Stuck in the past

Neurorehab teaching and practice desperately needs a kick in the ass.

I am in a bubble. I hadly talk with other therapist regarding stroke rehabilitation, other than few and some students. Had a shock as i found out PTs are still talking within the reflex hieracrcgial theory and think robotics, and other technologies are advancement. what a sad state.

It's been a while since I pointed out that PT education seems to be full of misguided ideas, so here we go.

Most physical therapy techniques we learn in college are rooted in reflex and hierarchical theories. These theories are based on the idea that providing a specific stimulus elicits a corresponding response. By applying a stimulus, we aim to evoke two types of responses: excitatory or inhibitory.

There are various techniques to achieve these responses. Let’s take the example of using ice on a muscle. Quick icing is used to excite a muscle response, while prolonged icing is applied to inhibit the response. The physiology behind this can be explained in a basic manner. Quick icing stimulates sensory nerves, which can alter the excitability of spinal neurons. (This information may travel to the sensory cortex and other areas of the brain, ultimately activating the targeted muscle.) In contrast, prolonged icing can desensitize sensory nerves, inhibiting the spinal reflex mechanism and temporarily reducing the excitability of spinal neurons. This mechanism can lead to a temporary inhibitory response. Thus, we can try to modulate a muscle’s activity, either to activate a muscle that is weak or unable to contract properly, or to inhibit excessive activity when needed.

Electrical stimulation provides a proper stimulus and gets a reliable response, particularly in patients with upper motor neuron (UMN) lesions. The underlying physiology may be similar to other reflex-based techniques. However, despite its effectiveness, it is not commonly used. Why? Is it because brushing or stroking the muscle with ice is different type of stimulus in turn differnt physiology? Why not simply start by stimulating the wrist extensors to improve upper limb function or stimulate the supraspinatus to prevent shoulder subluxation?

These approaches seems plausible until we realize that reflex-inducing activities do not necessarily lead to meaningful learning for the patient. The patient does not engage alternative neural pathways of the brain to activate spinal neurons and, in turn, the muscles.

This concept makes sense when we understand that isolated parts do not make up the whole. Activating individual muscles or movements does not equate to performing a functional activity. For example, riding a bicycle involves more than just alternating hip and knee flexion and extension—it’s a far more complex task that integrates coordination, balance, and motor control at multiple levels.

Simillary claims have been made joint compression leads to extension and distraction leads to flexion. We do keep on teaching this as though this is actual science. if you are confused, of course this is not true. Movements happen based on intreaction of numerous biological systems and the environement, not just joint senses.

And don't even get me started on robotics—it's nothing more than a white elephant made of papier-mâché.

How do you help a stroke patient regain a lost movement, especially when they have little or no activity?

The approach is straightforward: place them in the easiest position to perform the task and encourage them to keep trying. If there’s no progress after a month? Keep trying. Still nothing after 3–6 months? Unfortunately, it might not happen.

The key is to keep asking the patient to try—because, ultimately, that’s all we can do.

When I was younger and struggled to make a three-point shot, my coach didn’t hand me some magical solution. Instead, he pointed to a spot on the line and told me to focus, aim, and throw harder. The same principle applies here: effort, repetition, and practice are the foundations for relearning lost movements.

Take Shaquille O’Neal as an example—one of the greatest basketball players of all time, yet he never learned to sink a free throw. That’s just the reality of movement, the brain, and biology. You can’t go into someone’s brain and magically stimulate muscles or movements. There are no secret techniques like joint compression, stroking, patterns, or pressure points to unlock movement—except maybe in Shankar movies.

People often come to me and say, "But when we used these techniques, the patient showed improvement—the movements started coming back." Of course, they did! That’s the natural history of many diseases—they recover over time.

So, please, do some reading. Don’t be an idiot and keep repeating, “I’ve seen it in my practice.” That is the most childish response you can give when discussing science.

With so much love

Hariohm