Neuro Rehabilitation


A stroke happens when the blood supply to the brain is affected due to a block or a bleed. As a result, brain cells are starved of oxygen. This causes some cells to die and leaves other nearby cells damaged.

A stroke can result from different causes. One mode is a blockage to the blood supply to the brain, for example a blood clot formed within the brain (cerebral thrombosis), or a clot formed elsewhere in the body (such as the heart) that then travels to the brain. Blood clots can block one of the arteries (blood vessels) that carry blood to the brain. This type of stroke is called an ‘ischaemic stroke’. Conversely, a stroke can also occur when a blood vessel bursts inside the brain and bleeds (‘haemorrhage’). With a haemorrhage, blood seeps into the brain tissue and can cause additional damage.

A Transient Ischaemic Attack (TIA) or ‘mini-stroke’ is a short-term stroke were the symptoms lasts for less than 24 hours. The oxygen supply to the brain is quickly restored and often symptoms disappear. A person may experience a TIA without realising that is has happened, but may simply feel drowsy for a short period whilst it is occurring, displaying very minor symptoms immediately afterwards. A transient stroke needs prompt medical attention because it indicates pathology within the brain and also a serious risk of a major stroke occurring at some time in the future.

Strokes usually take place suddenly, without much warning. A stroke may affect each individual very differently, depending upon which area of the brain is damaged, and the type of stroke that has occurred. Different areas of the brain control different functions such as movement, sensation, speech, memory, swallowing and balance, therefore symptoms may affect any one of these areas in an individual.

Common Symptoms :

Physiotherapy management following a Stroke

The aim of physiotherapy following a stroke is to help regain as much strength, movement, co-ordination and function as possible. The severity of the stroke will indicate how much recovery is possible, but physiotherapy works to maximise potential recovery.

Given that the brain is ‘plastic’ (in other words, it can adapt and effectively re-programme to varying degrees following damage), correct and timely physiotherapy input can significantly improve both the physical and mental outcome for an individual.

Often, the unaffected side becomes dominant and overactive to compensate for the weaker (affected) side. This means that a person who has had a stroke will tend to rely heavily on the stronger side of their body. Physiotherapy input is important in focusing on getting the affected side of the body to work more effectively, helping with normal movement, co-ordination, balance and general function.

Recovery following a stroke is most significant within the first 3 months, as this is the optimal time for ‘neuroplasticity’ to occur. The degree of recovery depends upon many factors, the most important being the severity of damage caused to the brain by the stroke. Although the majority of a person’s recovery is achieved within the first 12 months following the injury to the brain, recent research has demonstrated that significant improvements can be made for up to 5-10 years after in some individuals.

A Specialist Neuro Physiotherapist will thoroughly assess an individual and their presenting symptoms and problems immediately after the stroke and then continuously throughout their rehabilitation process. Together with the individual and their family / carers, your physiotherapist can help to formulate a rehabilitation plan that is specific to that individual’s needs and personal goals.

If the stroke is severe, this could mean helping with getting from bed to chair, or on or off the toilet. We can teach family and carers how to move and handle patients following a stroke, how to help to facilitate the rehabilitation process through stretching, positioning etc, or with long-term management plans if significant future care is needed. If the stroke is mild, physiotherapy could help with perhaps a return to even running, cycling and other sporting activities.

Physiotherapy input may involve ‘hands-on therapy’ to facilitate normal movement of the body, to mobilise tight soft tissues to improve flexibility, and to provide the correct stimulus to the body to evoke normal muscle reactions and reduce spasticity and ‘high tone’. Rehabilitation aims to restore ‘normal movement’ as far as is possible. Exercise rehabilitation is important to support the effects of manual therapy and to increase the exercise tolerance of the individual recovering from a stroke. An exercise programme needs to be progressive, with clear aims, and ideally needs to be reproducible outside of the physiotherapy sessions (for example at home) to enable rehabilitation to continue regularly.

With the correct and timely physiotherapy intervention, long-term improvements can be made. Our team can help you to get your life back following a stroke. Physiotherapy sessions may take place at your home, your care home, or at our designated neuro-rehabilitation clinics. Rehabilitation can occur alongside other health professionals who are involved in your care, and we can provide intensive, regular and short-term physiotherapy, intermittent ‘bursts’ of treatment, or long-term rehabilitation, as required by you and your needs.


Multiple Sclerosis (MS) is an inflammatory disorder of the brain and spinal cord (central nervous system). It is predominantly a disease of the white matter tissue, which includes the nerve fibres that transmit signals around the body to and from the brain and spinal cord.

Each nerve fibre is surrounded by a protective sheath made up of a substance called myelin. In MS, the disease process causes plaques to appear on the myelin sheaths which lead to interruption of the nerve transmissions of those nerve fibres that are affected.

This block of transmission causes symptoms to occur, such as visual problems, muscle spasms, muscle weakness, limb tremors, pain, numbness, tingling, reduced balance, urinary symptoms and fatigue.

What causes MS?

About 1 in 1000 people in the UK develops MS. The disease can affect any age and any individual but is very rare in young children. Common disease onset is around the age of 30, more commonly amongst women than men.

