Neurosciences advances and physiotherapy in neurological

conditions
Physiotherapy a facilitator of neuroplasticity and recovery

Author: Patrícia Maria Duarte de Almeida1, Physiotherapist, PhD in Health Sciences

Co-authors

Ana Isabel Correia Matos Ferreira Vieira1, Physiotherapist, PhD in Health Sciences

Hugo Filipe Miragaia dos Santos1, Physiotherapist, Master in Neurorehabilitation

Isabel Baleia Batista1, Physiotherapist, Master in Neurorehabilitation

Rita Filipe Almeida Brandão1, Physiotherapist, Master in Neurorehabilitation

1
Alcoitão Health School, Estoril, Portugal

Artigo no prelo em edição para publicação como capítulo de livro e artigo em revista internacional
com peer-review.

Alcoitão, Fevereiro de 2023

1
Contents
Introduction
Major advances in neuroscience and impact in physiotherapy
• Neuroplasticity
• Motor relearning
• Physiotherapy approaches according to the neuroscientific discoveries
Impact of physiotherapy in functional outcomes
• Physiotherapy models
• Approaches with impact
Impact of physiotherapy in brain activity
• Impact on Brain maps
• Impact on Brain electricity
• Impact on Brain neurotransmitters
• Impact on neuronal activity
• Impact on neurological biomarkers
Conclusions and Recommendations for practice
Appendix 1 – Scoping review methodology and results
Appendix 2 – PRISMA Flow Diagram
Appendix 1 – Data extraction table

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Introduction
The content of this chapter, was developed by using two different methodologies of collecting data.
For the first and second sections, a simple literature review of most recent scientific updates was
made to collect data related with neurosciences advances and its impact in physiotherapy evolution
and related with physiotherapy impact in individual’s functional outcomes and autonomy. The third
section, provides a state-of-art of the impact of physiotherapy in brain activity after neurological
condition, as a result of a scoping-review.

For the purpose of better understanding of this chapter, we would like to define three major
concepts or terms that are used along the document: 1) brain activity, entails map areas of
activation, blood flow, neurotransmitters, biomarkers related with neuroplasticity; 2) physiotherapy
approaches refers to interventions, techniques or modalities; and 3) functional outcomes
comprehend the outcomes organized in body structures and functions, activity and participation.

Major advances in neuroscience and impact in physiotherapy

“Neurological physiotherapy (NPT) assists individuals who suffer from nervous system diseases that
cause motor disorders, to manage complex changes in movement and regain functionality” (Santos
et al., 2021). NPT has evolved substantially in recent decades. This is greatly associated with
scientific developments in the neurosciences, motor control and motor (re)learning understanding
(Santos et al., 2021). As a consequence physiotherapy became more scientific based and efficient for
the individuals benefits and better health care services.

The major impact of neurosciences developments is the shift of NPT aims. It moved from the goal to
reduce impairments, to the purpose of contributing to individuals to return to regular life as soon as
possible, with functional recovery that ensures a long-term reduction in impairment and an
improvement in autonomy and quality of life (Maier et al., 2019) .

The most relevant advances and cornerstones that influenced physiotherapy aims and procedures,
are summarized on box 1.
Box 1. Neuroscience cornerstones that influenced physiotherapy

CORNERSTONES IN NEUROSCIENCES DEVELOPMENTS THAT INFLUENCED PHYSIOTHERAPY

• The development of new imaging techniques, such as functional magnetic resonance

imaging (fMRI), which allows researchers to non-invasively study brain activity in living
subjects;
• Research on neural plasticity, confirming the ability of the brain to change and adapt in
response to experience, has led to new treatments for neurological conditions being
perhaps the most important cornerstone for physiotherapy developments;
• Understanding of motor control and motor learning associated to neuroplasticity, has
allowed physiotherapists to develop approaches that can more efficiently stimulate the
regain of new synapses with consequential movement and tasks acquisition;
• Understanding the genetic and neural basis of neurological, mental, cognitive and
memory disorders, which has led to the development of new therapies and treatments.

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In parallel to neuroscience research, the past 30 years are also characterized by physiotherapy
research, where the application of neuroscience discoveries into physiotherapy practice has been
the major focus in NPT.

Neuroplasticity

The discoveries about neuroplasticity made clear that physiotherapy interventions without
stimulating neuroplasticity and more specifically the establishment of long term-potentiation in
synapses, are irrelevant and not conducting to the best results possible. Neuroplasticity is the
neurobiological basis of physiotherapy. There are neuroplasticity features (Hylin et al., 2017; Nudo,
2013) that physiotherapy takes in consideration when designing treatment plans. Moreover, the
concept “use it or lose it” (Shors et al., 2012), highlights the need to use and stimulate the affected
body segments in specific tasks to stimulate and maintain neuronal synapses. In box 2, we can find
these features that guide physiotherapy prognosis and influenced the evolvement of several
approaches.
Box 2. Neuroplasticity features that guide NPT

