Evidence-Based Vs. Science-Based Therapy in Neurologic Rehabilitation

As a full-time clinician working with clients who are battling neurologic diseases, I often feel pressure to provide evidence-based therapy for an individually unique population in a sea of trials that lack randomized, controlled, and double-blinded research with a high number of participants.  Professional guilt regarding reliance on treatment that is evidence deficient often builds when evaluating and re-assessing my clients with functional impairments from strokes, PD, MS, spinal cord injuries, etc.  I give myself pep talks that healthcare is both an art and a science.  However, I sometimes worry about the long-term future of physical therapy because of the seemingly unattainable goal of creating neurologic rehabilitation trials with thousands of unique clients that are blinded and controlled to provide a foundation for the therapy we provide.  Is this level of research even possible or practical?

After reading the statement from Nielsen et al., my hope for our future has been renewed.  Paraphrasing their comments would be an injustice, so here are their comments relating to evidence-based neuro-rehab directly: “Foremost, it should be realized that it is not possible to apply the strict criteria that are required in clinical trials of new drugs in a clinical study of a physical intervention. Double-blinding is naturally not possible and placebo treatments are difficult if not impossible to design. Furthermore, although matched control groups receiving no treatment or conventional treatment are naturally desirable in these studies, it is not straightforward to deny a group of patients treatment that is believed to be efficient.”1

While the authors make a case for the challenges of pharmaceutical-grade clinical trials in neuro-rehab, they also recommend that the neuro-rehab world continue to strive to use evidence-based concepts as much as possible.  They insist neuro-rehab should still be “science-based.”  They suggest that optimal neurorehabilitation include the following key 12 science-based ingredients (my comments on the clinical application are in red):1

1. Active patient participation: Many of my clients who have had brainstem strokes suffer from depression and lack of motivation.  This is a large barrier to their progress.  I hypothesize that many of them have a constant sense of dizziness because of constant spontaneous nystagmus that makes survival unpleasant.  My focus is to seek help medically to slow the nystagmus.

2. Physical aids should only be given when really necessary: I usually wait until the very last minute to provide bracing. This has proven to be a success over the years.

3. Providing challenges that can support learning: Motivational education through biofeedback using distance, time, and visual cues to improve step length with gait has been beneficial.  One of my favorite exercises to help improve step length is “giant cone walking.”  This exercise incorporates having the client predict how many steps they believe they can take to make it to the next cone 20 feet away.  It is intrinsically competitive and attained great results.

4. Training should be the patient's responsibility- The therapist as a personal coach: Recovery likely takes thousands of hours of work.  My role is often to guide an intense HEP that goes well beyond the limits of clinical work.  The reality, though, is that many patients cannot put this kind of work in daily.

5. Train every day for as long as possible: see above

6. Ensure motivation and reward: Creating functional goals with celebratory opportunities throughout care is done regularly.

7. Structure practice to optimize acquisition and retention: I only work on task practice with attainable skills and utilize pneumonics like Step One-scoot to the edge of the chair.  Step two: feet back.  Step three: nose over toes.  Step four: push from the chair.

8. Improved function requires optimal consolidation: I think I could work more on this with my patients.  It sounds like we have to be careful we don’t add too many new tasks to be learned until we are confident one task is truly attained.  It also makes me think about the importance of purposeful reflection.  Perhaps using the four Fs: Facts, Findings, Feelings, and Future would be a good start for patients?

9. Less emphasis on spasticity- Focus on the paresis: This is so refreshing yet still bothersome to hear.  The greatest barrier to progress for many of my clients with stroke is spasticity/weakness.  There is usually nothing beyond Baclofen/Botox that can be done for spasticity.  Weakness is usually challenging to overcome because it is hindered by spasticity.

10. Other factors that influence learning and memory: Addressing learning and memory deficits are a must.  Sometimes it must be the foundation of rehab.

11. Individualization is necessary: This is usually innate for therapists.  We are used to setting individualized goals and treatment plans that are functionally meaningful.

12. Neurorehabilitation has effects late in life and long after the primary injury: One of my favorite coaching statements is that neuro-rehab is a lifelong process.  There is no end, and it continually changes.

“I attest that this submission represents my own work and is compliant with Arcadia’s standards for academic integrity.”