It is thought that MS is an autoimmune disease, where the immune system attacks the body itself instead of bacteria and viruses. The trigger for this process is unclear, but one theory is that a virus or environmental factor initiates this autoimmune response in individuals with a certain genetic makeup. So some people may be more prone to developing PD due to the way their bodies are programmed. It is also thought that there may be a possible geographical link to the disease.


A firm diagnosis is not usually made following the first symptoms, as many of the initial symptoms like short periods of blurred vision, leg tingling and numbness can be one-off problems which are linked to other conditions. Often the diagnosis is made after two or more relapses have occurred, as the symptom presentation then becomes more obvious. It is normally confirmed by MRI scan, and occasionally by performing a lumbar puncture, but always in conjunction with an examination and thorough history-taking by a GP / Neurological Specialist.

How does the disease progress?

MS is usually a slow progressive disease, and symptoms may vary hugely between individuals, depending upon the severity of the damage and the areas of the central nervous system which are affected. Some people can show few or occasional symptoms, where others are affected more significantly with widespread symptoms and severely impaired function. Once the disease process is triggered, it normally follows one of the following patterns:

Relapsing-remitting (R&R)

This pattern is characterised by relapses (exacerbations) which cause new symptoms to occur. Symptoms may last from a few days up to six weeks, but can also last for up to six months. Symptoms then remit (go away) and during the periods of remission, an individual can fully or partially recover from the deficits of the relapse.

Further relapses and remissions may then occur over time – one to two every two years is common. Consistent cycles of R&R over time cause more permanent scarring to the myelin of the nerve fibres which can result in reduced recovery following each relapse. Relapses can flare older symptoms or may result in new ones. After several years of R&R, some symptoms become permanent as the damage to the nerve fibres themselves occurs.

Secondary Progressive MS (SPMS)

This phase of MS may present a number of years after R&R MS has occurred and is characterised by a gradual worsening of the disease between relapses. The periods of remission become shorter and slowly the relapses merge into a general progression of deterioration. Some individuals in this phase may experience good and bad days / weeks but no real symptom recovery occurs.

Primary Progressive MS (PPMS)

This pattern occurs in about 1 in 10 people suffering with MS. It is characterised by a gradual progression of the disease from the outset, without any initial R&R course. Symptoms gradually worsen from the outset and do not recover. As with SPMS, there may be good and bad periods. Damage is confined more to the spinal cord than the brain and therefore symptoms with PPMS are less often cognitive and more physical.

Benign MS (BMS): This form of the disease affects less than 1 in 10 MS sufferers and is characterised by only a few relapses in a lifetime where no symptoms remain permanent.

Physiotherapy management for Multiple Sclerosis

The interruption of normal nerve signals from the brain to the limb muscles often means that movement becomes more difficult, balance and sense of position is affected and, in turn, functional ability becomes compromised.

Research evidence clearly shows that specialist physiotherapy input is vital in containing the effects of MS. This is achieved through a programme of muscle pattern re-training, stability and strengthening work, and various manual therapy techniques to reduce pain and spasticity, improve movement and co-ordination, and restore function. Regular physiotherapy input is an important way of managing the disease process and its progression.

Following a thorough assessment of the individual and an analysis of the particular areas of difficulty, a specific treatment and rehabilitation programme can be established to tackle the presenting symptoms and functional problems. The individual’s progress can then be monitored and the rehabilitation programme adjusted to respond to any changes in their condition as soon as they become apparent.

The aims of physiotherapy management are to:

Following a relapse, physiotherapy may need to be provided in intense and focused bursts of treatment, in order to tackle any newly-presenting symptoms and to optimise recovery. Ongoing exercises and rehabilitation may then be required on a maintenance basis during periods of remission, but continuous independent home exercises are strongly encouraged to ensure that the full potential is achieved and maintained.

Parkinson’s Disease (PD)

Parkinson’s Disease (PD) is a condition which disturbs the function of specific areas within the brain which are associated with the co-ordination of movement. Normally, messages from this area of the brain are sent along the spinal cord and into the muscles of the body to produce movement. Neurotransmitters (chemical messengers) are responsible for carrying this information along nerve junctions (synapses) from the brain, to the spinal cord, and finally to the muscles. In PD, a particular neurotransmitter called Dopamine becomes reduced in concentration, as the cells in the area of the brain that produce this chemical begin to die. Without these cells and their essential neurotransmitter, the messages that produce movement become slower and co-ordination and muscle tone becomes altered.

The exact cause of PD is unknown, but it is a progressive disease process with a time course from onset of between 10 and 15 years. Some cases progress more rapidly, others so slowly that degeneration may hardly be detected.


As the onset of symptoms in PD is gradual, it can take months or even years for the first signs and symptoms to develop, so it can therefore be difficult to diagnose. There are no specific tests to show that an individual has PD, rather the diagnosis is based largely upon a detailed history and examination of the individual and their presenting symptoms.

Common Symptoms/Characteristics:

Tremor: Begins in a limb, usually hands or finger. There will be a back and forth rubbing of thumb and forefinger. One characteristic of Parkinson disease is tremor of hand during rest.

Slowness of Movement (‘bradykinesia’): Over time, Parkinson's disease may reduce your ability to move and slow your movement, making simple tasks difficult and time-consuming. Your steps may become shorter when you walk, or you may find it difficult to get out of a chair. Also, you may drag your feet as you try to walk, making it difficult to move.