NEUROPLASTICITY FEATURES

• Present in any neural tissue, therefore, either cerebral or spinal lesions have potential;
• Permanent (for the good and mal-adaptations), therefore, facilitation is fundamental to
promote adequate synapses;
• Very active after injuries as in regular situations of learning;
• Indispensable, therefore, without stimulating it there are no results;
• Requires collateral sprouting, therefore, stimulus should be specific and intense and
based on motor learning principles;
• Depends on:
a. surviving neurons or extension of the damage, therefore, the extension of the
lesion is prognosis determinant;
b. time to control the injury, therefore, physiotherapy outcomes are dependent of
rapid emergency care;
c. diaschisis reversal, therefore, physiotherapy outcomes are dependent of this
phase ;
d. cognitive reserve; therefore, the extension of the lesion and age are prognosis
determinant;
e. increased brain-derived neurotrophic factor (BDNF), therefore, physiotherapy
should promote its synthetization;
f. experience, represented by tasks and not isolated muscles or movements, with
the major idea that for both the neural and body structures, they should be used
to maintain the connections and representations - Use or lose it.

Considering NPT as a working mechanism/ base to stimulate neuroplasticity and motor relearning,
approaches should be specific on ways to provide this stimulus, which can be reached by means of
motor learning training of the affected body segments. Clearly, based on these features, NPT should
be focused on task-oriented approached and not isolated segments or muscles training.

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Motor relearning

Motor relearning is a process that involves teaching the brain to relearn or reorganize motor
programmes after injury or disease (neuroplasticity). There are key principles of motor relearning
guiding current practice in NPT and the existing diversity of approaches. Depending on the author,
physiotherapists can find several of these principles that are considered to best stimulate
neuroplasticity. A recent review (Maier et al., 2019), identified fifteen principles of motor
relearning. Additionally to the list of Maier, attention (Song, 2019) and meaning (Winstein et al.,
2014), should be considered. Based these literature sources, box 3, presents a list of motor learning
principles that should be used to promote neuroplasticity and therefore, that guide NPT in terms of
approaches to select and how to deliver them (Fisher et al., 2014).

Box 3. Principles of motor learning that guide NPT

PRINCIPLES OF MOTOR LEARNING

PERCURSORS
• Attention - where it is fundamental to encourage the individual to actively participate in
their own rehabilitation and take an active role in the decision-making process can help to
increase motivation and engagement
• Meaning or salience – meaningful tasks promote intrinsic drive and self-responsibility to
perform, promoting synapses to make it happen;
• Modulate effector selection – often the level of activity and brain activity is so low, that
leads to the “Learning non-use” effect. NPT should dosage intensity and forced activity to
reach activation.

CONDITIONS OF PRACTICE
• Increasing difficulty - Gradually increasing the difficulty of exercises and movements helps
to challenge the brain and promote further learning; difficulty levels personalized to the
learner’s capabilities leads to superior learning outcomes, if subjects can control the task
difficulty by themselves, their motor performance during acquisition and retention is
significantly better
• Dosage/duration – depending on the phase post-lesion, it seems that high intensity (at
least 130 minutes per day) promotes delayed motor acquisition after the session, inducing
structural plastic changes as well as a reorganization of neural networks;
• Variable practice - by providing variability within a training sequence, or by randomizing
the presentation of individual training seems to lead to better retention with increased
neuronal activity;
• Massed practice/repetitive practice – intense sessions with very brief to no rest periods
where a skill can be trained repeatedly in a constant or blocked fashion.
• Spaced practice – as the opposite to the previous one, training should be structured in
time to include rest periods between repetitions or sessions
• Rhythmic cueing - pooled evidence provided in the reviews suggests that there are
neuronal interactions between auditory and motor systems and auditory-cued motor
training can change their mutual structural connectivity, while the existence of auditory
cueing related to movement.

CONDITIONS OF FEEDBACK
• Explicit feedback/knowledge of results - verbal, terminal and augmented feedback about
goal achievement seems to activate explicit learning mechanisms. A global motor plan is

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 learned represented by higher-order neuronal networks, which influence the cortical
sensorimotor representations differently;
• Implicit feedback/knowledge of performance - feedback given about movement
execution in the form of verbal descriptions, demonstrations, or visualisation of
recordings. Implicit sensory feedback enhances learning from sensorimotor prediction
errors.

TYPE OF PRACTICE
• Action observation/embodied practice – the discovery of mirror neurons demonstrate
how observing tasks and movements can stimulate motor areas in the brain to perform
those tasks, contributing to neural activity.
• Goal-oriented practice - movement control is achieved through the coupling of goal-
specific functional movements;
• Motor imagery/mental practice - rely on the ability to simulate actions mentally without
overt behavior, activating premotor areas, somatosensory cortex, and subcortical areas as
during movement execution;
• Multisensory stimulation - he integration of visual and proprioceptive information to
perform movements, has been shown that vision and proprioception are weighted
differently at various stages during motor planning;
• Social interaction - behavior in which the participants’ actions are both a response to and
a stimulus for the behavior.
• Task-specific practice - Focusing on activities and movements that are meaningful and
relevant to the patient, such as dressing, grooming, eating, and walking, helps to promote
functional improvement and collateral sprouting.