1. Nielsen JB, Willerslev-Olsen M, Christiansen L, Lundbye-Jensen J, Lorentzen J. Science-based neurorehabilitation: recommendations for neurorehabilitation from basic science. J Mot Behav. 2015;47(1):7-17.

Priming the Central Vestibular System: The Role of Neck Therapy for Dizziness and Balance Disorders

For 20 years, I have included specialized forms of neck therapy as one of the main treatment modalities for many clients with dizziness and balance disorders.  I have observed that these patients, who receive neck therapy, often improve faster than those receiving vestibular rehabilitation (VR).  Also, I have noted progress in clients battling dizziness which was not improving with VR only but made progress once I added neck therapy to their plan of care.  In this paper, I propose that specialized neck therapy is a form of priming for many clients battling dizziness and list treatment examples.

Various hypotheses exist for why neck therapy helps clients with dizziness.  One potential explanation is that cervical spine treatment addresses proprioceptive and kinesthetic mismatched signals from weak/tight suboccipital muscles, weak deep neck flexors, and/or poor cervical joint alignment1-6.  I also hypothesize that improvement is because neck therapy promotes parasympathetic nervous system activity.  I believe increased parasympathetic nervous system activity balances the often heightened sympathetic state of being in which many people battling chronic dizziness exist.  In my opinion, neck therapy is a form of neurologic priming that facilitates an optimal balance between parasympathetic and sympathetic activity needed to promote central vestibular compensation.

Priming is a fascinating theory.  According to Stoykov and Madhavan7, priming promotes change by targeting neural mechanisms needed to promote progress in function.  It is a form of “implicit” learning that does not require repetition.  It generates an implicit memory that remains.  It has the capability of both increasing (excitation) and decreasing (disinhibition) neuronal activity that is needed to acquire new skills.  The terms “homeostatic plasticity” and “gating” are used to describe these phenomena.  Gating would be utilized if too much inhibition impedes progress, and excitation would be used if a lack of neural excitability was present.  Stoykov and Madhavan list five major methods of motor cortex priming:

1. stimulation-based priming
2. motor imagery and action observation
3. manipulation of sensory input
4. movement-based priming
5. pharmacology-based priming

I would like to list various forms of neck therapy I use with many of my clients battling dizziness and balance disorders below with my belief on the likely corresponding form of motor cortex priming:

Neck therapy	Form of motor cortex priming
Cervical AROM including C1/C2	3 and 4
Cervical AROM with laser for biofeedback	3 and 4
Deep neck flexor strengthening	3 and 4
Cervical spine manual therapy with motivational education, AROM, and calming movement-based videos and music.	2, 3, and 4
Postural training	3 and 4

I regularly use neck therapy with my clients to manipulate the sensory input to their brains.  Not only does the sense of neck movement prepare the brain for learning, but it decreases pain and the sense of tightness. Simultaneously, promoting increased mobility helps the brain re-organize the perception of normal for the skull on the spine.  I hypothesize that it can also excite neuronal plasticity through AROM, strengthening, joint mobilization, and other forms of manual therapy.  I believe this is also accomplished through targeted proprioceptive and kinesthetic sensory training at the level of the occiput and C1/C2 segments through laser biofeedback.  Laser biofeedback adds visual stimulation, which may serve as an additional source of priming through sensory input.  

Visual stimulation for motor imagery and action observation during neck therapy warrants attention.  I often include relaxing youtube videos with beautiful scenic moving images and pleasant calming music during neck therapy.  This may assist central vestibular compensation through motor imagery and action observation.

Finally, As noted in Stoykov and Madhavan’s article, the order of priming activities is important in the direction of stimulation.  I often implement neck therapy before non-repositioning forms of vestibular rehab.  Providing neck therapy before vestibular rehabilitation that is more aggressive allows the brain to prepare for new movement patterns to influence reorganization.

“I attest that this submission represents my own work and is compliant with Arcadia’s standards for academic integrity.”