Rigidity / Stiffness: Muscle ‘tone’ becomes increased which causes resistance to movement of a joint and a resulting stiffness. This stiffness can make activities such as getting up from a chair or turning over in bed more difficult.

Altered walking (gait): As the disease progresses, a typical gait pattern emerges in individuals with PD. This is characterised by a short, shuffling pattern in which the individual finds it difficult to transfer their weight from one foot to the other unable to take longer strides. The trunk loses its normal pattern of rotation which is associated with walking , arm swing during walking also becomes affected as the muscles become more rigid

Speech changes: You may have speech problems as a result of Parkinson's disease. You may speak softly, quickly, slur or hesitate before talking. Your speech may be more of a monotonous rather than with the usual variations. A speech therapist may help improve your speech problems.

Automatic movements: Movements such as blinking and swallowing that are normally automatic can be specifically reduced or lost. This can cause the loss of expression on an individual’s face so that it becomes ‘mask-like’. It can also impair the swallowing of saliva, and disturb the coughing reflex. Socially, individuals may find these symptoms difficult to deal with.

Posture: A typical ‘Parkinsonian’ posture is characterised by flexed joints and a rounded spine which results in a stooped posture.

Balance: A combination of altered posture, muscle changes and reduced movement ability affects the overall balance of an individual with PD when standing and walking and, as such, they are at increased risk of falling.

Other associated symptoms of PD may include memory problems, fatigue, depression, altered bladder / bowel function and sleep disturbance.

Given the spectrum of symptoms and difficulties, individuals with PD need input and assistance from a number of health professionals, and whilst there is no cure, certain medications are used to try to control the symptoms.

Physiotherapy management for Parkinson’s Disease

Physiotherapy plays a very important role in the management of people suffering with PD, as neuro-rehabilitation focuses on assisting mobility, movement and function. Following a thorough assessment of an individual’s posture, balance, mobility and functional ability, a clearer impression of their specific difficulties and needs can be gained, and a rehabilitation plan formulated. This should include strategies of how to improve the safety of the individual by reducing their risk of falling, advice regarding any aids and adaptations that may be necessary, and liaison with other associated health professionals to assist with day-to-day functional activities if required.

Advice and support to the individual and their family /carers is an essential part of the management process, and this helps a person with PD to cope with the physical, emotional and social difficulties that this disease brings.

Head Injury

Head Injuries can be devastating for both the individual and their family, and can be a life changing event.

Head injury may be the result of sustaining a blow to the head, for example during a car accident, a bullet or other foreign object penetrating the skull and lodging in the brain matter or, from a simple fall where the individual hit their head on the ground. The consequences can be immediate, with symptoms occurring within seconds of the injury, or they may slowly develop over a period of days or weeks as blood leaks from the damaged brain area causing the brain to swell slowly against the skull.

Depending upon the type of the injury sustained and the medical attention received immediately after the injury the effects of a Traumatic Brain Injury can vary hugely,

Physical problems may include hearing loss, tinnitus (ringing or buzzing in the ears), headaches, seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, speech and language problems, changes to normal bodily functions, reduced strength, altered balance and co-ordination in the body or the arms and legs, sensory loss, chronic pain and altered muscle tone.

Cognition may be affected following a head injury and problems vary depending upon the location and severity of the injury. Such problems may include perceptual difficulties , lack of concentration , problems with memory and reasoning, and difficulty with executive functioning, for example goal-setting, planning tasks and events, initiating actions from thought, self-monitoring and evaluation of tasks and actions.

Communication may be affected. In such cases, the ability to express ideas through speech or writing, social communication such as tone of voice, appropriate response to conversation or commands, understanding how to take turns to talk, and appropriate response to facial and body expressions during a conversation with someone may be altered. During conversation, an affected individual may appear to display a lack of emotion or conversely may over-react inappropriately to a simple comment. Such effects can be extremely frustrating, not only for the individual concerned but also their family and friends. It is difficult when you are not used to an altered personality in someone that you know well, and you may not know how to respond to such emotions.

Physiotherapy input: Physiotherapy is important in order to achieve the maximum potential recovery. Neuroplasticity enables modifications to take place within the injured brain cells, in response to stimuli and therapeutic information from the outside. This means that ‘re-programming’ of nerve pathways and brain activity, through the correct therapy input can help an individual to re-learn skills, movements and functions by opening and optimising new pathways within the nervous system. Neuro-physiotherapy is therefore directed at providing the most appropriate stimuli at the most appropriate time, in order to optimally tap the Neuroplastic ability of the brain. Ideally this occurs at the earliest stage following an injury.

Rehabilitation following head injury is unlike any other field of rehabilitation. Recovery time is longer. In addition to head injury there will be other physical problems such as fractures and soft tissue damage. Improvements are often rapid during the immediate few weeks post-injury, followed by a slower period of recovery over the coming months into years. Although the majority of a person’s recovery is achieved within the first 12 months post-injury, evidence show that improvements can continue for up to 10 years with proper physiotherapy input.

Physiotherapy management can help with:

Damage to the spinal cord may result from a number of different causes, for example:

High-velocity type injuries to the spinal column can lead to ligament disruption and bony injury to the spine which may overstretch or tear the spinal cord and lead to a complete or incomplete spinal cord injury. This results in disruption of the nerve roots and causes problems with sensation and /or muscle power below the level of the spinal cord injury.

