10 Principles of Neural Plasticity to optimize the intervention in neurorehabilitation

  1. Use it or lose it

Decreased activation of specific brain areas can lead to functional degradation. Encourage the patient to perform the movements that he can do on his own and assist the movement that he cannot perform. Since it has been shown that the decrease in use or performance of a movement can cause a loss of this incipient ability to perform a movement.

  1. Use it and improve it

The training of a specific brain function can lead to the improvement of that function.

  1. Be specific

The nature of the training experience dictates the nature of plasticity. That is, if we want to cause improvements in the activation of patients’ motor cortex, we must be specific in the design of interventions to ensure the acquisition of new skills or the acquisition of lost skills.

  1. Repeat

To induce plasticity, enough repetition is necessary. The repetition of an activity tends to cause lasting neuroplastic changes that facilitate learning stability. The use of new technologies provides a great help at this level, since they allow the patient to repeat a desired movement many times.

  1. Intensity

To induce plasticity, intense training (amount of activity per period) is required. 100 repetitions of an exercise are better than 40. However, a negative side effect that worsens the function has been described if an amount of extreme use is made in the vulnerable period after the injury after a stroke. There is an increase in the extiotoxicity of vulnerable tissues that involve the primary lesion. The intensity should be adapted to the patient’s level to obtain optimal results.

  1. Duration of therapy

Different forms of plasticity occur at different times. Functional changes in synapses become, over time, structural changes, outbreaks of neuronal growth and formation of new synapses, leading to cortical reorganization. Therpy must be durable enough to generate neuroplasticity.

  1. Motivation

The experience must be remarkable and innovative enough to induce plasticity. We must generate emotion during treatment as emotions modulate memory consolidation.

  1. Age

While it is true that plasticity occurs more easily in young brains, it does not mean that older adults do not have these abilities. What happens is that they need to compensate by activating more brain areas to maintain good functionality.

  1. Transfer

Plasticity in response to a training experience can improve the acquisition of similar behaviours. The best way is to integrate everything learned in therapy, into the activities of the daily life of patients, so that there is frequent use of skills and progressively improve the performance of tasks.

  1. Beware of maladaptive learning

In the initial stages after the injury, compensatory behaviours, for example, hight trunk movement to replace loss of upper limb function, interfere with the relearning of lost function. Thus, they limit the acquisition of movements in the upper limb and reduce the work requirement of the arm. In more advanced phases, in many occasions the compensations allow to integrate the affected limb in the activities of the daily life, integrating the capacities learned in the therapy and improving the performance of the patients.

 

In the design of the neurological rehabilitation sessions, these principles should be considered to improve the motor learning of patients, promote neuroplasticity and achieve better treatment results.

Kleim J, Jones T. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Journal of speech, language and hearing research. 2008; 51: S225-S239.

Gait speed with Functional Electrical Stimulation

Functional Electrical Stimulation, known as FES, is a therapeutic approach that uses a small electrical device to produce electrical currents and stimulate the peripheral nerve by means of adhesive electrodes placed on the skin. The applied electrical stimulus produced a muscular contraction that will help in the execution of the proposed task and therefore it is said “functional”.

Example: while walking, I use an electrical device that produces muscle contraction in the foot so that it rises from the ground at the moment of taking the step

This example is quite common among neurological patients, the equine foot due to nervous system injuries such as stroke and cranio-encephalic trauma. But it is among patients with spinal cord injury and multiple sclerosis that this device can act more significantly in reeducation and correction of gait.

In 2017, colleagues from Belgrade have published a study on the introduction of these devices in the therapy of hemiplegic patients by stroke. The aim of the study was to assess the additional effects that the introduction of Functional Electrical Stimulation could bring in the sessions of physiotherapy, especially in the aspects related to the rehabilitation of the march of hemiplegic patients by stroke. Although the study has only sixteen patients, they have observed that the eight patients who performed sessions of 30 minutes of walking with Functional Electrical Stimulation in addition to physiotherapy, improved the speed of walking, compared with the other eight patients they only performed physiotherapy. Apart from this change, other small changes have been observed in the way of running, mobility and autonomy in the activities of daily life.

Dujovic SD, Malesevic J, Maesevic N, Vidakovic AS, Bijelic G, Keller T, Konstantinovic L. Novel multi-pad functional electrical stimulation in stroke patients: A single-blind randomized study. NeuroRehabilitation. 2017;41(4):791-800


What footwear should I wear after a stroke?

