Patient Education

Neurological Conditions we treat at Impact physical therapy

• Multiple Sclerosis [MS]
• MS Post liberation[ CCSVI] treatment reconditioning program.
• Stroke
• Brain injury - Traumatic & Non traumatic.
• Cerebral ataxia
• Hydrocephalus
• Transverse myelitis
• Spinal cord injury
• Peripheral neuropathy
• Polyneuropathy
• Trigeminal neuralgia
• Cerebral plasy.

• Post tumour removal neurological insult (central & peripheral).
• Foot drop due to central origin – Bioness L300 &Walkaide fitting and retraining.
• Paralytic/spastic hand Rehab with Bioness H200. ( www.bioness.com)
• Traumatic peripheral nerve injuries with Functional electrical stimulation.
• Poliomyelitis
• Parkinson’s disease.
• Wilson’s disease.
• Developmental disorders.
• Undiagnosed balance and gait issues.
• Neurological hand functions deficit.

Methods we follow 

• Bobath’s Neurodevelopmental Therapy Approach.
• Motor control relearning model.
• Proprioceptive Neuromuscular facilitation approach.
• Suspension therapy
• LSVT BIG neurorehab program.
• Functional Electrical stimulation.( Bioness H200/L300).

Hydrocephalus

Hydrocephalus is mainly known as the excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water on the brain," the "water" is actually cerebrospinal fluid (CSF) — a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of   spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

Different types of hydrocephalus:

• Congenital/acquired.
• Communicating/non-communicating.
• Stroke/traumatic brain injury acquired.

Symptoms:

Symptoms of hydrocephalus vary with age, disease progression, and individual differences in tolerance to the condition.

In infancy, the most obvious indication of hydrocephalus is often a rapid increase in head circumference or an unusually large head size. Other symptoms may include vomiting, sleepiness, irritability, downward deviation of the eyes (also called "sun-setting"), and seizures.

Older children and adults may experience different symptoms, because their skull could not expand to accommodate the accumulation of CSF fluid. Symptoms of normal pressure hydrocephalus include, problems with walking, impaired bladder control leading to urinary frequency and/or incontinence, and progressive mental impairment and dementia. An individual with this type of hydrocephalus may have a general slowing of movements or may complain that his or her feet feel "stuck.

Treatments provided at Instep for hydrocephalus:

Specific treatment procedures are numerous, functional training for activities of daily living; therapeutic exercise; manual techniques such as mobilization and stretching; and therapeutic modalities.

Motor control, development, and learning theories focus on the idea that several factors contribute to emergence of motor behavior. These factors include not only the central nervous system (CNS) as the driving force, but also biomechanical, psychological, social, and environmental components. Teaching and practice of skills under these theories is task-oriented and intermittent versus rote and repetitive. Higher-level learning takes place through problem-solving by the child rather than by the therapist's hands-on facilitation. Emphasis has also been placed on the importance of family-centered care, transdisciplinary service, and treatment in natural environments.

The common goal usually is that functional activity increases and that disability decreases.

Multiple sclerosis:

The brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms. Disease onset usually occurs in young adults, and it is more common in females. MS affects the ability of nerve cells in the brain and spinal cord to communicate with each other. Nerve cells communicate by sending electrical signals called action potentials down long fibers called axons, which are wrapped in an insulating substance called myelin. In MS, the body's own immune system attacks and damages the myelin. When myelin is lost, the axons can no longer effectively conduct signals. Although much is known about the mechanisms involved in the disease process, the cause remains unknown. Theories include genetics or infections. Different environmental risk factors have also been found.

Different types of MS:

1. relapsing remitting,
2. secondary progressive,
3. primary progressive, and
4. Progressive relapsing.

Signs and symptoms:

In the same way there are different forms of MS, the symptoms of the disease can vary from person to person and can crop up at any stage of the illness. Most commonly, symptoms include:

• problems with balance and coordination
• blurred or double vision
• numbness or weakness in muscles, sometimes paralysis
• severe fatigue
• bladder or bowel irregularities.