Complete tears: These result in no function, voluntary movement or sensation below the level of the spinal cord injury. The paralysis affects both sides of the body equally.

Incomplete tears: These have variable effects depending upon the severity and the level of the cord injury. The individual may be able to function, move or feel one side or part of their body more than other areas.

Each individual with spinal cord injury presents differently because the effects and nature of the paralysis of a spinal cord injury entirely depends upon the type of injury, the severity of the damage and the site of the lesion, Sensory and motor changes occur below the level of the lesion and may include the following:

Diagnosis: Any complaints of pain in the neck, between the shoulder blades, in the chest, or the lower back following a accident should be treated with suspicion of a spinal injury. Any unconscious individuals, those who have fallen from a height or those who have sustained a road traffic accident are always considered for spinal injury. Symptoms such as reduced sensation, tingling, altered reflexes and muscle weakness may also be suggestive of a cord / nerve injury.

Physiotherapy management: A spinal cord injury is a life-changing event for both the individual and their family, often with long-term changes to function. The specific treatment approach will depend upon the severity and the level of the spinal cord injury, but should always be goal-orientated and tailored to the needs of the individual.

Rehabilitation includes:

Physiotherapy aims to maximise normal movement and function whilst helping to prevent complications arising from the injury such as joint and soft tissue contractures, muscle spasm and compensation, and breathing difficulties resulting from reduced mobility and higher spinal cord lesions. Rehabilitation may be necessary over the long term, or until an individual with this type of injury has stabilised and reached their optimal potential.

Huntingtons Disease

Huntington's disease usually causes movement, cognitive and psychiatric disorders with a wide spectrum of signs and symptoms. Which symptoms appear first varies greatly among affected people. Some disorders appear to be more dominant during the course of the disease

Common Symptoms/Characteristics:

Movement disorders

Cognitive disorders

Psychiatric disorders

Depression is the most common psychiatric disorder associated with Huntington's disease n. Depression appears to occur because of injury to the brain and subsequent changes in brain function. Signs and symptoms may include:

Problems that often present themselves early in the course of the disease include:

Behavioral changes

Physical changes

Physiotherapy management for Huntington's Disease

People with Huntington's disease (HD) present with a variety of physical symptoms owing to the complex degeneration that occurs in the basal ganglia, the centre within the brain for controlling voluntary movement and establishing postures. Physiotherapists can help people with HD at various stages of the disease with certain aspects of these physical changes and are essential members of the multidisciplinary team (MDT).

Physiotherapy in the earlier stages

It is important to encourage people with HD to remain as active as possible, maintaining cardiovascular fitness should also be encouraged. In this stage people with HD are dealing with the onset of their symptoms, it can be very stressful and depression is common.. There may well be physical limitations, which restrict the person participating in some generic exercise classes. The physiotherapist assess appropriateness of different forms of exercise and make suitable recommendations.

At the first session the physiotherapist will complete a full assessment taking into consideration muscle weakness, muscle shortening, balance deficits and analysis of gait. It is not uncommon for the postural neck and trunk muscles to be weakened in the earlier stages; these people tend to walk lurching forwards at the hips. Subtle changes in posture can occur, and postural re-education can help in the long run. Any specific alterations in musculature, balance and gait identified should benefit from a specific exercise programmes, which will be developed to minimise the impact of these factors.

The physiotherapist teaches deep breathing exercises for relaxation purposes and also to help maintain lung capacity.

Fine hand movements and gripping will be difficult, exercises to prevent this will form part of the treatment plan. Simple strategies such as taking part in cards and board games will help to maintain hand function.

The middle stages

With the progression of HD the movements typically worsen, this can make walking increasingly difficult and so falls become more of an occurrence. Falling is a concern for both the person with HD and the carer. It would be easier when falls start to occur to just rely on a wheel chair for transport but it is really important that person remains active. People with HD will develop their own gait patterns as the disease progresses; it is important however that person is mobilising in a safe as possible manner. The physiotherapist will identify possible specific physical causes of falls such as poor balance, muscle weakness or shortening and devise specific exercises to help combat this. Walking aids can be used for those people whose movements and handgrip allows them to do so. To help minimise the impact of any falls people can wear protective padding on vulnerable bony prominences including hip protectors, knee and elbow pads and reinforced hats.

The person will spend an increasing amount of time sitting down, therefore the seating should be considered carefully. Seat should provide sufficient support so that the patient can sit upright and is comfortable and in a functional position. At the mean time encourage patient to use the use the trunk stabilising muscles. Poor postural habits for long periods of time will result in negative soft tissue changes occurring commonly found ones are shortening of hamstrings or the feet not resting flat on the floor and turning inwards. The person should be able to support his or her own body in the chair. Rounded shoulders and slouching will impair chest expansion and therefore lung functioning. It is important the seat provides some support but still ensures the patients are utilising their postural stability muscles in the trunk. The person's trunk stabilising muscles will benefit from a daily period of unsupported seating.

People with HD have decreased awareness of their body position, decreased spatial awareness and are often impulsive. This can result in rather precarious transfers. Practicing completing safe transfers should be emphasised. People with HD cardiovascular fitness will inevitably decline during this stage; activity should continue to be encouraged as much as possible but always ensuring the patient is safe. Hand exercises should be continued as many people have real difficulty with fine hand movements in the middle and later stages. Exercises particularly concentrating on the small muscles in the feet should form part of the treatment plan, as these are essential in maintaining balance.