After having suffered an Ictus, it is possible to present several alterations such as speech alterations, memory and attention problems, sensory and sensory changes, alteration of movement among other less common ones.
Related to the alterations of the posture and of the movement, a great alteration is in balance and march above all when the patient loses the motor control of the leg and foot (lower extremity).
From the point of physiotherapy, we know that the care of the foot is fundamental since it is the part of the body that supports the whole body, it is the body area that connects the body with the floor, in summary, it is the support surface. Sometimes, for ease and agility, caregivers, family members and the patient itself usually opt for the use of comfortable shoes such as slippers or slippers, however it is not the most recommended type of footwear. Using some type of splint in the foot or not, it is advisable to use a well-closed shoe, such as a sports shoe.
One of the most named studies on this subject reports to the year 2010 to Age and Ageing magazine. This study summarizes the information on the influence of footwear on the balance and gait of stroke patients and concludes that the use of closed shoes such as the sports shoe increases gait speed and increases the step length compared with other footwear such as flip flops, slippers or barefoot.
To make it easier for patients to put on and take off their shoes, which are often limited by the lack of skill and movement, there are several alternatives such as learning to tie the laces with one hand, using elastic laces with zippers or zippers and strong velcro. It is also important that the footwear is stable (eg, type of material) and that the sole is wide that allows freedom of movement of the toes of the foot. We understand that the selection of footwear depends on person for person and therefore it is advisable to take into account the opinion of the professional whether physiotherapist or podiatrist.


Ng H, McGinley JL, Jolley D, Morris M, Workman B, Srikanth V. Effects of footwear on gait and balance in people recovering from stroke. Age Ageing. 2010; 39(4):507-10

Bobath Concept

As every year, we receive the training sessions of the Spanish Association of Therapists trained in the Bobath Concept (AETB).
At the beginning of the month of March, Saturday, September 9, the XXXII AETB Training Days will take place in Madrid. These conferences, open to members and non-members, aim to keep interested parties up-to-date regarding the Bobath Concept and neurological rehabilitation, whether in children or adults.
This year will be treated issues such as the treatment of patients with acquired brain damage, in the acute phase of the process that corresponds to the first 3 months after suffering a stroke. In this phase the intervention of physiotherapy is paramount since it is when more and better results are obtained, the progress and level of recovery in this phase, which is usually hospitable, is usually an indication of recovery in future phases of evolution (subacute and chronic).
After addressing this issue several lectures will be given by highly qualified professionals such as the speech therapist Elía Rodríguez, the physiotherapist and tutor Bobath Maria Angeles Tejedor and the physiotherapist and tutor Bobath Carlos Leite Martins who comes from Portugal.
This year prior to the days of the Bobath Concept, the Association promotes a monographic course of physiotherapy treatment for patients with acquired brain damage. The course will address issues related to critical aspects of the patient in the acute phase and clinical aspects of the medical and therapeutic intervention. They will also relate the sensory integration treatment techniques and the construction of the body’s median line and its symmetry as a requirement to ensure that the patient acquires stability at the time of getting up and standing upright.
The Neurorehabilitation Clinic from Barcelona always marks its presence to bring to the working group new ideas and updates in the treatment of physiotherapy and occupational therapy of patients with brain damage.

(Español) Tratamiento miofascial para disminuir la espasticidad y mejorar el equilibrio

Este fin de semana he empezado una formación interesantísima de valoración y tratamiento de miofascial impartida por el fisioterapeuta y osteópata Ricard Tutusaus autor del recomendado libro: Sistema fascial, anatomía, valoración y tratamiento. Así que hoy he empezado a aplicar todo lo aprendido a mis pacientes y como no me parecía interesante compartir algunos conceptos interesantes sobre el tejido fascial que he refrescado y actualizado.
El tejido conjuntivo o fascial es un elemento de sostén y de relación conecta todo el cuerpo humano. Desarrolla tareas imprescindibles para la correcta función visceral y la coordinación neuromuscular. Sus principales funciones son:
– suspensión y conexión de estructuras viscerales;
– envoltura de vasos sanguíneos y estructuras nerviosas asegurando la vascularización e inervación;
– recubrimiento de músculos;
– adaptación a las fuerzas mecánicas y transmisión de movimientos;
– mantenimiento de la integridad postural;
– papel destacado en la propiocepción y en la recepción del dolor;
La evidencia científica demuestra que los pacientes con espasticidad, hipertonía o rigidez soportan tensiones continuas a nivel fascial lo que causa cambios estructurales permanentes en músculos y tejido conectivo. Una tensión mecánica prolongada sobre el tejido fascial estimula la formación de fibras de colágeno y causa una densificación que altera su capacidad elástica. Por otro lado, diversos autores afirman que el grosor de la fascia puede también incrementarse con la inmovilización muscular, que presentan por ejemplo los pacientes con imposibilidad de mover un segmento corporal tras un ictus.
Es por ello que en mis tratamientos incluyo técnicas de liberación miofascial con el objetivo de disminuir la espasticidad, favorecer la función fascial y muscular y mejorar la postura en sedestación y en bipedestación de mis pacientes.
Os dejo un estudio piloto que me ha parecido interesante y la referencia del libro de Ricard Tutusaus y Josep Maria Potau, que sin duda recomiendo leer.
Park DJ1, Hwang YI2. A pilot study of balance performance benefit of myofascial release, with a tennis ball, in chronic stroke patients. J Bodyw Mov Ther. 2016; 20(1):98-103
Ricard Tutusaus Homs, Josep María Potau Ginés. Sistema Fascial. Anatomía, valoración y tratamiento. Madrid: Panamericana; 2015.

