Beyond Muscle Atrophy: Why Neuro-Rehabilitation Should Start Before the Orthosis Comes Off.

Written by:

Sydney MacWilliams CPAM, OTR/L

VHSF Fellow '25

Introduction

I am an aspiring hand therapist who unexpectedly found herself in a neurologically driven outpatient clinic. At first, this seemed far from my original path, but I quickly realized how valuable this opportunity could be. I am fortunate that my outpatient setting is housed within a hospital known for its distinguished neurological rehabilitation center. Within this setting, I was asked to take on the smaller orthopedic population we serve at our community hospital while also managing a mixed caseload of neurological and cognitive patients. Some might assume that balancing such a varied caseload would be overwhelming; however, for me, it has been the perfect fit.

As a clinician who once feared having to choose just one specialty, this environment has become the dream I didn’t realize was possible. I get to build skills across different populations under one roof, and I’ve found that the variety not only enriches my clinical growth but also provides a meaningful buffer against burnout. Working in this blended environment also changed the way I think about healing. It showed me that recovery is never just physical—it is neurological, behavioral, and functional. That realization shaped the way I approach immobilization and rehabilitation.

Spanning plate x 4 months

The Hidden Neural Cost of Disuse

In my experience with neuro patients, I often focus on re-educating the brain after events like a CVA, where motor planning and neural pathways must be actively retrained. Interestingly, my neuro perspective has shaped how I approach orthopedic patients’ post-immobilization. For instance, even when the injury is purely musculoskeletal, retraining the brain to relax the shoulder and elbow is critical before meaningful hand therapy can occur. Seo et al. (2024) studied the changes in brain functional connectivity following upper limb immobilization. They immobilized one arm of 12 healthy young females for 14 days; limiting elbow flexion/extension. They tested both arms for strength, muscle size, and brain and nerve changes. The study found that there was a 20-21% drop in strength but muscle size was only affected ~1.2% to ~2.9% noting that strength loss was not just from muscle shrinkage. When looking at the brain and nerve changes, they did see changes in resting-state brain connectivity especially in the regions involved in movement planning and detecting errors in movement execution.

This study shows that strength loss after immobilization isn’t just about muscle atrophy—it’s about how the brain’s motor network adapts to disuse, affecting movement. That’s why functional neurological retraining after orthopedic immobilization can make a real difference, helping patients regain efficient movement, rebuild strength, and improve functional outcomes. This is occupational therapy at its core: connecting the body, the brain, and meaningful activity.

Neuro-Protective Sensory Input During Immobilization

            Now understanding the impact of disuse at a neurological level, what can we do as clinicians to facilitate the healing process—even before the cast comes off? In a study by Roll et al. (2012), sixteen healthy adults were immobilized in a custom orthosis for 5 days preventing hand and finger movements. Eight of the participants received proprio-tactile stimulation designed to evoke illusory movement during immobilization. They used tiny vibrators on the hand and wrist to create sensations that tricked the brain into feeling like the hand was moving. The other half of participants received no stimulation. The study used fMRI to measure brain activity before and after immobilization and observed how well the hand could move after immobilization. The study found that without treatment there was not only a reduced range of motion to hand and wrist but the brain areas controlling movement showed much less activity. The participants who had received the treatment showed better preserved hand and wrist range of motion as well as well-preserved brain activity staying nearly the same as before immobilization. This study suggests that early rehabilitation can benefit from interventions that provide movement perception during immobilization, potentially reducing retraining time once the limb is freed. This strengthens our implication for sensory-driven rehabilitation such as vibration, tactile patterning (deliberately structured touch signals that mimic real movement sensations), movement visualization or mirror therapy.

Clinical Strategies for Neuro-Focused Rehab

Before Orthosis Removal / During Immobilization

Unaffected hand

Even while a hand or arm is immobilized, there are ways to keep the brain engaged and preserve motor function. Proprioceptive vibration or sensory illusions—such as handheld vibrators or textured materials applied over immobilized joints—can create the sensation of movement, helping maintain activity in the sensorimotor cortex. Motor imagery and action observation involve having patients imagine or watch hand movements, which can activate motor networks despite the inability to physically move the limb. Finally, bilateral training or cross-education leverages the unaffected limb: performing task-specific movements with the healthy hand can promote neural activation on the immobilized side, supporting strength and coordination through shared cortical pathways.