One should keep in mind that, motor learning does not follow the rule one-size-fits-all and the
application of these principles should be customized to the individuals. It is rather dependent on
personal features, like person´s age, motivation, experience and pathological condition or
neurological damage. Therefore, it is fundamental to try to understand which learning mechanism is
still intact to use it as the form to learn or relearn movements again (Roemmich & Bastian, 2018).
However, many studies are not conducted in pathological populations or results are not conclusive
(Fisher et al., 2014). Approaches are developed according to results in healthy populations or
animals or based in low quality studies with low statistical generalization (according to current
standards to value quality of research).

Currently, it is still not clear by neuroscience which mechanism are involved in different types and
features of movement and if different mechanics can replace or substitute others. Nevertheless,
there are some mechanisms of motor learning that seems to have some stability (Roemmich &
Bastian, 2018):

• Adaptation as result of error sensory feedback - this seems to be more dependent of some
brain regions than others, this means depending on the brain lesion this strategy can be
used or not
• Reinforcement learning - the need to associate the learning achieved with meaningful
rewarding for the person - this is crucial to be identified
• Instructive learning - the most used by therapists, where they instruct the patient about
specific features of the movement (take a bigger step, more to the left, extend your hip)
over repeated sessions. However, this mechanism is not sufficient. When a person is able to
voluntarily correct the movement after instruction, the challenge is to keep this ability at

6
 long term and without instruction. Studies point for high intensity, which shows good results
for gait in rehabilitation phases, however not demonstrated in upper extremity training. Also
in acute phase intensity is still inconclusive. Some conditions like Parkinson, Multiple
Sclerosis and Spinal Cord Injuries do not confirm this strategy also.

This leads to the need to research further the motor learning mechanisms and to hypothesise the
best efficacy in the combination of more than one mechanism.

Physiotherapy approaches according to the neuroscientific discoveries

Table 1, presents an historical perspective of physiotherapy evolution in terms of aims and types of
approaches and techniques. In this overview, it is visible that only after the 70s, physiotherapy
started to implement approaches directed to stimulate motor learning and therefore
neuroplasticity.

The major advances of the contemporary approaches are:

• Greater understanding of the neural mechanisms of motor recovery and the use of
neuroimaging techniques to track changes in the brain as a result of physiotherapy.
• Development of new assessment tools, which allows therapists to more accurately measure
a patient's motor function and track their progress over time.
• Increased use of robotic and assistive technologies, such as exoskeletons and functional
electrical stimulation (FES) devices, to help people with neurological conditions improve
their mobility and independence.
• Greater emphasis on task-oriented and goal-directed rehabilitation, which focuses on
helping patients achieve specific functional goals and activities of daily living, instead of
approaches focused on body segments and functions.
• Increased use of virtual reality (VR) and augmented reality (AR) technologies to enhance
rehabilitation and provide patients with immersive and engaging therapy experiences.

Overall, these advances in neurological physiotherapy have improved our ability to effectively treat
people with neurological conditions and help them achieve better outcomes.

Impact of physiotherapy in functional outcomes

NPT is supported by some models of reasoning, which are combined in the NeuroQR framework
(Santos et al., 2021). This framework is organized in four dimensions: 1) the “concepts”,
corresponding to the fundamental concepts a physiotherapist should master for accurate
and efficient clinical reasoning, such as the 4-element movement system model (McClure et al.,
2021) ,as the key identity for physiotherapy profession; neuroplasticity, international classification
of functioning, disability and health (ICF), motor control and behaviour, motor learning,
neurological dysfunction and research methods and analysis; 2) the “approach”, where the major
guiding principles and ideas orienting collaboration and intervention with the patient are applied:
patient-centered care, evidence-based practice, and 24h approach; 3) the methods, which
describes the intervention plans to implement, and finally; 4) the “techniques”, the practical
strategies to implement and evaluate the plans informed by the best scientific evidence available.

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Under these models, NPT is informed on the most recent scientific developments in terms of
neuroscience and physiotherapy approaches with impact. For this, one’s needs to frequently
knowledge update.

Table 1. Historical and conceptual classification of techniques in neurorehabilitation. Modified from (Cano-de-la-Cuerda,
2021)

Description Aim Approaches and Techniques

<1940 Compensation techniques Stimulate unaffected side Exercise and tools

1940–1960 Facilitation techniques Improve quality of Proprioceptive neuromuscular facilitation

movement on the affected 1940
side
Bobath concept 1948

>1970 Neurocognitive techniques Introduction of cognitive
functions in the
rehabilitation process
>1970 to Modern techniques Motor learning
1980
>1980 Technologic approaches Sensory and motor
learning, functional
recovery and compensation
approaches
2020 Hybrid approaches Meaningful approaches
from the individual
prespective
Brunnstrom 1950
Rood Method 1954
Perfetti Method 1970
Task-oriented motor learning 1984 Body-
weight–supported treadmill training 1987
Constraint-induced movement therapy
1970–1980
Muscle strengthening programs and
physical reconditioning 1970–1980
Robotics
Virtual reality
Video games
Functional electrical stimulation Brain-
Computer interface Transcranial magnetic
stimulation Transcranial direct current
stimulation
Mobile applications Telerehabilitation
All the above