References:

1. Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Arch Physiother. 2017;7:12. Published 2017 Sep 12
2. Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Man Ther. 2015;20(1):148-156.
3. Wrisley DM, Sparto PJ, Whitney SL, Furman JM.  Cervicogenic Dizziness:  A review of Diagnosis and Treatment>  Journal of Orthopaedic & Sports Physical Therapy.  2000; 30 (12):  755-766. 
4. Herdman, Susan. Vestibular Rehab.  FA Davis, 2000.
5. Willis Jr WD. The auditory and vestibular system.  In: Berne RM, Levy MN, eds.  Phsiology.  St. Louis: Mosby Year Book Inc, 1992: 166-88.
6. Karlberg M; Magnusson M; Malmstrom EM; Melander A; Moritz U.  Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Archives of Physical Medicine and Rehabilitation. 1996: 874-82
7. Stoykov ME, Madhavan S. Motor Priming in Neurorehabilitation. J Neurol Phys Ther. 2015 January;39(1): 33–42.

Neuroplasticity for Mixed Peripheral and Central Vestibular Dysfunction

Pt example:  A 48-year-old with motion sensitivity from an AICA stroke two months prior that caused an inner ear weakness, lack of peripheral vision, poor depth perception, poor movement transition tolerance (like a truck slamming on brakes instead of using the jake brake), and a sense of things having to catch up when turning head.  The client had no spontaneous nystagmus, no saccades with smooth pursuit, no dysmetria, hypermetria, or dysdiadokinesia, normal UE/LE strength, scored 56 on Berg and 23 on Functional Gait Assessment as well as walked 860 ft in six minutes independently.  DTRs were WNL, and the client had no spasticity or neglect.   Was six lines off with dynamic visual acuity testing.

Chief complaints:  Unable to drive without getting sick, unable to walk without a sense of being off-balance and slight motion sensitivity, and unable to return to work as a factory supervisor.  

Clients key goals: drive without motion sickness to return to work and have a better sense of confidence walking and jogging.  

What worked well?:  The following chart and symptom guideline helped me progress my client with mixed peripheral and central vestibular dysfunction well.  Also, intense one-on-one motivational dizziness neuroscience education with biofeedback-related training helped improve self-efficacy, confidence in general, understanding of safe progression, and optimized proper self-dosing and self-direction of functional training at home.

• Symptom severity guideline: I progressed his return to driving and improved confidence jogging program to provoke intense symptoms that would go away in one minute or less and yucky/motion sick feelings to go away in 30 minutes or less as my guide for proper dosing training.  

• Vestibular training variable progression chart:  I used smooth pursuit, saccadic eye movements, convergence, divergence, VOR cancellation, and adaptation exercises while adjusting the following key variables in treatment:

Variable	Progression
Background	Non-moving blank to busier checkerboard type background.  Then driving simulation using a progressively stimulating youtube playlist.  Progressed to riding in in his car with the actual background moving from the parking lot to back streets to highways.
Position of body	Lying down Sitting up Standing feet apart Standing feet together  Standing in tandem
Movement of body	Standing still Walking, lunges, squats, 180-360 turns Bouncing on Theraball  Riding in the car (parking lot to slow city streets to highways)
Speed of head movement	From very slow up to 2-4. (120-240 BPM).  Used metronome to help find optimal speed for client’s deficit.
Target distance	Start at 60” and progress to 120”. Moved to a variety of distances to provoke symptoms.
Target movement	Begin with still (X1) and progress to moving in the opposite direction of head (X2)
Duration of head movement	Start with a few seconds and work up to one minute.  Worked toward the following: Subacute – Three times/day minimum (At least 12 minutes/day)   Chronic – Three times/day minimum (At least 20 minutes/day)1
Degree of head movement	Start very small and progress to 10 -20 degrees to more functional movements like turning to look at mirrors or behind the shoulder.
Cognitive distraction	Begin with none and progress to holding a conversation with memory questions (name all items in your refrigerator) to problem-solving.

This program allowed me to meet the following main goals listed in the Winstein and Kay article2:

1. Ensure challenging and meaningful practice (Driving simulation and jogging training progressed, so practice was “repetition without repetition”3).

2. Address important (interfering) changeable impairments (progressing variables above).

3. Enhance motor capacity through overload and specificity (functional training pushing motion tolerance daily with dizziness neuroscience education to guide client).

4. Preserve natural goal-directedness in movement organization (progression of return to driving with dizziness neuroscience education).

5. Avoid artificial task breakdowns when possible (worked toward sitting in the car and driving activities as quickly as possible as well as walking and jogging).

6. Assure active patient/participant involvement and opportunities for self-direction (asked him to suggest progression ideas and ways to return to driving quicker through practice.  Utilized dizziness neuroscience education to help him learn how to properly progress functional training at home).