Physical Therapy for MS:

Physical therapy cannot cure the primary symptoms of MS (such as weakness, tremors, tingling, numbness, loss of balance, vision impairment, paralysis, and bladder or bowel dysfunction), but therapy can enable you to compensate for the changes brought about by MS. These "compensatory treatments," as they're called, include learning about new movement techniques, strategies, and equipment.

Physical therapy can also be very helpful at lessening and even stopping secondary symptoms of MS. A physical therapist can teach you exercises to strengthen and loosen muscles. Many of these exercises can be performed at home. The goal of physical therapy is to improve your independence and quality of life by improving movement and function and relieving pain.

POST CCSVI { LIBERATION } PROCEDURE RECONDITIONING PROGRAM.

At In step we offer tailor made neurorehab reconditioning program for post operative multiple sclerosis patients. We are already involved in successful treatment outcomes for our patients who had the CCSVI procedure done from various parts of the world.

Physical therapy can help with:

• Balance problems
• Lack of coordination
• Fatigue
• Pain
• Immobility
• Weakness

Spinal Cord Injuries:

Spinal Cord Injury (SCI) is damage to the spinal cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma (car accident, gunshot, falls, etc.) or disease (polio, spina bifida, Friedreich's Ataxia, etc.). The spinal cord does not have to be severed in order for a loss of functioning to occur. In fact, in most people with SCI, the spinal cord is intact, but the damage to it results in loss of functioning. SCI is very different from back injuries such as ruptured disks, spinal stenosis or pinched nerves.

The effects of SCI depend on the type of injury and the level of the injury. SCI can be divided into two types of injury - complete and incomplete. A complete injury means that there is no function below the level of the injury; no sensation and no voluntary movement. Both sides of the body are equally affected. An incomplete injury means that there is some functioning below the primary level of the injury.

Physical therapy interventions:

A physical therapy (PT) program can facilitate the restoration of muscle strength, flexibility, improve mobility, coordination, and maintain body functions through exercise. Massage, hydrotherapy, and other modalities can relieve pain.

Gait training may be taught to patients with difficulty walking, which could include teaching the patient how to use assistive devices (e.g., walker, cane). Physical therapy benefits the patient be preventing complications from surgery or illness.

Traumatic/Non-traumatic Brain injury:

Traumatic brain injury (TBI, also called intracranial injury) occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g. occurring in a specific location or over a widespread area). Head injury usually refers to TBI, but is a broader category because it can involve damage to structures other than the brain, such as the scalp and skull.

Brain trauma can be caused by a direct impact or by acceleration alone. In addition to the damage caused at the moment of injury, brain trauma causes secondary injury, a variety of events that take place in the minutes and days following the injury. These processes, which include alterations in cerebral blood flow and the pressure within the skull, contribute substantially to the damage from the initial injury.

Classifications:

TBI is usually classified based on severity, anatomical features of the injury, and the mechanism (the causative forces). Mechanism-related classification divides TBI into closed and penetrating head injury. A closed (also called nonpenetrating, or blunt) injury occurs when the brain is not exposed A penetrating, or open, head injury occurs when an object pierces the skull and breaches the dura mater, the outermost membrane surrounding the brain.

Common effects of traumatic brain injuries are arm and leg weakness, facial weakness and speech problems. These lead to decreased mobility, balance problems and difficulty performing everyday tasks.

Rehabilitation after TBI:

The overall goal of rehabilitation after a traumatic brain injury is to improve the patient's ability to function at home and in society in the face of the residual effects of the injury, which may be complex and multifaceted. Therapists help the patient adapt to disabilities or change the patient's living space and conditions to make everyday activities easier and to accommodate residual impairments. Education and training for identified caregivers who will be involved in assisting the patient after discharge are also critically important components of the rehabilitation program.