Tratamiento del pié en fisioterapia neurológica

The foot is an area of ​​the body of extreme importance. It is seen as the base that sustains our whole body when we are standing or when we walk and an alteration in one or both feet induces alterations of postural control, that is, balance and consequently in gait.
In the neurological patient, Multiple Sclerosis, Friedreich’s Ataxia, stroke, among other pathologies of the nervous system, it is common to find alterations of the foot, such as:

  • Structural alterations: loss of the plantar arch, claw toes, etc.
  • Hypertonia or Spasticity: foot in equine or equine-varus
  • Hipotonia: flat foot
  • Joint instability:
  • Sensitivity: hyperreflexia, hypesthesia, etc.

By presenting alterations of the foot the patient can experience the reduction of balance reactions, known as ankle balance strategy, and therefore see their balance compromised. It is known that to improve the recruitment of these equilibrium reactions so necessary to standing posture, it is advisable to perform a structural preparation work such as:

  • Liberation of amplitudes or joint ranges, often limited by spasticity and often called equine foot;
  • Muscle recruitment and its potentiation, especially in the foot lift muscles;
  • Reciprocal innervation and coordination between muscle groups of the foot,
  • Among others

The preparation of the foot as a base of support and support of the body also includes a sensitive approach, that is, improving the sensitivity of the joint complex of the foot. The foot contact with the ground and therefore must present tactile or tactile capacity preserved. Kinesthesia, proprioception or deep sensitivity are also crucial to balance and gait. At all times we should be able to identify the weight that supports our joints of the feet and compare them to know if we are more or less inclined to one side or another, in front or behind.
Finally, the load. The ankle-foot joint complex is composed of large and strong joints, capable of receiving and supporting body weight. However, it is not just that the joints support the weight, but that the muscular system is able to keep them aligned in order to guarantee our balance in any situation (inside and outside the home, barefoot or with shoes, standing or moving, with light or low light, etc.).
As you can see, from the physiotherapy we have many tools to work the foot and improve the balance, either reducing spasticity and equine foot, strengthening the muscles that raise the foot or improving their sensitive perception.
Soon we will talk about how the foot behaves during walking and how physiotherapy can help patients with pathologies or neurological diseases.

El impacto de la discapacidad en la vida sexual de los individuos con enfermedades neurológicas

Individuals with acquired neurological diseases (such as stroke, head trauma, spinal cord injury, etc.) suddenly see their lives limited by alterations and functional, motor, sensory, and cognitive problems, among others. In addition to these limitations that on their own lead to a disability, there are other affected areas such as family, work, social life and even sexuality.
The motor, sensory, emotional and cognitive disability of patients with neurological disorders interrupts the sexual life of those affected and their respective partners and spouses.
The therapists of the rehabilitation team of the Neurorehabilitation Clinic of Sant Cugat del Vallés (Barcelona) recommend that patients overcome the tabu, shyness, shame and talk about this issue with a doctor, neurologist, psychologist, physiotherapist and even social worker. Different professionals can help in the search of strategies and therapeutic options (pharmacological and non-pharmacological) to face problems related to sexual life (erection, ejaculation, fertility, orgasm, reproduction, etc.).
Neurological patients, whether due to brain or spinal cord disease, may experience different symptoms or alterations that affect sexual activity. For example, the sensitive alteration can affect aspects related to the excitement or pleasure sensation, the motor alteration can affect the aspects related to the erection or ejaculation and even emotional alterations can influence the sexual libido and behavior.
Communication can also be a limiting factor to address the issue. Patients with aphasia (comprehension, expression, mixed, others) may have difficulty expressing their concern about the sexual issue, either with rehabilitation professionals, or at home with their partners. In a similar way it happens at an emotional level. Patients usually see their life changed completely, their body is not the same, they feel useless, unwanted, insecure of their family role and their position as a couple. Thus, we must assume that any type of disability can lead to an interruption and limitation in your sex life.
Nowadays you can find several therapeutic strategies apart from the help and impulse that is received by the professionals (psychologist, occupational therapist, physiotherapist). Some of the best known options are sensory and sensory stimulation, neuroprosthetic implantation, sensitive substitution therapy, transcranial electrostimulation, vibro-stimulation among others.
There are strategies for men and women equalizing the importance of sexual life in both genders, at different ages and for people and couples with different needs.
With this, in the Neurorehabilitation Clinic, we do not forget that a patient is a person with needs and demands in different areas. One of the objectives as a therapeutic team is to help the individual and his family achieve a better quality of life.