Later stages

In the later stages the person may become dependent on a wheel chair and posture and seating will be the main focus of physiotherapy input. A daily posture plan should be developed; this should involve the person, carers, nursing staff; speech and language therapist and occupational therapy staff. The emphasis should be on comfort, maximising functional ability and to minimise secondary complications such as muscle contractures, pressure sores, chest infections etc. Specialist wheelchairs will be required as people with HD have great difficulty fitting into standard prototype wheel chairs. Sleeping posture needs to be taken care of. The person with HD will spend an increasingly large amount of time in bed; poor postural habits are often acquired in the bed undoing the good postural work achieved in the daytime. Stretching to be done to prevent contractures. Muscle contractions can become painful and make personal hygiene tasks become difficult.

For those people still able to weight bear safely independent or assisted wheelchair transfers should be continued, this can provide an important feeling of some independence. Standing if possible should be encouraged throughout, this will help maintain muscle strength, muscle length, bone density, assist with bladder and bowel functioning and decrease the risk of pressure sores. If the person is able to only partially weight bear then standing can take place in a standing frame or walking hoist. In the later stages the chest physiotherapy will have an increasingly important role in monitoring the chest status as the person with HD may become more susceptible to chest infections. The physiotherapist will be working closely with the speech therapist to develop ideal posture at meal times to minimise the risk of choking and aspiration of the fluid into the lungs and ultimately chest infections.


People with HD will experience many physical changes; a physiotherapist is an essential member of the MDT to help manage this aspect of the triad of symptoms. Specialised physiotherapy input is essential at each stage of the disease as it can help to maintain optimum physical function and minimise the complications during the progression of the disease.

Cerebellar Ataxia

Ataxia is a term that describes a group of neurological disorders that affect co-ordination, balance and speech. It usually results from damage to a part of the brain called the cerebellum, but it can also be caused by damage to other parts of the nervous system.

The symptoms of ataxia can affect every part of the body and cause difficulties with:

Types of ataxia

There are currently more than 50 recorded types of ataxia. Some experts believe the true figure could be more than 100, each with its own specific cause.

There are three broad categories of ataxia:

acquired ataxia – where symptoms develop as a result of trauma, stroke, multiple sclerosis (MS), brain tumour, nutritional deficiencies, poisoning or other health conditions that damage the cerebellum or nervous system

hereditary ataxia – where the symptoms develop slowly over many years and are caused by underlying problems with the genes that a person inherits from their parents

idiopathic late onset cerebellar ataxia (ILOCA) – where the cerebellum is progressively damaged over time for reasons that are still unclear

Acquired ataxia

Acquired ataxia can have a wide range of potential causes, including:

Hereditary ataxia

Hereditary ataxia is caused by a genetic mutation or by a faulty gene

Ataxia can be inherited in two possible ways:

autosomal recessive – such as the mutations responsible for Friedreich's ataxia and ataxia-telangiectasia

autosomal dominant – such as the mutations responsible for some cases of spinocerebellar ataxia

Autosomal recessive

When ataxia is autosomal recessive, it means the affected person has inherited the mutated gene from both their mother and their father. If they only received one mutated gene, the other normal gene will cancel out the effects of the mutation and they will just be a carrier of the condition. It's estimated that around 1 in 75 people are carriers of the mutated gene that causes Friedreich's ataxia, and around 1 in 100 people are carriers of the mutated gene that causes ataxia-telangiectasia. The likelihood of two carriers meeting by chance is very lowand hence these types of ataxia are so rare.

Autosomal dominant

When ataxia is autosomal dominant (as is the case for spinocerebellar ataxia), you can develop the condition if you receive a single mutated gene, either from your mother or father. This is because the mutation is strong enough to override the other normal gene. If you have autosomal dominant ataxia, any children you have will have a one in two chance of developing ataxia, regardless of sex.

Physiotherapy management for Ataxia

The goal of the physiotherapist in the rehabilitation of ataxia resulting from defects in neurological structures and effecting the functions of the patient, is to improve the functional level of the patient through restorative techniques. When this is not possible, the therapist makes use of compensatory strategies to make the patient perform as independent as possible within the present functional level. The goals of restorative physical treatment can be briefly described as:

Main principles of training

Treatment method involves

In the standing position, following the transferring of body weight onto the front, back and sides, narrowing the support surface and balance training in tandem position, balance training on one leg should be performed. This is a position with which ataxic patients have great difficulty.

Another option is to perform balance training on the post urography device in order to benefit from visual feedback obtained from observing the patient's ability to sustain his/her postural oscillation in the center of gravity (Qutubuddin et al. 2007).

Gait training should be given including the following applications : walking on two narrow lines, tandem gait, backward gait, slowed down gait (soldier's gait), stopping and turning in response to sudden directions, flexion, extension and left-right rotations of the head.