Physiotherapy treatment is very importantfollowing a traumatic brain injury. It should commence as soon as possible and continue until an individual has reached their maximum potential. Physiotherapy can improve an individual’s quality of life by increasing their independence, mobility and ability to perform everyday tasks.

Stroke:

A stroke, known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

Strokes can be classified into two major categories: ischemic and hemorrhagic.[7] Ischemic strokes are those that are caused by interruption of the blood supply, while hemorrhagic strokes are the ones which result from rupture of a blood vessel or an abnormal vascular structure. 87% of strokes are caused by ischemia, and the remainder by hemorrhage. Some hemorrhages develop inside areas of ischemia ("hemorrhagic transformation"). It is unknown how many hemorrhages actually start off as ischemic stroke.

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.

Stroke rehabilitation in physical perspective

Physical therapist’s assess the stroke survivor's strength, endurance, range of motion, gait abnormalities, and sensory deficits to design individualized rehabilitation programs aimed at regaining control over motor functions. Physical therapists help survivors regain the use of stroke-impaired limbs, teach compensatory strategies to reduce the effect of remaining deficits, and establish ongoing exercise programs to help people retain their newly learned skills. Disabled people tend to avoid using impaired limbs, a behavior called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticityand helps reduce disabilities.

Strategies used by physical therapists to encourage the use of impaired limbs include selective sensory stimulation such as tapping or stroking, active and passive range-of-motion exercises, and temporary restraint of healthy limbs while practicing motor tasks. Some physical therapists may use a new technology, transcutaneous electrical nerve stimulation (TENS), that encourages brain reorganization and recovery of function. TENS involves using a small probe that generates an electrical current to stimulate nerve activity in stroke-impaired limbs.

In general, physical therapy emphasizes practicing isolated movements, repeatedly changing from one kind of movement to another, and rehearsing complex movements that require a great deal of coordination and balance, such as walking up or down stairs or moving safely between obstacles. People too weak to bear their own weight can still practice repetitive movements during hydrotherapy (in which water provides sensory stimulation as well as weight support) or while being partially supported by a harness. A recent trend in physical therapy emphasizes the effectiveness of engaging in goal-directed activities, such as playing games, to promote coordination. Physical therapists frequently employ selective sensory stimulation to encourage use of impaired limbs and to help survivors with neglect regain awareness of stimuli on the neglected side of the body.

Cerebral palsy:

Cerebral palsy is a name given to a group of different nervous system disorders that are present at birth or appear in the first 3 years of life. What these disorders have in common is that the underlying brain damage doesn't get worse over the years. They also all cause some degree of damage in the motor neurons of the brain, affecting coordination and muscle strength.

Although cerebral palsy is often considered a congenital (present at birth) syndrome, it can also develop after birth. A brain injury resulting from a brain infection (e.g., meningitis, encephalitis) or from a fall or accident is termed acquired cerebral palsy. On the other hand, congenital cerebral palsy is a result of something going wrong during fetal development or during the birth process itself. It used to be believed that lack of oxygen during delivery was the main cause, but researchers now think this only account for about 10% of cases.

Types of Cerebral palsy:

Spastic cerebral palsy: muscles tend to be in contracted strong enough to bend the joint permanently or to cause paralysis. Common type of gait seen is scissoring type.

Athetoid cerebral palsy: Slow writhing movements, limbs, facial and also muscles including the tongue

Ataxic cerebral palsy: Poor coordination and depth perception makes people with ataxic cerebral palsy unsteady walkers, with a wide-based gait. They also have difficulty with quick and precise movements like writing. They may suffer from intention tremor, in which the arm or hand trembles when reaching for an object, and the trembling gets worse the closer the hand gets to the target.

Physical therapy for cerebral palsy:

Physical therapy for cerebral palsy patients consists of activities and education to improve flexibility, strength, mobility, and function. A physical therapist also designs, modifies, and orders adaptive equipment. Physical therapy can take place in clinics, hospitals, schools, and should carry on in the home through an exercise program. Physical therapy for cerebral palsy patients will not be successful without an ongoing daily home program.

