The past ten years of brain research has pointed increasingly towards the fact that physiotherapy, physical therapy, neurorehabilitation and occupational therapy are misrepresented as separate disciplines. The brain and body learn using simultaneous multi-modal inputs, often with substantial cross-modal overlaps [1]. Brain training and muscle training are so deeply intertwined in each other that as we move into the domain of fine motor training and re-learning of motor skills after a stroke or injury, the boundary between where cognitive ability ends and physical ability begins gets increasingly blurred. For example, not being able to execute a fine motor task successfully could be as much due to poor musculature and physical co-ordination difficulties as due to inadequate short term memory and poor sequential and executive control. Or a combination of the above. The underlying mechanics of the disability become even more difficult to precisely identify as we move into repetitive practice. Here, additional confounding factors such as fatigue, postural instability and the psychological aspects of failure and success in executing the task come into play. Often this makes therapy design and delivery fraught with trials and errors that are time consuming, expensive, demotivating for the patient and tedious for the therapist, perhaps more so in the chronic phase when a patient is expected to largely exercise at home.
An ever-increasing number of “permanent” stroke and brain injury disabled persons (many below the age of forty) living in the community is now a global reality [2]. Aging populations, reduction of the median age of stroke, coupled with increasing survival rates have transformed stroke related disability from being a mere clinical problem to one of the great socio-economic crises in human history, similar to HIV [3]. In my research, the youngest stroke survivor I came across was 19 years old! While stroke has emerged in several countries as the highest cause of long term disability threatening to disrupt national healthcare budgets and national productivity, recent findings about how the brain learns and re-learns lost function are bringing new hope and redefining some of the basic principles of how we design and deliver therapy [4].
One of the most basic challenges when we see patients is to selectively maximize existing strengths while addressing weaknesses sensitively in such a way that a robust neural pathway is established towards a biomechanically appropriate re-learning of movement rather than blind adaptation and compensation. Some therapists and doctors have asked the question why we should not train for adaptation and compensation when that can be achieved using intensive repetitive practice, teaching adaptation techniques and employing assistive tools [5,6]. After all, it does help to make patients somewhat independent! While this can certainly be a part of the approach for some patients, it cannot be the mainstay of treatment. It is pertinent to note that the patients visiting stroke rehabilitation wards are demographically quite different now than a couple of decades ago. Therapists are frequently confronted with patients who are in the prime of the lives, often a bread winner for the family or a single parent with little children to bring up. This means they need to return to their professions and livelihood, regain sufficient motor and cognitive skills to support their families, excel professionally, travel and see the world, pursue hobbies and maximize their potential to lead a fulfilling life. Who can achieve these within the limited scope of compensation? In such a new world, is training towards compensation enough? The case for training for recovery is supported by modern research which confirms that neuroplasticity exists at all ages and that brain-muscle retraining is possible at any age [7].
If we agree that this is true and desirable, where then is a tool to help us distinguish where compensation ends and true motor and neural re-learning begins? Can we, as professional therapy providers, use new-age technology to sensitize ourselves to this paradigm to help our patients? Given the tremendous workload that therapists need to handle in hospitals, which technology tools can help speed up the process of identifying how to personalize therapy based on how individual patients learn? Can we get better data regarding how the patient is managing with home based exercises and ensure that he/she is not falling into the trap that is compensation and maladaptation when exercising at home? These are the challenges facing the therapy community in the 21st century.
Albert Einstein said in his wisdom, “We cannot solve a problem with the same thinking that created it in the first place”. The new findings of neuroplasticity combined with the old knowledge of developmental biology are converging to help us understand how humans can re-learn lost skills and abilities, using brain and body together. Research has shown us that as much as mental engagement is necessary in healing physical disability, so also physical movement and exercise is necessary to heal mental disability eg. dementia [8,9]. The treatment of mind and body as separate entities which is a legacy of the Descartes era of the 16th century is now being reversed and we are seeing modern brain research reshaping how therapy needs to be designed and administered. This is well aligned with the thrust towards holistic ways of treatment, integrated care and the use of lifestyle change to address chronic conditions such as heart disease, hypertension and diabetes.
