Mini Review

published: 07 December 2017

doi: 10.3389/fpubh.2017.00333

Physical Therapy for Neurological

Conditions in Geriatric Populations
Eli Carmeli*

Department of Physical Therapy, University of Haifa, Haifa, Israel

With more of the world’s population surviving longer, individuals often face age-related
neurology disorders and decline of function that can affect lifestyle and well-being.
Despite neurophysiological changes affecting the brain function and structure, the aged
brain, in some degree, can learn and relearn due to neuroplasticity. Recent advances
in rehabilitation techniques have produced better functional outcomes in age-related
neurological conditions. Physical therapy (PT) of the elderly individual focuses in par-
ticular on sensory–motor impairments, postural control coordination, and prevention
of sarcopenia. Geriatric PT has a significant influence on quality of life, independent
living, and life expectancy. However, in many developed and developing countries, the
profession of PT is underfunded and understaffed. This article provides a brief overview
on (a) age-related disease of central nervous system and (b) the principles, approaches,
and doctrines of motor skill learning and point out the most common treatment models
Edited by:
that PTs use for neurological patients.
Ahmed A. Moustafa,
Keywords: physical therapy, aging, neurology, motor learning, brain
Western Sydney University,
Australia

Reviewed by:
Shahanawaz Syed, INTRODUCTION
JSS College of Physiotherapy, India
Daniel Rossignol, With increased age, individuals often face age-related neurological decline as well as disorders that
Rossignol Medical Center, can affect activities of daily living (ADL), general function such as gait and balance, and well-being
United States (1). Hence, preserving brain, muscle, and neuromuscular function is critical to health and quality
*Correspondence: of life.
Eli Carmeli Neurorehabilitation research has progressed substantially over recent decades. Lauenroth et al.
[email protected] (2) have indicated that neuroplasticity, or the ability of the brain to restructure synaptic connec-
tions, specifically in reaction to learning or experience or following injury is a process that occurs
Specialty section: throughout the lifespan, even among the aged (3).
This article was submitted to Child The amount of research focusing on motor learning structural and/or functional brain altera-
Health and Human Development,
tions in old people is increasing (4). The knowledge of changes in brain state in neuropathological
a section of the journal
conditions becomes particularly interesting when the motor learning ability is translated into
Frontiers in Public Health
functional ability (5).
Received: 26 September 2017
Regarding the involvement of physical therapy (PT) in neurological patients, there are several
Accepted: 23 November 2017
Published: 07 December 2017
treatment methods that available for the neurorehabilitation (6). A commonly applied treat-
ment is neurodevelopmental treatment (NDT) (7). PT for the elderly neurologically involved
Citation:
patient with sensory–motor impairments, postural control (i.e., balance), and coordination, and
Carmeli E (2017) Physical Therapy
for Neurological Conditions
it does so through the knowledge of motor learning and motor control (8). The PT is part of
in Geriatric Populations. an interdisciplinary team targeted to prevent functional decline, restore function, and ADL,
Front. Public Health 5:333. prevent secondary complications and comorbidities, allow compensating to offset and adapt
doi: 10.3389/fpubh.2017.00333 to residual disabilities, and to maintain of function over the long term. The prevention of falls,

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Carmeli PT Neurology Geriatric

frailty, fatigue, and sarcopenia could improve the patient’s to measure certain qualities such as quantitative electroencepha-
health and life span (9, 10). PT for neurological patients also lography and electromyography both in academia and in clinical
has a role in immediate or acute care, when there is a require- setting.
ment to provide hospital-based short-term intensive PT aimed
at the recovery of musculoskeletal and neurological function, AGING BRAIN
limbs positioning, and handling due to hypertonic or spastic
muscles (11). Not infrequently seen in the aging brain are momentary (i.e., tran­
Many factors are associated with the lack of compliance sient ischemic attack) (18), permanent impairment, functional
with a PT regimen in the elderly or with the availability of the disability, and personality changes (19), which can vary greatly
service. This could be attributed due to internal and external in severity and progression. Aging brains may oftentimes be
impediments such as insufficient time, malnutrition, lack of associated with deficiencies in various regions of the nervous
motivation, no pleasure while exercising, fear of falling, and system responsible for vestibular function and motor control
lack of social support, no space to exercise, limited finances, (e.g., reduced reaction time, impaired coordinative movements),
no transportation, and so forth. Such reasons can impede speech and language function (e.g., anomias), thinking (e.g., con­
achieving the maximum benefits from PT (12). Cognitive fusion, disorientation), sensory perception, learning, mental
impairment, such as dementia and delirium, and psychological fatigue, attention, judgment, problem solving (e.g., agnosias,
impairment such as depression and anxiety can addition- apraxias), ADL and instrumental ADL (e.g., dressing, eating,
ally affect the patient’s neurorehabilitation goals and outcomes personal hygiene, shopping, house work, transportation) sleep-
(13, 14). ing, mood (e.g., depression and melancholy), behavioral changes
The major aim of this mini review is to describe the role of (e.g., stress, anxiety, confusion or delirium, fear, loneliness/isola-
PT in neurorehabilitation for elderly people and to introduce the tion) (20), and disorganized behavior and doing unusual things
main rehabilitation approaches and techniques of doing so. (e.g., shouting, undressing in public).