A physical therapy program consist of a number of exercises that include neurodevelopmental therapy, stretching, strengthening, and positioning. To stretch the muscles, the arms and legs must be moved in ways that produce a slow, steady pull on the muscles to keep them loose. Because of the increased muscle tone of the cerebral palsy patient, they tend to have generally tight muscles. Therefore, it is extremely important to perform daily stretches to keep the arms and legs limber, allowing the child to continue to move and function. Strengthening exercises work specific muscle groups to enable them to support the body better and increase function. Positioning requires the body to be placed in a specific position to attain long stretches. Some positions help to minimize unwanted tone. Positioning can be done in a variety of ways. Bracing, abduction pillows, knee immobilizers, wheelchair inserts, sitting recommendations, and handling techniques are all part of positioning techniques used in physical therapy for cerebral palsy patients.

Physical therapy for cerebral palsy patients does not cure spasticity but can improve impairments and limitations. Physical therapy for cerebral palsy patients is an important step towards an independent lifestyle. If these changes happen only in the therapy gym, the disability remains unchanged. Therapy must improve abilities to perform meaningful tasks in everyday life. Changing the level of disability is the ultimate goal of physical therapy for cerebral palsy.

How does neuro-physical therapy differ from general physiotherapy?

Neurological physical therapy is a discipline focused on working with individuals who have a neurological disorder or disease. These include Alzheimer's disease, ALS, brain injury, cerebral palsy, multiple sclerosis, Parkinson's disease, spinal cord injury, and stroke. Common problems of patients with neurological disorders include paralysis, vision impairment, poor balance, inability to ambulate, and loss of functional independence. Neurological physiotherapists work with patients to improve these areas of dysfunction using the following approaches.

Bobath Approach :

Bobath concept is named after the inventer Berta Bobath, the Bobath Concept is usually referred to as 'neuro-developmental treatment'  (NDT). It is based on the brain's ability to reorganize and recover after neurological insult (neuroplasticity).This approach to neurological rehabilitation is multidisciplinary, primarily involving physiotherapists, but may also include occupational therapists and speech and language therapists.

Proprioceptive Neuromuscular facilitation approach (PNF):

PNF was developed in the late 1940’s and 1950’s,as a means of rehabilitation for neurological disorders like ,multiple sclerosis, cerebral plasy and poliomyelitis. The PNF method is a holistic approach; elements of motor development, anatomy, neuro-physiology and kinesiology are used. The basic principle is that movements of the body are the combination of spiral and diagonal patterns. It is in these patterns that muscles function most effectively and naturally.

Motor control relearning model:

 The motor control relearning model works on two significant related theories schema & performing. The information is stored in memory following a movement attempt. The schema then begins to develop, with each additional movement attempt; the schema becomes stronger, which results in from of practice which is a strong motor response schema.

 When you perform a skill in a situation, you subconsciously subtract four pieces of information.

• Initial conditions (start of the movement)
• Response specifications(parameters used in specification of movement, such as speed)
• Sensory consequence of the movement
• Response outcome (end result)

Moto response consists of 2 relationships:

Recall Schema: responsible for organizing the motor capable of initiating and controlling the movement.

Recognition Schema: responsible for evaluating the last executed movement attempt based on the initial conditions, past actual outcomes and past sensory information. With every attempt the recall schema updates the instructions to the muscle based on the recognition schema (continually revises the initial conditions, past outcomes and past sensory consequences) which leads to a more accurate response.

 In summary learner decides what to movement to execute in a given situation by subconsciously retrieving the general motor programme for memory based on the existing schema and parameters. The desired movement is therefore organized in advance by the motor programme and sent to the rest of the body to carry it out.

LSVT BIG

Intensive Amplitude based exercise program for the limb motor system. LSVT BIG Fundamental Treatment concepts includes high amplitude , sensory calibration, intensive and empowering.