The need of the hour is for every therapist, no matter what their specialty, to think like “integrated care” therapists. I hereby highlight the 5 principles for the modern, 21st century therapist to consider in practice:
The brain contributes as significantly as muscle, and perhaps more so in complex fine-motor tasks. For every compensation that is physical, the brain re-maps itself accordingly making later re-learning and breaking of compensatory habits more difficult. Hence, compensation must be arrested early and not encouraged.
Every time the patient uses excessive force to achieve a relatively simple task goal, the brain learns to overexert in simple tasks, heightening fatigue and adaptation in everyday life. Management of fatigue does not happen automatically after trauma but needs to be a new learned behaviour. Fatigue management techniques in movement are as essential as movement training itself.
Muscle fibres can develop contractile force ONLY when they elongate sufficiently prior to contraction. This indicates that relaxation training is as important as muscle contraction training in therapy. Allocate specific time to relaxation and tissue elongation in the therapy session.
Antagonist muscle hyperactivity is detrimental to smoothness of movement and co-ordination. Hence, antagonist activity management after trauma is a precursor to agonist muscle training with high intensity, strength training and the use of electrical stimulation.
A deeper understanding of brain and muscle bio-potential activity in the individual patient while performing movements and tasks is essential before recommending home exercises or use of technology at home. Stimulation or passive movement, unless closely supervised, can give rise to exaggerated controlling reactions in the neuromuscular system, thus unknowingly wiring these associatively into the brain and contributing to plateaus.
The understanding and knowledge of these 5 key principles needs to be translated to the patient at an early stage of rehabilitation so that he/she may remember these principles in managing exercises better and self-regulating maladaptation and compensation. If patients feel they are the drivers of recovery and the therapist is a facilitator and supporter, rather than the other way around, this is known to encourage neuroplasticity and produce improved outcomes [10].
The world of therapy has changed. As per the World Health Organization, the number of people living with chronic disability has outnumbered the number of people with infectious disease. For the first time in human history, therapists will play a role as significant as that of physicians and doctors in managing the pandemic of long term disability.
Are you ready to re-invent yourself and your profession?
REFERENCES
[1] Stein BE, Stanford TR, Rowland BA, 2014. Development of multisensory integration from the perspective of the individual neuron, National review of Neuroscience, Vol 15(8): 520-535
[2] Smajlovic D, 2015. Strokes in young adults:Epidemiology and prevention, Vascular Health Risk Management, Vol 11: 157-164.
[3] Chin JH, Vora N, 2014. The global burden of neurologic diseases, Neurology, Vol 83(4): 349-351.
[4] Muratori LM, Lamberg EM, Quinn L, Duff SV, 2013. Applying principles of motor learning and control to upper extremity rehabilitation, Journal of Hand Therapy, Vol 26(2): 94-103.
[5] Dobkin BH, 2004. Strategies for stroke rehabilitation, Lancet Neurology, Vol 3(9): 528–536.
[6] Liu W, McCombe Waller S, Kepple T, Whitall J, 2013. Compensatory arm reaching strategies after stroke: Induced position analysis, Journal of Rehabilitation Research and Development, Vol 50(1): 71-84.
[7] Kauffman TL, Barr JO, Moran ML, 2007. Geriatric Rehabilitation Manual, Elsevier Health Sciences, Pages 27-30.
[8] Koenig A, Omlin X, Zimmerli L, Sapa M, Krewer C, Bolliger M, Muller F, Riener R, 2011. Psychological State Estimation from physiological recordings during robot-assisted gait rehabilitation, Journal of Rehabilitation Research and Development, Vol 48(4): 367-386. [9] Teri L, Logsdon RG, McCurry SM, 2008. Exercise interventions for dementia and cognitive impairment: The Seattle Protocols, Journal of Nutrition Health and Aging, Vol 12(6): 391-394. [10] Merzenich MM, Van Vleet TM, Nahum M, 2014. Brain plasticity-based therapeutics, Frontiers of Human Neuroscience, Vol 8: 385.
Author: Dr. Subhasis Banerji PhD
Profile: Dr. Subhasis Banerji holds a PhD in biomechatronics and studies brain plasticity and rehabilitation. He is the inventor and founder of SynPhNe, the world’s first wearable, connected health solution that trains brain and muscle as ONE system. He is based in Singapore and works in the fields of Stroke, TBI, Dementia, Cerebral Palsy and Dyslexia.