Approaches with impact

Physiotherapy in general, entails many treatment approaches and techniques. The past 20 years
were dedicated to determining the scientific evidence of physiotherapy impact and currently, there
is no doubts about the efficacy of physiotherapy in neurological conditions. It is an area where
physiotherapists have evidence-based treatments available for most of the common functional
problems. The most studied neurological condition is “Stroke”, followed by “Multiple Sclerosis”,
“Parkinson”, “Incomplete Spinal Cord Injuries”, “Brain injury” and “Dementia disorders”. Among
these conditions, there is a substantial differentiation with regards to the structural localization of
the disorder: upper motor neuron lesions (stroke, spinal cord injuries, multiple sclerosis and
traumatic brain injury), basal nuclei lesions (Parkinson) and cognitive areas disorders (dementia),
with impact and specificities in physiotherapy approaches.

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Regarding lesions from the upper motor neuron

A systematic review that analysed 467 (randomized) control trials entailing 25373 individuals in post-
stroke physiotherapy (Veerbeek et al., 2014) , presents high or moderate evidence for several
physiotherapy approaches. These approaches are organized according to ICF dimensions in figure 1
and are summarized here:

• Approaches related to gait and mobility related functions: sitting and standing balance
training; activities balance training; electromechanics functional stimulation; neuromuscular
stimulation; strength training; cardiorespiratory training; body-weight supported gait
training; overground walking; virtual reality; circuit class training; TENS; speed training.
• Approaches related to upper limb activities: high-intensity constraint-induced movement
therapy; low-intensity constraint-induced movement therapy; robotics; mental practice
with motor imagery; mirror therapy; neuromuscular stimulation; somatosensory
stimulation; biofeedback with electromyography; virtual-reality.
• Approaches for activities of daily life: leisure therapy focused on the development of
individual and social activities as part of the intervention programme.
• Approaches for physical fitness: strength exercises; cardiorespiratory exercises; mixed
strength and cardiorespiratory exercises.

Transversal to all of these, intensive high repetitive task-oriented and task specific training,
demonstrates high evidence.

Although the level of evidence may differ, these same strategies are also applied in most of the
other neurological the other upper motor neuron lesions presented above.

A review of systematic reviews, meta-analysis and meta-synthesis (Momsen et al., 2022), analysing
72 studies, demonstrate evidence for the impact of physiotherapy including robotics, virtual reality,
electric stimulation, respiratory training, aquatic therapy, exercise, balance training.

Specifically for spinal cord injuries, a systematic review (Harvey et al., 2021), analysing 27 trials
encountered that in any study NPT, independently of the approach has impact in functional
outcomes. Differentiations are made to functional electric stimulation and bed positioning for upper
limb training; robotics for gait training and; activity-based training, resistance training, transfer
training and exercise for global functioning. These approaches when compared with the control
group, demonstrated statistical benefits evidence.

With regards to traumatic brain injuries, the evidence is scarce and the studies available present
poor levels of evidence in their recommendations. A systematic review (Bland et al., 2011), that
analised 20 trials found positive effects for balance and gait training. The same limited evidence was
found in a more recent review (Alashram et al., 2020). However, another systematic review(Hellweg
& Johannes, 2008), presents strong evidence for intensive task-oriented approaches.

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Figure 1. Physiotherapy approaches with high to moderate recommenations. Retrieved from Veerbeek, Janne & van Wegen, Erwin &
Peppen, Roland & Wees, Philip & Hendriks, Erik & Rietberg, Marc B. & Kwakkel, Gert. (2014). What Is the Evidence for Physical Therapy
Poststroke? A Systematic Review and Meta-Analysis

Legend: Overview of outcomes for which interventions are available with significant summarized effects. Legend: A green point indicates
that the intervention has a significant positive effect on the outcome, while a red point indicates that the intervention has a significant
negative effect on the outcome; *, shoulder external rotation; **, dependent walking patients in the early rehabilitation phase; n,
dependent walking patients when compared to electromechanical-assisted gait training or BWSTT; %, independent walking patients;
BWSTT, Body-weight supported treadmill training; CIMT, Constraint-induced movement therapy; EMG-NMS, Electromyography-triggered
neuromuscular stimulation; ES, Electrostimulation; mCIMT, modified Constraint-induced movement therapy; NMS, Neuromuscular
stimulation; prox., Proximal; TENS, Transcutaneous electrical nerve stimulation. doi:10.1371/journal.pone.0087987.g008

Not included in these high to moderate level of recommendations, but largely used in physiotherapy
practice-are “hands-on” approaches that very much characterize physiotherapy. In a systematic
review which included 9 studies entailing in total 483 stroke patients (de Almeida, Santo, et al.,
2015), a limited level of evidence recommends the use of low-stroke back massage for shoulder

10
pain; range-of-motion exercises for upper-limb and lower-limb structures and functions of muscles
and joints; proprioceptive neuromuscular facilitation (PNF) for gait step; walking backwards with hip
facilitation for gait parameters and performance; and conventional physiotherapy with facilitation
techniques for gait parameters. Recommendations with indicative findings favor PNF with trunk
rhythmic stabilizations for function and mobility of upper limbs.

