7. Neurologic physiotherapy
Nick Southorn
Additional reading for neurologic physiotherapy comes in the form of Physical management in neurological rehabilitation by Maria Stokes (2004). This is a particularly well-structured book that guides you through your learning in a very accessible way. Also available is Neurological physiotherapy: a problem solving approach by Susan Edwards (2002). This is a very nice book that is more concise with its fact delivery. It is exactly what it claims to be, though – a problem-solving book.
This knowledge is vital if you are to understand your patient’s condition, their prognosis, their goals, their potential and their experiences. Your knowledge will also link in with how you are affecting the nervous system. Are you getting the desired effect? Are you eliciting another effect that is not desirable (a side effect)? What is the mechanism and how do you work around it? If you are lucky enough to have a placement with neurologic physiotherapists, you will gaze in wonderment at their apparent ability to instinctively create a desirable action from the patient and how they utilize this movement. Please don’t feel threatened by this: they are highly experienced clinicians and a great deal of their knowledge has evolved after qualification. It is a complex area and one that takes time to get the hang of.
What you need to know
Before you learn how physios treat neurologic conditions you need to acquire some basics.
• Brain anatomy and association areas
• The cranial nerves and function
• Ascending and descending spinal tracts and function
• The autonomic nervous system (parasympathetic, sympathetic and enteric)
• Dermatomes and myotomes (as in spinal levels of innervation)
Then start learning about the conditions that may present to a neurologic physiotherapist. As is the running theme in this book, these are the basic “must know” lists and will get you well grounded with knowledge.
Then comes the treatment types. You will be expected to know about different treatment options available to patients regarding medical and surgical interventions as well as your more specialist knowledge of physiotherapeutic treatment. Treatment types include:
• vestibular and balance
• pain management
• exercise rehabilitation
• functional rehabilitation
• proprioceptive neuromuscular facilitation (PNF)
• orthotics and strapping.
Basics
Brain association areas are very important to get to grips with. As part of the diagnostic work-up, you will have a report detailing the area of a lesion of the brain. Neurologic physiotherapists know instinctively what the implications of that location are. An understanding of what the brainstem has to offer in comparison to the cerebellum and cerebrum will also help you relate injury to symptoms.
Learning about the brain usually results in a headache as you come across words that you know you will never remember the meaning of. However, if you take a methodologic approach (that’s right, get the basics first) you will slowly get to grips with it all. The best bit of advice I had from a lecturer was: learning about the nervous system takes time. An example of progressive learning for the central nervous system is as follows.
The brain lies in the skull and is a mass of nerve bodies and axons. It is encased in a series of layers (externally inwards): the dura mater, arachnoid mater (encasing the subarachnoid space where large vessels lie), pia mater, gray matter and finally the white matter. Note the differences in the words “mater” and “matter.” Mater, in this context, is apparently translated to mean “mother of the brain” (think of a mother cuddling her child) and matter is obviously as in “substance.” The brain has two distinct sections – the cerebrum (the two large hemispheres at the top) and the cerebellum (the smaller bit posterior to the brainstem and inferior to the cerebrum).
The cerebral cortex has four lobes:
Pick one part at a time. For example, the frontal lobe plans sequences of response and controls emotions; it also has motor control over the eye muscles and speech. Look up Broca’s area.
By having just that bit of information, you can already see that damage to the area may result in difficulty controlling emotions and communicating, while behavior deemed to be socially inappropriate may be displayed due to lack of discretion. This can be crudely described as losing the filter between the brain and the mouth as one may find someone lacking executive prowess (i.e. someone with frontal lobe damage) to be offensive.
So the point is that you work through the brain systematically, ensuring that you hit the right bits relevant to physiotherapy, such as:
• medulla
• corpus callosum
• pons
• midbrain
• basal ganglia connections (cortex, thalamus, globus pallidus, substantia nigra, caudate and putamen)
• blood supply – very important that you understand the circle of Willis.
Once you have the “brain” you can move on down the body and this includes the cranial nerves. You will remember their names due to the clever mnemonic discussed in Chapter 3. But what do they do? Fortunately, you will only have to develop a basic knowledge of these to begin with and build upon it if need be. The great thing about these is the fact that their names give away what they do (mostly anyway). To save you having to look these up, here they are.
| I | Olfactory | Sense of smell |
| II | Optic | Visual information |
| III | Oculomotor | Eye movements |
| IV | Trochlear | More eye movements |
| V | Trigeminal | Sensations from the face and innervates |
| VI | Abducens | mastication Yet more eye movement |
| VII | Facial | Facial motor control, taste sensation and saliva production |
| VIII | Vestibulocochlear | Sound, rotation and gravity |
| IX | Glossopharyngeal | Taste sensation |
| X | Vagus | Most laryngeal and pharyngeal motor control |
| XII | Accessory | Neck muscles and shared function with the vagus |
| XIII | Hypoglossal | Tongue muscles |
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