NEUROPLASTICITY
PT IN DEVELOPED AND DEVELOPING
COUNTRIES Despite physiological and structural changes affecting the
brain tissue, the aged brain, to some degree, can learn and
In many developed and developing countries, the profession of relearn due to dynamic events known as “neuroplasticity” (21).
PT is significantly underfunded, underestimated, and under- Neuroplasticity can occur by producing certain proteins such as
staffed (15). These results in either low quality of physiotherapy brain-derived neurotrophic factor, by evolving new connections
and unavailable PT services, long waiting periods and in many between synapses and forming new pathways in the central
cases patients seek therapy in (evidence-based treatment options, nervous system. Although neuroplasticity emerges more often
which frequently worsen the individual’s overall health status). right after birth and during the first years of life (22), our brain’s
Unfortunately, unsubstantiated treatments and unavailable ability to learn new skills, to relearn old skills, and to adapt
medicine, practitioners, and health services are situations all activities continues frequently also as we aged; however, the abil-
too common in many Third World countries (mostly in Africa ity, quality, and rate of learning and relearning are expected to
and some in mid-Asia) where those in poverty cannot afford to diminish and proceed at a slower pace. Neuroplasticity is likely
establish modern, evidence-based medical services, and where due to two major neurophysiological processes: neurogenesis
adequate training for physicians and allied health-care providers and synaptogenesis (23).
is not up to the highest standards. Moreover, in these health-
and-welfare-deprived countries, national policy and regulations, AGE-RELATED NEUROLOGY DISORDERS
roles, standard of care, absence of internship accommodations,
and medical regulations are not adequately enforced, allowing Neurodegenerative conditions are a general term for a range of
unsubstantiated practices even flourish and replace universally conditions, which primarily affect neurons in the central nervous
accepted interventions (16). system, both at the brain and spinal cord level. Neurodegenerative
The first step in overcoming the shortage of health services diseases such as dementia, Alzheimer’s, Parkinson, and amyo-
in general and skilled PTs in particular is to open academic PT trophic lateral sclerosis (Lou Gehrig’s disease) are incurable and
programs that train students according the Commission on debilitating conditions that result in progressive degeneration
Accreditation in Physical Therapy Education (17) guidelines and or even death of nerve cells (24).
(e.g., 4  years program for pursuing Bachelor PT that contain Other neurological or pathological conditions affecting
approximately 3,000 academic hours and 1,000 h of supervised the brain such as CVA (i.e., stroke), seizure, or any condition
clinical internship). Simultaneously, policy makers must create composed of the intracranial components of the cerebral cortex:
national board exam along with official documentation to define white matter, thalamus, amygdala, hypothalamus, brain stem,
job description, code of ethics, duties, responsibilities, and scope and cerebellum, is associated with movement impairments,
of practice for PT. Second step is to develop research fields relate visual–motor learning (25) communication difficulties, loss of
to PT, such as gait and balance analysis lab, muscle strength/ cognitive abilities such as memory and decision making, psycho-
power objective evaluation tools, electron diagnostic instruments logical changes demonstrates strong association between anxiety

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Carmeli PT Neurology Geriatric