Regarding lesions from the basal nuclei

A meta-analysis, that analysed 191 trials entailing 7998 individuals with Parkinson’s disease (Radder
et al., 2020), confirms the efficacy of physiotherapy associated to medication. Conventional
physiotherapy significantly improved motor symptoms, gait, and quality of life. Resistance training
improved gait. Treadmill training improved gait. Strategy training improved balance and gait. Dance,
Nordic walking, balance and gait training, and martial arts improved motor symptoms, balance, and
gait. Exergaming improved balance and quality of life. Hydrotherapy improved balance.

Regarding dementias

A systematic review and meta-analysis that analysed 23 (randomized) control trials entailing
individuals with Alzheimer’s disease (Zhu et al., 2015), refer to limited evidence to the benefits of
physiotherapy in general. However, a more recent systematic review that analysed 43 trials entailing
3988 individuals with dementia (Lam et al., 2018), presents evidence that exercise therapy improves
strength, balance, mobility, and endurance during functional activities. The impact is higher in
individuals with mild cognitive impairment or dementia.

Impact of physiotherapy in brain activity

While it is scientifically proved the impact of physiotherapy on individual’s functional outcomes, the
same requires further research in terms of impact on brain activity. Nevertheless, there seems to be
a universal belief that physiotherapy facilitates neuroplasticity. This assumption might be based on
the premises that:

• Functional outcomes can only result from brain reorganization and neuroplasticity,
• Results observed in normal subjects, might be similar in individuals with a neurological
condition.

Some research has shown that physiotherapy can have a positive impact on brain activity. Studies
indicate that NPT can lead to changes in brain structure and function, particularly in areas associated
with motor control and sensory processing. Additionally, exercise and physical activity have been
shown to promote the growth of new nerve cells (neurogenesis) in the hippocampus, a region of the
brain involved in learning and memory. This can help to improve cognitive function and may be
beneficial in conditions such as Alzheimer's disease. At last, NPT has been found to be effective in
reducing pain and inflammation, which in turn can have positive effects on brain function, mood and
activity levels.

A systematic review performed in 2013 (Almeida et al., 2013.Pdf, n.d.), which included 7 studies
entailing a total of 148 individuals, points out to some evidence in terms of physiotherapy impact in
brain activity. In this study, the following interventions were identified:

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Directed to upper limb:

• Proprioceptive passive training promoted increase of brain maps of ipsilesional pre-frontal,

the contra-lateral ventral pre-frontal and primary and secondary somatosensory cortices.
• Mental imagery increases the metabolism of cerebral glucose in the ipsilesional
supplementary motor and the brain map of motor and somatosensorial areas.
• Robotics, promotes the increase of ispsilesional brain activity at the primary somatosensorial
cortex.
• Constraint-induced movement therapy, promotes the increase of bilateral brain activity at
the motor and somatosensorial areas and hippocampus, and the ipsilateral supplementary
motor area.

Directed to lower limb:

• Treadmill training with body weight support (TTBWS) promotes increases on ipsilesional
brain map representation of the big toe.

However, the studies included in this review were of moderate to low level of quality and the limited
amount of studies do not permit for generalization.

All in all, there is not yet a systematic overview of these studies and what the real impact of
physiotherapy is in brain activity that indicates neuroplasticity. Therefore, to fill in this gap, the
authors of this chapter performed a scoping review; reviewing studies published in the past 10
years, regarding the impact of physiotherapy in brain activity (see methodology, PRISMA flowchart
in the appendices 1 and 2 of this chapter). Seventy three studies were analysed, entailing a total of
xxx individuals with a neurological disorder.

From this review the impact of physiotherapy is clear in different dimensions of brain activity (entails
map areas of activation, blood flow, neurotransmitters, biomarkers related with neuroplasticity).
The most analysed type of brain activity (Table 2), are the brain maps with increased activity and
BDNF levels. The approaches found with effects in brain activity are listed in table 2 and box 4.
Table 2.

Brain Activity
NPT Approaches Neuro
Maps/activity BDNF
transmitters
Action observation followed with practice •
Task-oriented approach •
Aerobic Exercise training • •
Balance training •
TTBWS • •
Virtual reality •
CIMT •
Sensory stimulation •
Mental imagery •

A more systematic overview of physiotherapy approaches and specific effects in brain activity is
presented in box 4, summarizing the results displayed in the data extraction table in appendix 3.

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Box 4. Impact of physiotherapy approaches in brain activity

IMPACT OF PHYSIOTHERAPY IN BRAIN ACTIVITY

Resultados preliminares a serem apresentados na aula.

These results confirm the impact of several physiotherapy approaches. Interestingly though, is the
fact that, the majority are not using the most common physiotherapy strategy: the hands on
approaches or manual facilitation. However, there are interesting studies directed to brain activity
that are promising in terms of the impact of manual facilitation.