Vestibular Rehabilitation

Vestibular rehabilitation therapy (VRT) is an exercise-based program designed to promote central nervous system compensation for inner ear deficits. VRT can help with a variety of vestibular problems, including benign paroxysmal positional vertigo (BPPV) and the unilateral or bilateral vestibular hypofunction (reduced inner ear function on one or both sides) associated with Ménière’s disease, labyrinthitis, and vestibular neuritis. Even individuals with long-term unresolved inner ear disorders who have undergone a period of medical management with little or no success may benefit. VRT can also help people with an acute or abrupt loss of vestibular function following surgery for vestibular problems.

Why is VRT needed?

When the vestibular organs are damaged with disease or injury, the brain can no longer rely on them for accurate information about equilibrium and motion, resulting in dizziness, vertigo, balance problems, and other symptoms. Many people will be able to recover from these symptoms on their own after a few weeks of normal activity because the brain has adapted with a process called vestibular compensation.

However, if the vestibular compensation process is not successful, a person's ability to maintain posture and coordinate balance may become overly dependent on input from the eyes (vision) and muscles and joints (proprioception). In addition, the person may develop new patterns of head and body movement in an attempt to avoid dizziness and nausea. For example, a person with a vestibular disorder might compensate with an exaggerated hip sway as a method of balancing, turning entire body rather than just the head when turning to look at something, or always look down at the floor to avoid what appears to be a confusing swirl of activity.

The goal of VRT is to retrain the brain to recognize and process signals from the vestibular system in coordination with vision and proprioception. This involves desensitizing the balance system to movements that provoke symptoms.

What are the effects of VRT and how does it help?

With the exercises there will be an increase in the symptoms as the body and brain attempt to sort out the new pattern of movements. Balance improves over time if the exercises are correctly and faithfully performed. Muscle tension, headaches, and fatigue will diminish, and symptoms of dizziness, vertigo, and nausea will decrease or disappear. Many times, VRT is so successful that no other treatment is required.

What is decompensation?

After the brain has learned to compensate for vestibular dysfunction, events such as a bad cold or flu, minor surgery, or even anything that interrupts normal activity for a few days can cause the brain to “forget” what it learned and symptoms to reoccur. This is called decompensation. Most people are able to quickly recover from decompensation by immediately returning to the home-based exercise program developed during their initial course of VRT. However, if symptoms persist or are severe, it is important to get a diagnosis and medical treatment because this suggests that additional vestibular damage has occurred.

VRT and surgery

VRT is an important part of treatment when surgery is required to treat a vestibular disorder. A therapist may perform a pre-surgery vestibular evaluation, make daily visits during the hospital stay to help with the temporary increase in symptoms that often accompanies surgery, and provide a series of simple exercises to do at home upon discharge from the hospital. Often, therapists provide further therapy after a person has recovered from the surgery.


Anyone can have a fall, but older people are more vulnerable than others. This is mainly because long-term health conditions increase the chances of a fall. Falls are a common but often overlooked cause of injury, and sometimes death. Around one in three adults over 65 who live at home will have at least one fall a year, and about half of these will have more frequent falls.

Most falls do not result in serious injury, but there is a risk of problems such as broken bones. Falls can also have an adverse psychological impact on elderly people. For example, after having a fall some people can lose confidence, become withdrawn and may feel as if they have lost their independence.

What should you do if you fall ?

Keep calm, If you are not hurt and you feel strong enough to get up, do not get up quickly. Roll onto your hands and knees and look for a stable piece of furniture, such as a chair or bed.

Hold on to a furniture with both hands and slowly get up. Sit down and rest for a while before carrying on with your daily activities.

If you are hurt or unable to get up, try to get someone's attention Try to reach something warm, such as a blanket or dressing gown, to put over you, particularly your legs and feet. Stay as comfortable as possible and try to change your position at least once every half an hour or so.

What Causes a fall?

The natural ageing process means older people have an increased risk of having a fall. In the UK, falls are the most common cause of injury-related death in people over the age of 75.

There are three main reasons why older people are more likely to have a fall. These are:

Another common cause of falls, particularly among older men, is falling from a ladder while carrying out home maintenance work. In older women, falls can be particularly troublesome because osteoporosis (thinning and weakening of the bones) is a widespread problem. Osteoporosis can develop in men and women – especially in people who smoke, drink excessive amounts of alcohol or take steroid medication

Preventing a fall

There are several measures you can take to help prevent a fall. Simple everyday measures around the home include:

Removing clutter and ensuring that all areas of the home are properly lit can also help prevent falls. Healthcare professionals take falls in older people very seriously because of the serious impact that they can have. As a result, there is a great deal of help and support available for older people, and it's worth asking your GP about the various options.

Your GP may carry out some simple tests to check your balance. They can also review any medicines you are taking in case their side effects may increase your risk of falling.

Your GP may also recommend:

As we get older, exercise is incredibly important to our overall health. Active older people talk about how physical activity has enhanced their lives and experts give their advice.

Physiotherapy management for Falls Prevention

This service provides a holistic assessment in identifying pre-disposing factors of falling and a management plan to address these and reduce the risk of further falls.

The most important consideration when it comes to commissioning and delivering falls prevention exercise is that there is no ‘one-size fits all’ solution. The principle of falls prevention exercise is to counter the effects of muscle deterioration, particularly those that keep us upright and enable us to walk without swaying. Therefore, all falls prevention exercise focuses on strengthening leg and ankle muscles and challenging balance. Exercise programme includes resistance training and exercises done while standing.