7. Balance immediate and future needs (needed to feel well driving to therapy with wife on back streets before returning to driving to work on own on a busy highway).

8. Drive task-specific self-confidence high through performance accomplishments (many events were timed for competitive biofeedback, and I provided positive feedback regularly with motivational education regarding his performance).

A few other examples: I used timed ladder walking drills, timed driving tolerance with youtube simulation, and provided positive feedback and motivational dizziness neuroscience education during these events.  

“I attest that this submission represents my own work and is compliant with Arcadia’s standards for academic integrity.”

1. Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION. J Neurol Phys Ther. 2016;40(2):124-155.

2. Winstein CJ, Kay DB. Translating the science into practice: shaping rehabilitation practice to enhance recovery after brain damage. Prog Brain Res. 2015;218:331-360.

3. Lee, T. D., Swanson, L. R., & Hall, A. L. (1991). What is repeated in a repetition? Effects of practice conditions on motor skill acquisition. Physical therapy, 71(2), 150–156.

The Power of Evidence Based Uniformity In Neurologic Physical Therapy

The concept of constructing movement system diagnoses is an initiative through the Academy of Neurologic Physical Therapy.  The goal is to standardize physical therapy neurological diagnosis through consistent and evidence-based terminology describing problems we identify with the following movement systems: integumentary, neurological, musculoskeletal, cardiovascular, pulmonary, and endocrine.  The initiative is targeted to inform our examination, evaluation, diagnosis, prognosis, outcomes, and interventions.  Hedman et al. describe the need to see this initiative to fruition by stating, “while this practice may be inherent for many PTs, the profession lacks a consistent approach to movement analysis and, importantly, lacks the terminology to describe movement dysfunction in a standardized manner.”¹  

In my opinion, this initiative is labeling the optimal goal that PTs and PT educators have worked toward accomplishing since the beginning of our profession.  We all want to do the best job at figuring out why our clients have difficulty moving through a detailed exam of the movement system.  We want to provide the best treatments and communicate our findings, and plan in the best way possible.  However, as our profession and vast skills evolve, we realize that we do not all agree or possess awareness relating to the optimal ways to investigate, describe, and treat these disorders.  Some of us simply lack the opportunities to train to gain the necessary skills to provide optimal care.

As a neuro/vestibular PT, I have had the opportunity to teach and mentor hundreds of therapists over the last 21 years in evaluating and treating some of the most common disorders that impact our balance system.  I have helped train these therapists onsite and through conversations over the phone, email, and texting.  I have been able to build long-term relationships with many of these therapists.  As a result, I have discovered that unless PTs are seeing a high volume of clients with dizziness and balance disorders, they will become confused when trying to complete an efficient history, objective exam, evaluation, assessment, and treatment.  

Even if PTs complete several courses directed at teaching these skills, a high caseload of clients with the appropriate diagnosis is needed consistently so that the skills can be practiced regularly.  Intense professional drive is required to put newly learned skills into practice.   If PTs do not have a high caseload of clients with the appropriate diagnosis, they will not practice the things they have learned, and concepts learned in courses can quickly be forgotten.  

Lack of patients with a key diagnosis that complements a PT's specialized training is crucial.  Without these two elements combined at the proper time in the proper environment, providing optimal quality care can be very difficult.  For instance, some PTs may forget to ask clients questions relating to the timing or triggers of symptoms.  As a result, discovering all reasons for dizziness or balance disorders may not occur.  PTs may omit core oculomotor, vestibular, and balance tests in the exam.  They may exclude postural or sensory testing.  This may lead to unnecessary discomfort for clients trying to overcome their movement disorders.  PTs may become confused when a chosen treatment is not as effective as expected, leading to an unnecessary delay in recovery.  

In summary, I support an evidence-based standardized approach to examining, evaluating, assessing (including prognosis, predicting outcomes), and providing optimal evidence-based interventions.  Building movement system diagnosis tools and databases will help provide guidance for PTs wanting to provide optimal care to all clients.  It will provide a framework that will guide decision-making, help build the best skills over larger populations of PTs, and ultimately help more people experience optimal outcomes.  

“I attest that this submission represents my own work and is compliant with Arcadia’s standards for academic integrity.”