Early Post-Orthosis Phase

Once the orthosis is removed, therapy can progress to actively retraining both the brain and the hand. Mirror therapy and tactile feedback reinforce sensorimotor mapping through visual and sensory input. Task-specific, sensory-enriched activities, such as buttoning, grasping soft objects, or manipulating textured materials, pair functional use with deliberate sensory cues to enhance motor learning. Finally, progressive load with neural focus emphasizes tasks that challenge coordination, timing, and error detection, not just strength, promoting more efficient and purposeful movement.

Affected hand

Practice Pearls

·      Begin sensory input interventions on day one of immobilization (textures, light touch, vibration).

·      Use motor imagery and bilateral task practice to keep cortical networks engaged.

·      Apply cross-education: strengthen the non-immobilized limb to help preserve neural drive to the affected side.

·      After orthotic removal, start with graded sensory–motor retraining (mirror therapy, tactile cueing, coordinated bilateral use).

·      Pair early functional tasks with deliberate sensory cues (textures, resistance, external feedback).

·      Progress loading gradually, but maintain a neural emphasis—focus on coordination, timing, and error correction, not just force.

Clinical Crossroads

As a hand therapist in a neurologically driven clinic, I treat patients post-orthopedic injury. Traditionally, immobilization is viewed as a musculoskeletal issue: the joint stiffens, the muscle atrophies, the tendon weakens. But in practice, I’ve seen something deeper at play. The brain and nervous system begin adapting the moment movement is restricted. Patients often describe feeling “disconnected” from their hand or cautious in ways that don’t match the physical injury. They present with maladaptive compensatory movements. This tells me that immobilization is as much a neurological event as it is an orthopedic one.

Rewiring Recovery

Immobilization isn’t neutral. Even in purely orthopedic cases, disuse drives neural changes that shape recovery. Research shows that cortical representation of a limb can shrink with immobilization, altering how the brain “maps” movement. This can contribute to weakness, clumsiness, or delayed confidence when patients return to functional use. For me, this highlights why therapy must go beyond stretching and strengthening. We are retraining the brain to reconnect with the limb, restoring both movement and the sense of ownership over that movement. In short: healing is never only local—it’s systemic, and it starts with the nervous system.

References

Freddie Seo, Julien Clouette, Yijia Huang, Alexandra Potvin‐Desrochers, Henri Lajeunesse, Frédérike Parent‐L’Ecuyer, Claire Traversa, Caroline Paquette, & Tyler A. Churchward‐Venne. (2024). Changes in brain functional connectivity and muscle strength independent of elbow flexor atrophy following upper limb immobilization in young females. Experimental Physiology, 109(9), 1557–1571. https://doi.org/10.1113/EP091782

Roll, R., Kavounoudias, A., Albert, F., Legré, R., Gay, A., Fabre, B., & Roll, J. P. (2012). Illusory movements prevent cortical disruption caused by immobilization. NeuroImage, 62(1), 510–519. https://doi.org/10.1016/j.neuroimage.2012.05.020

Kavounoudias, A., Roll, J. P., Anton, J. L., Nazarian, B., Roth, M., & Roll, R. (2008). Proprio-tactile integration for kinesthetic perception: An fMRI study. Neuropsychologia, 46(2), 567–575. https://doi.org/10.1016/j.neuropsychologia.2007.10.002

Farthing, J. P., Krentz, Joel R., Magnus, Charlene R. A., Barss, Trevor S., Lanovaz, Joel L, Cummine, Jacqueline, Esopenko, Carrie, Sarty, Gordon E., Borowsky, Ron. Changes in Functional Magnetic Resonance Imaging Cortical Activation with Cross Education to an Immobilized Limb. Medicine & Science in Sports & Exercise 43(8): p.1394-1405, August 2011. | DOI: 10.1249/MSS.0b013e318210783c