When it comes to the type of exercise, it is also important to note that although programmes for both primary prevention (preventing first falls) and secondary prevention (preventing further falls) will be the same, (i.e. both focus on strength and balance), they will vary in the way they are delivered in order to meet the needs of the individual, especially where there is higher risk of falls. Programmes for secondary prevention, for example, will need to provide more support in the form of targeted interventions with controlled movements, and in some cases, operate on a one-to-one basis.

Dementia & Alzheimers Disease Care

As you get older, you may find that memory loss becomes a problem. It's normal for your memory to be affected by age, stress, tiredness, or certain illnesses and medications. This can be annoying if it happens occasionally, but if it's affecting your daily life or is worrying you or someone you know, you should seek help from your GP.

How common is dementia?

According to the Alzheimer's Society there are around 800,000 people in the UK with dementia. One in three people over 65 will develop dementia, and two-thirds of people with dementia are women.

The number of people with dementia is increasing because people are living longer. It is estimated that by 2021, the population with dementia in the UK will increase to around 1 million

Dementia is a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities. This includes problems with:

People with dementia can become apathetic or uninterested in their usual activities, and have problems controlling their emotions. They may also find social situations challenging, lose interest in socialising, and aspects of their personality may change.

A person with dementia may lose empathy (understanding and compassion), they may see or hear things that other people do not (hallucinations), or they may make false claims or statements.

As dementia affects a person's mental abilities, they may find planning and organising difficult. Maintaining their independence may also become a problem. A person with dementia will therefore usually need help from friends or relatives, including help with decision making.

Your GP will discuss the possible causes of memory loss with you, including dementia. Other symptoms can include:

Most types of dementia can't be cured, but if it is detected early there are ways you can slow it down and maintain mental function.

Physiotherapy management for Dementia and Alzhemier’s

How can a person with Alzheimer's disease or dementia benefit from rehabilitation when they don't even recognize their own family or places that should be familiar to them?

This is a very common question. Physiotherapy, occupational therapy and speech-language pathology services can be beneficial to the person with dementia as well as their family and caregivers at various stages of Alzheimer's or dementia.

In the early stages, rehabilitation services can help your loved one be as functional as possible for as long as possible. The focus of physiotherapy with dementia care is to improve balance, muscle strength, and mobility and provide pain management. Another goal of PT treatment is preventing falls. People with Alzheimer's or dementia are at greater risk of falls and mobility problems due to muscular weakness, history of falls, gait, balance deficits and cognitive impairment. Safe physical activity, including exercise, will maintain strength, balance, ability to walk and ability to get into or out of a chair or car.

Both the physical and occupational therapist may assist you in changing and enhancing your loved one's environment to improve function and safety. Environmental modifications such as adding signs on bathroom doors and labeling drawers for socks and shirts may allow a person with dementia to function at the highest level possible for as long as possible.

Physiotherapy can assess one's ability to walk safely, the risk of falls, and other functional tasks. The therapist will develop a treatment program, including exercise to maintain the present condition. Participating itself in the exercise programme helps the individual a lot and they don’t have to remember the exercise.

In the late stages, the role of physiotherapies change yet again. Rehabilitation therapists can recommend and help you obtain a custom wheelchair to maximize comfort and function for seating and positioning. Skilled therapists can also help prevent and manage the shortening of muscles or joints, and train you in overall care for your family member at the end-stages, including proper feeding.

Rehabilitation services have much to offer at all stages in the disease process to maximize function, manage day-to-day activities, reduce caregiver stress and improve the quality of life for all.


Hip replacement surgery is a procedure in which a doctor surgically removes a painful hip joint with arthritis and replaces it with an artificial joint often made from metal and plastic components. It usually is done when all other treatment options have failed to provide adequate pain relief. The procedure should relieve a painful hip joint, making walking easier.

What Happens After Hip Replacement Surgery?

Patient stays in the hospital for four to six days and may have to stay in bed with a wedge-shaped cushion between your legs to keep the new hip joint in place. A drainage tube will likely be placed in your bladder to help you go to the bathroom. Physiotherapy usually begins the day after surgery and within days you can walk with a walker, crutches, or a cane. You will continue physiotherapy for weeks to months following the surgery.

What Activities Should I Avoid After Hip Replacement Surgery?

For anywhere from six to 12 months after hip replacement surgery, pivoting or twisting on the involved leg should be avoided. Crossing the involved leg past the midline of the body, turning the involved leg inward and bending at the hip past 90 degrees should be avoided. This includes both bending forward at the waist and squatting.

The physiotherapist will provide techniques and adaptive equipment that will help in following any of the above guidelines and precautions while performing daily activities. Remember, by not following the therapist's recommendations one could dislocate the newly replaced hip joint and may require another surgery.

Even after your hip joint has healed, certain sports or heavy activity should be avoided. The replacement joint is designed for usual day-to-day activity.

Management at Home After Hip Replacement Surgery?

There are a few simple measures that you can take to make life easier when you return home after hip replacement surgery, including:

Physiotherapy management for Hip Replacement

It is important to exercise after surgery to increase the strength and flexibility in your new hip and to help prevent blood clots. You may feel uncomfortable at first, but exercising will help you to get back to your normal everyday activities sooner. Physiotherapist will alter and add up new exercises to help you recover faster.