1. Hedman LD, Quinn L, Gill-Body K, et al. White Paper: Movement System Diagnoses in Neurologic Physical Therapy. J Neurol Phys Ther. 2018;42(2):110-117.

The Future of Outpatient Neurological Rehabilitation: Should We “Discharge” the Word Discharge?

Should outpatient neurological rehabilitation therapists use the word discharge when helping clients with neurological conditions?  In my opinion, discharging outpatient clients battling neurological diseases implies an end to their journey toward being the best version of themselves they can be.  The IV STEP conference conducted in 2017 at Ohio State University provided direction for the future of neurological rehabilitation by identifying four key elements to include in patient care.1  These four themes support a holistic approach that rightfully makes discharging clients with neurological conditions in outpatient settings a treatment strategy of the past.  The four elements named include: 

1. Prevention

2. Prediction

3. Plasticity

4. Participation 

As we focus on our role as leaders in outpatient neurologic rehabilitation into the 20s and beyond, I believe these four critical themes outlined will help us expand and sharpen our focus to be involved in lifelong rehabilitation for individuals battling neurological conditions.  Lifelong rehabilitation involves helping create programs and environments.  It establishes new behaviors to help prevent the disease from getting worse. Lifelong rehabilitation encourages occasional exams through the year or years to help predict functional improvement/decline and monitor neurological performance, which helps provide accountability and leads to skilled decision making.  Lifelong rehabilitation helps guide behavioral exercises physically and mentally to optimize neuronal plasticity as our bodies change with time and includes support for participation in wellness programs long term.  These four elements are continuous with one another and really have no end.  I have included a graphic of my view of these elements in rehab of our clients below:     

 

We, as neuro therapists, may migrate more naturally toward one or two of the elements with our clients, but we should work hard to include all four elements in our rehabilitation plan of care.   These elements help confirm our need to be involved in our client's rehab through the entire lifespan, not just a short period of time.  I have never felt discharging clients battling neurological diseases was appropriate, and these elements support my belief.

Provide at least one example of a theme and/or key finding from the conference which you believe you already integrate into your practice regularly. 

At this time, I integrate all four elements into my practice regularly.  For instance, if I am working with a patient who has had a stroke, I will work on overall health and wellness through counseling on diet, stress management, medication compliance, sleep hygiene, aerobic and strength training, and social interaction.  I regularly take blood pressure, pulse and encourage consistent follow-up physician appointments.  All of these professional behaviors are forms of prevention.  

After working with clients who have had strokes for 21 years, I have learned how to predict which clients will recover high levels of normal movement function and which will need to learn compensatory strategies to be as mobile as possible.  I encourage plasticity through task practice and high levels of functional training daily and recommend participation in stroke support groups, exercise classes, and health and wellness programs throughout their rehab experience.  

I regularly teach my patients with neurological conditions that rehab is a lifelong process.  I do not like having to “discharge” clients from my care as I believe that terminology provides an impression that therapy is ending.  I explain to my clients that therapy will never end and that their lifelong participation in becoming the best version of themselves can be a lifelong goal.

Comment on elements from the article that surprised you, questions or concerns you have about the conference findings, AND/OR barriers you foresee in translating findings to real-world practice (either personally in your practice or as a profession). 

The comment that surprised me the most in the article was regarding the idea that certain genetic markers likely have a profound influence on motor learning and impact plasticity.1,2  Up until this point, I have usually considered non-genetic variables, such as stroke severity, medications, timing, and therapy intensity, as reasons for lack of progress following a stroke.  The idea that we could predict the likelihood for plasticity following a stroke based upon genetic makeup is fascinating.  If this type of testing and application to rehabilitation is accurate, our energy toward compensation vs. functional recovery may be impacted.

“I attest that this submission represents my own work and is compliant with Arcadia’s standards for academic integrity.”

1.Kimberley TJ, Novak I, Boyd L, Fowler E, Larsen D. Stepping Up to Rethink the Future of Rehabilitation: IV STEP Considerations and Inspirations. J Neurol Phys Ther. 2017 Jul;41 Suppl 3 Supplement, IV STEP Special Issue: S63-S72. doi: 10.1097

2.  Pearson-Fuhrhop KM, Minton B, Acevedo D, Shahbaba B, Cramer SC. Genetic variation in the human brain dopamine system influences motor learning and its modulation by L-Dopa. PLoS One. 2013;8(4):e61197.