and depression and fear of falls (26), and decline in function and learning are essential and crucial, yet they are typically learned
social participation. and performed done circumstantially. Motor skills both learned
and relearned are not all acquired at once, but build upon and
are shaped by what already has been experienced and is known
PT FOR NEUROREHABILITATION AND and by the need and drive to truly achieve them. As the brain
NEURO-MAINTENANCE BY DIDACTIC learns it undergoing electrical, chemical, and structural changes
MEANS (e.g.,  signal transducing adapter proteins, G-proteins and ion
channels, intra-membrane receptors) that finally, produce a
In general, the PT uses the International Classification of relative permanent change representing long-term procedural/
Functioning, Disability, and Health model in a problem solving implicit memory.
approach to assess activity, function, and participation. In this
way, the PT can identify and prioritize relevant needs, concerns,
and expectations as a basis for establishing achievable outcomes
BIOFEEDBACK IN PT
with patients and caregivers (27, 28). Therefore, in addition to The question that arises in motor learning is what is the best
specific neurotreatment, PT includes activities to maintain way to learn sensory–motor skills? One of the most helpful
general fitness, muscle strength and length, aerobic capacity, techniques is the use of biofeedback (36–38). A biofeedback
good posture and postural control, and education of the patients system recommend external (i.e., augmented information that
and caregivers about the disease and how to reinforce PT strate- is an on demanded learning technique which provided by an
gies for preventing falls and inactivity, and ways in which to external source) and intrinsic feedback is response-produced
prevent secondary complications such as contractures, and leg training that is (a) interactive, (b) safe, and (c) allows the
ulcers and swelling. Furthermore, one can educate formal and individual motivation to discover and relearn motor skills and
unpaid/family caregivers about safe techniques for lifting and thus to regain cognitive capacities. External feedback is often
transfer and how to assist with bed mobility and environmental categorized as “knowledge of performance” (KP) also known as
restructuring is indispensable (29). In addition, as necessary, kinematic feedback, and “knowledge of results” (KR) augmented
PT prescribes appropriate wheelchairs, chairs, bed mattresses, information (39).
walking aids, orthopedic shoes, and other assistive technologies Knowledge of performance refers to information provided to a
and devices. patient during the activity/task/movement, and it includes infor-
mation about suitability, accuracy, efficiency, quickness, and veloc-
MOTOR LEARNING ity. KR is augmented information provided to a patient, verbally
and non-verbally after the activity/task/movement was concluded.
Motor learning in the elderly is not simply applied, and for KR focuses at the success level of the task, so eventually it provides
successful neurorehabilitation the aged individual requires the a quantity score (%, points, etc.). Typically, KR feedback can be
capacity to learn acquire new information and recall that informa- vocal (“well done,” “great job”) auditory (applause) or visual (such
tion, to practice and train with many repetitions [i.e., with many as smiley, or thumb up for good performance and thumb down for
combinations (when the order of the exercises does not matter) poor performance). Carmeli (40) had noted that for biofeedback
and with permutation (when the order does matter) (30, 31)]. to be most successful and beneficial for geriatric populations, an
The accomplishment of motor skills involves a process of motor individual must include several functional factors such as motiva-
control and motor learning. Motor control theories and principles tion, challenge point framework, guidance, and should be proven
provide an integrated framework from different disciplines such by evidence-based practice. Feedback can improve neuroreha-
as psychology, neurology, biomechanics, occupational therapy, bilitation if attention, task-related memory, and “reaction time”
and physical education (32). are practiced.
Older adults must frequently accommodate to the gradual Motor learning requires many combinations and permuta-
deterioration of their sensory–motor systems, emotional and tions. For new synapses and pathways to be formed and for
cognitive functions that occur associated with aging, adjust how functional connections to be created and developed, neurons
they perform multitasks and how they manage their health (33). must be aroused. Specific ways of administering feedback
Individuals in the fourth age with associated neurological condi- can activate neurogenesis. Training the brain by repeated
tions may need to relearn previously acquired motor skills such as and varied practices facilitates positive results. Lisa Muratori
bathing, eating, dressing up, or keeping hygiene with limited and and Ben Sidaway described the five necessary categories
distorted quality of resources available and accessible to them. for efficient motor learning practice including (1) blocked
Motor skill learning involves many principles, approaches, or obstructed practice is when the patient perform a single/
and doctrines (34). Formal and informal learning is a process identical skill over; (2) by contrast, the patient works on a
of change and dependent on intrinsic plasticity and neuronal number of different tasks in combination with each other;
dynamics (35) rather than on a collection of accurate and (3) distributed practice is when the patient receives more
practical knowledge, where a patient is gaining new knowledge, rest time than practice time; (4) massed practice is when the
functions, tasks, or skills. Progresses eventually require patience patient does more practice than rest time; and (5) contextual
and persistence and tend to follow learning curves. For an indi- interference—a series of skills are practiced in a random
vidual’s survival, motor development, maintenance of skill and sequence (41, 42).