Knee replacement, or knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability. It is most commonly performed for osteoarthritis, and also for other knee diseases such as rheumatoid arthritis and psoriatic arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk.

Other major causes of debilitating pain include meniscus tears, cartilage defects, and ligament tears. Debilitating pain from osteoarthritis is much more common in the elderly.

Knee replacement surgery can be performed as a partial or a total knee replacement. In general, the surgery consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components shaped to allow continued motion of the knee.

The operation typically involves substantial postoperative pain, and includes vigorous physical rehabilitation. The recovery period may be 6 weeks or longer and may involve the use of mobility aids (e.g. walking frames, canes, crutches) to enable the patient's return to preoperative mobility.

Physiotherapy management for Knee Replacement

Post Knee Replacement surgery, the patient would be able to walk independently with crutches or sticks and be able to safely negotiate stairs. The patient would be able to bend the knees by atleast 90 degrees at the time of discharge. The patient is also usually advised to undergo a home exercise programme through a physiotherapist.


The shoulder is the most flexible joint of the body. It allows one to place and rotate the arm in many positions in front, above, to the side, and behind your body. This flexibility also makes your shoulder susceptible to instability and injury. Depending on the nature of the problem, nonsurgical methods of treatment often are recommended before surgery. However, in some instances, delaying the surgical repair of a shoulder can increase the likelihood that the problem will be more difficult to treat later. Early, correct diagnosis and treatment of shoulder problems can make a significant difference in the long run.

Shoulder Problems and Treatments

Bursitis or Tendinitis

Bursitis or tendinitis can occur with overuse from repetitive activities, such as swimming, painting, or weight lifting. These activities cause rubbing or squeezing (impingement) of the rotator cuff under the acromion and in the acromioclavicular joint. Initially, these problems are treated by modifying the activity which causes the symptoms of pain and with a rehabilitation program for the shoulder.

Impingement and Partial Rotator Cuff Tears

Impingement and partial tear of the rotator cuff. Partial thickness rotator cuff tears can be associated with chronic inflammation and the development of spurs on the underside of the acromion or the acromioclavicular joint.

The conservative nonsurgical treatment is modification of activity, light exercise, and, occasionally, a cortisone injection. Nonsurgical treatment is successful in a majority of cases. If it is not successful, surgery often is needed to remove the spurs on the underside of the acromion and to repair the rotator cuff.

Full-Thickness Rotator Cuff Tears

Full-thickness tear of the rotator cuff. Full-thickness rotator cuff tears are most often the result of impingement, partial thickness rotator cuff tears, heavy lifting, or falls. Nonsurgical treatment with modification of activity is successful in a majority of cases. If pain continues, surgery may be needed to repair full- thickness rotator cuff tears. Arthroscopic techniques allow shaving of spurs, evaluation of the rotator cuff, and repair of some tears.

Both techniques require extensive rehabilitation to restore the function of the shoulder.

Instability of the shoulder.

Instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of sudden injury or from overuse of the shoulder ligaments.

The two basic forms of shoulder instability are subluxations and dislocations. A subluxation is a partial or incomplete dislocation. If the shoulder is partially out of the shoulder socket, it eventually may dislocate. Even a minor injury may push the arm bone out of its socket. A dislocation is when the head of the arm bone slips out of the shoulder socket. Some patients have chronic instability. Shoulder dislocations may occur repeatedly.

Patients with repeat dislocation usually require surgery. Open surgical repair may require a short stay in the hospital. Arthroscopic surgical repair is often done on an outpatient basis. Following either procedure, extensive rehabilitation, often including physiotherapy, is necessary for healing.

Fractured Collarbone and Acromioclavicular Joint Separation

A fractured collarbone and acromioclavicular separation are common injuries of children and others who fall on the side of their shoulder when playing. Most of these injuries are treated nonsurgically with slings or splints. Severe displaced fractures or acromioclavicular joint separation may require surgical repair.

Fractured Head of the Humerus (Arm Bone), or Proximal Humerus Fracture

A fractured head of the humerus is a common result of falls on an outstretched arm, particularly by older people with osteoporosis. If fragmented or displaced, it may require open surgical repair and possibly replacement with an artificial joint (prosthesis).

Osteoarthritis and Rheumatoid Arthritis

Osteoarthritis and rheumatoid arthritis can destroy the shoulder joint and surrounding tissue. They can also cause degeneration and tearing of the capsule or the rotator cuff. Osteoarthritis occurs when the articular surface of the joint wears thin. Rheumatoid arthritis is associated with chronic inflammation of the synovium lining which can produce chemicals that eventually destroy the inner lining of the joint, including the articular surface.

Shoulder replacement.

Shoulder replacement is recommended for patients with painful shoulders and limited motion. The treatment options are either replacement of the head of the bone or replacement of the entire socket. Your orthopaedic surgeon will discuss with you the best option.

Physiotherapy Management for Shoulder Injury

Managing shoulder injury with physiotherapy is successful. Normally, there are two options: non-operative or a surgical approach. The patient’s condition will dictate which option is best at the time. Non-operative care is also referred to as conservative rehabilitation.


If your loved ones in care homes needs Physiotherapy treatment please refer to Access Phsio Service!

We offer Physiotherapy service to Care Homes on contract basis or provide Physiotherapy treatment to residents who are privately funded.