The study from (de Almeida, Vieira, et al., 2015), found that the use of manual facilitation to move
the lower limb promotes similar brain activity (activation areas) compared to those when the
movement is done without facilitation and by means of voluntary movement. It elicits cortical and
subcortical activation in white matter, the thalamus, pons, and cerebellum. Similar results were
found in the study of (Vieira et al., 2018), where just touching body regions of the lower limb,
activated the same brain areas that are activated during voluntary movement. A study directed to
the upper limb (Vidal et al., 2017), confirm the same results for movement facilitation of the upper
limb.

These three studies are also relevant in the perspective that they demonstrated a different pattern
of brain activity in terms of laterality. While the activation of the lower limb conducts to bilateral
brain activity, the activation of the upper limb generates primordial activation of the contra-lateral
side. These results are highly relevant for physiotherapy practice as they can guide the best way to
activate different sides of the brain.

Conclusions and Recommendations for practice

Returning to the topic of this chapter, physiotherapy benefited immensely with neuroscience
developments and its currently a safe and scientifically based profession, disposing of several proved
efficacy treatment strategies.

Responding to the questions posed by Prof. Castro Caldas in 2009:

“What is the impact of physiotherapy in neurological conditions recovery?”

The impact in several dimensions of functionality according to ICF, is scientifically proved.

Physiotherapy reaches recovery beyond muscles and isolated movement. Physiotherapy has
impact in functional activities, levels of autonomy and independence.

“Does physiotherapy have impact in brain activity?”

In line with the results for functional outcomes, physiotherapy indeed influences brain activity
being a therapeutical approach to stimulate neuroplasticity.

The response to these two questions also makes clear that physiotherapy is not a technique.
Physiotherapy is a health profession with an holistic approach, entailing different strategies centered
in movement, with impact in body structures and functions as in activity and participation.

13
In terms of recommendations for researchers, more studies should be developed with facilitation
techniques to really determine if the most common approach should be continued or dismissed.
Additionally, more studies with traumatic brain injuries, spinal cord injuries and dementias should be
promoted in a paradigm of contextualized research. When analysing critically this research and
many others used by other researchers to set the scientific knowledge, one might consider it as a
paradox. In most studies the conclusions refer to the need of larger samples or better control of
variables. On the other hand, in neurology the variability is real, not controllable and part of our
daily life in practice. Therefore, we appeal to the need to adjust our view on how to do and value
research. Context and variability should be integrated and instead of looking to generalization of
results to larger populations, we might value clusters by longitudinal collection of case studies.
Transformative research could gain salience.

In terms of recommendations for physiotherapists in practice, the information in this chapter should
be taken in consideration when designing a treatment plan for a patient under the paradigm of
informed-based practice.

In terms of recommendations for neurorehabilitation services and teams, considering the scientific
information critically analyzed and presented in this chapter, the major recommendation is that
physiotherapists, in large numbers, should be integrated in any neuro-rehabilitation team.

Bibliography
Agosta, F., Gatti, R., Sarasso, E., Volonté, M. A., Canu, E., Meani, A., Sarro, L., Copetti, M., Cattrysse,
E., Kerckhofs, E., Comi, G., Falini, A., & Filippi, M. (2017). Brain plasticity in Parkinson’s disease with
freezing of gait induced by action observation training. Journal of Neurology, 264(1), 88–101.
https://doi.org/10.1007/s00415-016-8309-7

Alashram, A. R., Annino, G., Raju, M., & Padua, E. (2020). Effects of physical therapy interventions on
balance ability in people with traumatic brain injury: A systematic review. NeuroRehabilitation,
46(4), 455–466. https://doi.org/10.3233/NRE-203047

Almeida et al., 2013.pdf. (n.d.).

Ashcroft, S. K., Ironside, D. D., Johnson, L., Kuys, S. S., & Thompson-Butel, A. G. (2022). Effect of
Exercise on Brain-Derived Neurotrophic Factor in Stroke Survivors: A Systematic Review and Meta-
Analysis. Stroke, 53(12), 3706–3716. https://doi.org/10.1161/STROKEAHA.122.039919

Bland, D. C., Zampieri, C., & Damiano, D. L. (2011). Effectiveness of physical therapy for improving
gait and balance in individuals with traumatic brain injury: A systematic review. Brain Injury, 25(7–8),
664–679. https://doi.org/10.3109/02699052.2011.576306

Cano-de-la-Cuerda, R. (2021). Proverbs and Aphorisms in Neurorehabilitation: A Literature Review.

