everyday movement
problems you face and provide practical advice and support. She also has the
opportunity to address the problems you encounter in the community, e.g.
freezing in local shops, difficulty getting on /off the bus, or crossing the
road.
How Do We Evaluate if Physiotherapy is
Effective?
One of the main ways is
obviously to ask your opinion, i.e. to fill in a questionnaire, to note what
changes you feel each day. We may also use visual observation of functional
activities by photography or video analysis of walking.
Time tests provide
objective measures. The most common ones include:
1. timing a person walking 10 metres [the timed 10 metre
walking test];
2. timing one's ability to stand on one leg, which is a
reflection of your ability to balance;
3. Another test is the "get-up and go" test. This
times how long it takes to get from a chair, walk three meters, turn come back
and sit down.
4. Also, evaluation of hand dexterity could consist of timing
the closing of buttons
These are but a few of the many
tests which provide information to the person with Parkinson’s on the
performance in any areas that need to be addressed. Alternatively the patient
and physiotherapist may set very specific goals and time limits relating to
everyday situations, e.g. getting out of bed independently or being able to
walk to the shops each day.