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TASK ANALYSIS AND TASK-SPECIFIC effectiveness of the Bobath concept is lack of a unified framework
TRAINING for both experimental identification and treatment of neurological
motor deficits” (48).
Task-specific or task-oriented practice is an approach to reha-
bilitation that focuses on performance of functional tasks that CONSTRAINT-INDUCED MOVEMENT
are meaningful to the individual (43). In many neurological
conditions, specifically in Parkinson’s disease, knowledge of the THERAPY (CIMT)
biomechanics of movement can be used to make certain that the In this rehabilitation model, initially designed for adults post-
most efficient strategy is trained. It is equally important for PT stroke, the unaffected arm is restrained, requiring the individual
to occur within the context of functional tasks such as walking to use the affected side to complete numerous repetitions of vari-
(with variations in movement speed, direction, and distance), ous tasks that challenge the system (49, 50). Study outcomes that
stairs climbing, standing up from a sitting position, sitting down, investigated the effect of CIMT have demonstrated that intense
turning around, obstacle negotiation, to pick up products from structured practice leads to improvements in function, quality
the shelf in the supermarket and place them in a cart, to hang of movement, reaction time, and even changes in the neurosub-
clothes on a clothesline, insert and remove products from the strates of the brain, which correspond to improved movement
refrigerator, picking up objects off the floor or counter, reaching capabilities.
for a glass, grasping bottle, drinking from cups of different sizes
and shapes and manipulating objects with different sizes, shapes,
textures, and weights. PROPRIOCEPTIVE NEUROMUSCULAR
Functional training is effective in enhancing transfer and FACILITATION (PNF)
retention and very helpful when there is a high degree of
similarity between the trained task and new variations of the task. Proprioceptive neuromuscular facilitation is a common stretch-
Moreover, task-specific training also means that PT takes place ing and strengthening practice with broad applications in
not in a formal environment such as a PT clinic or laboratory treating patients with neurological and musculoskeletal condi-
but in the natural environment where the individual’s functional tions mainly for increasing muscle elasticity and endurance,
movements are most difficult to perform yet most important for and improve active, passive range of motions, to increase joint
maintaining effective ADL skills (e.g., person’s home/bedroom/ stability, to enhance neuromuscular coordination and control
kitchen, street, sidewalk/curbs). But, if such environment is not in the athletic and clinical setting (51, 52). When performed in
available, PT can provide environmental modifications such as addition to prescribed exercise, PNF may also increase muscular
creating ramps, rails, stairs, and different walking surfaces (grass performance. Two PNF techniques are mostly used include the
field, asphalt, sand track, gravel path). contract–relax method and the contract–relax–antagonist–con-
There is currently no evidence-based PT to cure neurode- tract method. For more information about PNF techniques,
generation diseases. However, a PT can provide specific means please see Ref. (53).
for relieving the symptoms and incapacities of a pathological
condition, provide a means of preventing musculoskeletal side IN SUMMARY
effects, and help to improve patients’ quality of life. For example,
psychomotor exercises such as Tai Chi can improve cognitive Physical neurorehabilitation can enhance brain and neuro-
function in older people at risk of cognitive decline (44), and gait muscular adaptation in the fourth age. PT for neurological
training for Parkinson can increase postural stability and reduc- patients is a comprehensive process that intends to teach, guide,
ing muscle rigidity (45). and promote brain plasticity, thus reducing the threats for any
functional and cognitive variations (54, 55).
Although there is strong support that a structural PT program
THE NDT/BOBATH (NDT) for neuropatients could actually affect brain plasticity by assisting
Neurodevelopmental treatment is a holistic clinical practice neurogenerative, neuroadaptive, and neuroprotective processes.
that emphasizes individualized therapeutic handling based Neurorehabilitation may be implemented in the framework
on movement analysis for rehabilitation. NDT is based on recommended by the International Classification of Function,
knowledge of human movement patterns, including atypical Health and Diseases. The final goal of gerontology-based PT
patterns, and in-depth knowledge in analyzing postural control, neurorehabilitation is to improve quality of life for those in the
righting reactions, motor learning, associated movements, and fourth age and, together with global health education program-
activation of key points of control (46, 47). Movement facilita- ming, to allow individuals the most independence possible and
tion is accomplished by handling techniques, weight-bearing social participation.
exercises to guide patients through initiation and completion of
intended task. Thus, patients learn how to control postures and AUTHOR CONTRIBUTIONS
movements and then progress to more difficult ones. However,
two associates, Prof. Mindy Levin and Ms. Elia Panturin, clearly The author confirms being the sole contributor of this work and
stated, “…that a major barrier to the evaluation of the therapeutic approved it for publication.

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Carmeli PT Neurology Geriatric

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Conflict of Interest Statement: The author declares that the research was
constraint-induced movement therapy: a multisite, randomized controlled
conducted in the absence of any commercial or financial relationships that could
trial with a 12-month follow-up. Physiother Res Int (2017). doi:10.1002/
be construed as a potential conflict of interest.
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Frontiers in Public Health  |  www.frontiersin.org 6 December 2017 | Volume 5 | Article 333