International Journal of Environmental Research and Public Health, 18(17), 9240.
https://doi.org/10.3390/ijerph18179240

Castellano, C.-A., Paquet, N., Dionne, I. J., Imbeault, H., Langlois, F., Croteau, E., Tremblay, S., Fortier,
M., Matte, J. J., Lacombe, G., Fülöp, T., Bocti, C., & Cunnane, S. C. (2017). A 3-Month Aerobic Training
Program Improves Brain Energy Metabolism in Mild Alzheimer’s Disease: Preliminary Results from a
Neuroimaging Study. Journal of Alzheimer’s Disease: JAD, 56(4), 1459–1468.
https://doi.org/10.3233/JAD-161163

14
de Almeida, P. M. D., Santo, A., Dias, B., Faria, C. F., Gonçalves, D., Silva, M. C. E., & Castro-Caldas, A.
(2015). Hands-on physiotherapy interventions and stroke and International Classification of
Functionality, Disability and Health outcomes: A systematic review. European Journal of
Physiotherapy, 17(3), 100–115. https://doi.org/10.3109/21679169.2015.1044466

de Almeida, P. M. D., Vieira, A. I. C. M. de F., Canário, N. I. S., Castelo-Branco, M., & de Castro Caldas,
A. L. (2015). Brain Activity during Lower-Limb Movement with Manual Facilitation: An fMRI Study.
Neurology Research International, 2015, 701452. https://doi.org/10.1155/2015/701452

Fisher, B. E., Morton, S. M., & Lang, C. E. (2014). From Motor Learning to Physical Therapy and Back
Again: The State of the Art and Science of Motor Learning Rehabilitation Research. Journal of
Neurologic Physical Therapy, 38(3), 149–150. https://doi.org/10.1097/NPT.0000000000000043

Harvey, L. A., Glinsky, J. V., & Chu, J. (2021). Do any physiotherapy interventions increase spinal cord
independence measure or functional independence measure scores in people with spinal cord
injuries? A systematic review. Spinal Cord, 59(7), 705–715. https://doi.org/10.1038/s41393-021-
00638-0

Hellweg, S., & Johannes, S. (2008). Physiotherapy after traumatic brain injury: A systematic review of
the literature. Brain Injury, 22(5), 365–373. https://doi.org/10.1080/02699050801998250

Hylin, M. J., Kerr, A. L., & Holden, R. (2017). Understanding the Mechanisms of Recovery and/or
Compensation following Injury. Neural Plasticity, 2017, 1–12.
https://doi.org/10.1155/2017/7125057

Johansson, M. E., Cameron, I. G. M., Van der Kolk, N. M., de Vries, N. M., Klimars, E., Toni, I., Bloem,
B. R., & Helmich, R. C. (2022). Aerobic Exercise Alters Brain Function and Structure in Parkinson’s
Disease: A Randomized Controlled Trial. Annals of Neurology, 91(2), 203–216.
https://doi.org/10.1002/ana.26291

Kuk, E.-J., Kim, J.-M., Oh, D.-W., & Hwang, H.-J. (2016). Effects of action observation therapy on hand
dexterity and EEG-based cortical activation patterns in patients with post-stroke hemiparesis. Topics
in Stroke Rehabilitation, 23(5), 318‐325. https://doi.org/10.1080/10749357.2016.1157972

Lam, F. M., Huang, M.-Z., Liao, L.-R., Chung, R. C., Kwok, T. C., & Pang, M. Y. (2018). Physical exercise
improves strength, balance, mobility, and endurance in people with cognitive impairment and
dementia: A systematic review. Journal of Physiotherapy, 64(1), 4–15.
https://doi.org/10.1016/j.jphys.2017.12.001

Maier, M., Ballester, B. R., & Verschure, P. F. M. J. (2019). Principles of Neurorehabilitation After
Stroke Based on Motor Learning and Brain Plasticity Mechanisms. Frontiers in Systems Neuroscience,
13, 74. https://doi.org/10.3389/fnsys.2019.00074

McClure, P., Tevald, M., Zarzycki, R., Kantak, S., Malloy, P., Day, K., Shah, K., Miller, A., & Mangione,
K. (2021). The 4-Element Movement System Model to Guide Physical Therapist Education, Practice,
and Movement-Related Research. Physical Therapy, 101(3), pzab024.
https://doi.org/10.1093/ptj/pzab024

Momsen, A.-M. H., Ørtenblad, L., & Maribo, T. (2022). Effective rehabilitation interventions and
participation among people with multiple sclerosis: An overview of reviews. Annals of Physical and
Rehabilitation Medicine, 65(1), 101529. https://doi.org/10.1016/j.rehab.2021.101529

15
Nudo, R. J. (2013). Recovery after brain injury: Mechanisms and principles. Frontiers in Human
Neuroscience, 7. https://doi.org/10.3389/fnhum.2013.00887

Radder, D. L. M., Lígia Silva de Lima, A., Domingos, J., Keus, S. H. J., van Nimwegen, M., Bloem, B. R.,
& de Vries, N. M. (2020). Physiotherapy in Parkinson’s Disease: A Meta-Analysis of Present
Treatment Modalities. Neurorehabilitation and Neural Repair, 34(10), 871–880.
https://doi.org/10.1177/1545968320952799

Roemmich, R. T., & Bastian, A. J. (2018). Closing the Loop: From Motor Neuroscience to
Neurorehabilitation. Annual Review of Neuroscience, 41(1), 415–429.
https://doi.org/10.1146/annurev-neuro-080317-062245

Santos, H., Baleia, I., Almeida, P., & Brandão, R. (2021). Theoretical framework of clinical reasoning in
neurological physiotherapy: NeuroQR. RevSALUS - Revista Científica Da Rede Académica Das Ciências
Da Saúde Da Lusofonia, 3(2). https://doi.org/10.51126/revsalus.v3i2.139

Shors, T. J., Anderson, M. L., Curlik, D. M., & Nokia, M. S. (2012). Use it or lose it: How neurogenesis
keeps the brain fit for learning. Behavioural Brain Research, 227(2), 450–458.
https://doi.org/10.1016/j.bbr.2011.04.023

Song, J.-H. (2019). The role of attention in motor control and learning. Current Opinion in Psychology,
29, 261–265. https://doi.org/10.1016/j.copsyc.2019.08.002

Veerbeek, J. M., van Wegen, E., van Peppen, R., van der Wees, P. J., Hendriks, E., Rietberg, M., &
Kwakkel, G. (2014). What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and
Meta-Analysis. PLoS ONE, 9(2), e87987. https://doi.org/10.1371/journal.pone.0087987

Vidal, A. C., Banca, P., Pascoal, A. G., Santo, G. C., Sargento-Freitas, J., Gouveia, A., & Castelo-Branco,
M. (2017). Bilateral versus ipsilesional cortico-subcortical activity patterns in stroke show
hemispheric dependence. International Journal of Stroke, 12(1), 71–83.
https://doi.org/10.1177/1747493016672087

Vieira, A. I., Almeida, P., Canário, N., Castelo-Branco, M., Nunes, M. V., & Castro-Caldas, A. (2018).
Unisensory and multisensory Self-referential stimulation of the lower limb: An exploratory fMRI
study on healthy subjects. Physiotherapy Theory and Practice, 34(1), 22–40.
https://doi.org/10.1080/09593985.2017.1368758

Winstein, C., Lewthwaite, R., Blanton, S. R., Wolf, L. B., & Wishart, L. (2014). Infusing motor learning
research into neurorehabilitation practice: A historical perspective with case exemplar from the
accelerated skill acquisition program. Journal of Neurologic Physical Therapy: JNPT, 38(3), 190–200.
https://doi.org/10.1097/NPT.0000000000000046

Zhu, X.-C., Yu, Y., Wang, H.-F., Jiang, T., Cao, L., Wang, C., Wang, J., Tan, C.-C., Meng, X.-F., Tan, L., &
Yu, J.-T. (2015). Physiotherapy Intervention in Alzheimer’s Disease: Systematic Review and Meta-
Analysis. Journal of Alzheimer’s Disease, 44(1), 163–174. https://doi.org/10.3233/JAD-141377

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Appendix 1 Methodological procedures of the scoping review

Clinical question: What is the Impact of physiotherapy in neurological conditions in brain

activity?
P – neurological conditions: Stroke, TBI, SCI, MS, Alzheimer, dementia, Parkinson
I – physiotherapy interventions
C – n.a
O – brain activity

Search expression
(Stroke or "spinal cord injury" or SCI or "brain injury" or TBI or "multiple sclerosis" or MS or Parkinson or Alzheimer or dementia)
and (rehabilitation or physiotherapy or “physical therapy”) and (“Neural activity” or “Cerebral activity” or “Brain function” or
Neuroactivity or Brainwaves or “Neural function” or “Brain processes” or “Cerebral processes” or “Neural processes” or “Brain
dynamics” or “Neural dynamics” or “Cerebral dynamics” or “Brain metabolism” or “Cerebral metabolism” or “Brain states” or
“Neural states” or “Cerebral states” or “Brain patterns” or “Neural patterns” or “Cerebral patterns” or “Brain activity patterns” or
“Neural activity patterns” or “Cerebral activity patterns” or “Brain circuits” or “Neural networks” or “Neural pathways” or “Cerebral
circuits” or “Brain pathways” or “Neural connections” or “Cerebral connections” or “Brain connections” or “Neural web” or “Brain
web” or “Neural system” or “Cerebral system” or “Brain system” or “MRI markers” or neuroplasticity or biomarkers)

Search limits
• Humans
• Publications of the last 10 years (2013), since previous publications were scarce, and the existing ones mentioned as of low
quality
• RCT, CT, Systematic Reviews and Meta-analysis
• Language: Portuguese, English, Spanish, French and Dutch
•
Searched Databases
Found Eliminated duplicates
PubMed 892 212

Cochrane/Central 853 trials

7 SR
Total 1752 1540 to read title and abstract

Inclusion criteria
• Neurological conditions: Stroke, SCI, TBI, MS, Dementia and Parkinson
• Adults
• Physiotherapy interventions
• Rehabilitation interventions used by physiotherapists
• Studies directed to improve movement and functionality disorders
• Outcomes that include any form of assessment of brain activity

Exclusion criteria
• Transcranial electric stimulation
• Intervention study protocol
• Any other patient condition
• Retracted items from publishers/journals

Study selection and data extraction

PRISMA procedures were followed.
• Reviewers
o 2
• Data extraction dimensions
o First author and year of publication,
o Neurological condition
o Eligibility criteria
o Number of patients (in each group when applicable)
o Physiotherapy approach
o Timing of assessment,
o Brain activity outcomes
o Functional outcomes
o Conclusions

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Appendix 2 PRISMA Flow diagram

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Appendix 3 Data Extraction Table

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