PTs can help their patients live without weakness or pain with exercises specific to their symptoms
By Meghann Koppele Duffy, MA, NCP
If your client has neurological damage stemming from multiple sclerosis, Parkinson’s, a brain injury or a stroke, strategies aimed to help rewire the brain and improve balance, mobility, and strength are vital to help prevent disability/falls, slow disease progression and most importantly, maintain as much function as possible. Living without weakness or pain is an attainable goal if you keep in mind these below recommendations:
Find Proper Sensory Dosage and Be Ready to Adjust
Information comes into the body from the senses. If there is damage along the pathways that process that information, there can be sensory loss, so it is important to increase sensory feedback. Since every client with a neurological condition has his or her own unique symptom profile and sensory preferences, we recommend you chose sensory feedback that is meaningful for each client. It is easy to overdo sensory feedback, so a good rule of thumb is to use as much sensory feedback as needed, but as little as possible to teach new movement patterns. You can use vibration, tapping, cupping, Thera-Bands, and feedback through other senses, but if patients can only do movement with your sensory feedback, it will not transfer outside the clinic. Take your time to slowly integrate new movement patterns into your patient’s gait cycle and slowly decrease the sensory input over time.
Work the Feet and Ankles
If you have clients with neurological conditions, you probably see their feet doing some pretty crazy things (like sickling, spasming, pronating, supinating, or dragging). Feet are one of the first places weakness can occur, and problems such as numbness and foot drop can make walking difficult. Moving up the chain, ankles become increasingly unstable over time, often because spasticity, weakness, and muscle imbalances can all impact a person’s ability to stand and balance easily. Foot and ankle problems often sneak up on someone, and are not addressed until major gait issues are present. Walking just slightly “off” can lead to detrimental changes in the joints, so preventing foot and ankle issues should be a top priority. We recommend performing foot exercises in every session and integrating them with hip exercises to maximize the results. Start with subtalar mobility and toe exercises, and encourage patients to work barefoot to utilize and activate the proprioceptors in the sole of the foot.
Challenge Balance Safely
Balance is almost always affected in clients with neurological conditions. Since the neurological determinants of balance are the visual, vestibular, and proprioceptive systems, at least two of them should be addressed in every session. Balance work should be challenging, but also be sure to provide support and modify if your patient seems fearful. The fear of falling can increase the risk of falling, so if a patient seems nervous, work on increasing their ability to reflexively stabilize or modify to foster success.
Address Spasticity with More Than Just Stretching
It is important to understand that spasticity is a protective mechanism to protect a joint from weak muscles. Traditionally, patients were told to complete static stretches, but it is important to educate patients that muscle spasticity connot simply be stretched away (and often, you do not want to). A muscle experiencing spasticity is weak, and that neurological response is often what is giving the patient the tone needed to stand up and walk. The goal is to decrease spasticity enough to improve the range of motion of a joint, while also slowly building strength in the muscle. Range of motion exercises (in the range of motion the patient can control) are always a good idea. Deep stretches have to be done strategically because patients can experience weakness afterward. If a client needs or wants to stretch, do it late and do it last.
Include Standing Exercises in Every Session
Since it is very difficult to create a new movement pattern in a standing position, we recommend beginning your session in supine, prone, or side-lying positions. Once a new movement pattern is achieved, challenge the movement in different body positions to help it become efficient. For the pattern to be used in the patient’s gait cycle, it must be implemented into a gait-specific exercise in a standing position. A great tool for implementing standing exercises is a Fuse Ladder, which is an extremely versatile and effective full-body workout apparatus. Designed to be fun, challenging, and ever-changing, the Fuse Ladder combines spring weight exercises with climbing, hanging, agility, and balancing techniques – all of which are great for patients with neurological conditions.
Work the Hip Stabilizers…and Find the Hip Cuff
For people with neurological illness or injuries, hip stabilizer strength is critical to maintain (or achieve) normal gait. Weakness in the hips often occurs as a patient’s disease progresses. The gluteus medius is frequently blamed for many gait dysfunctions, but inefficiency in the entire hip is the problem. Before isolating any individual muscles, it is important to understand the importance of femoral joint centration, or what I call the “hip cuff.” If hips cannot reflexively stabilize when in stance, the entire gait cycle will be affected. In every session you should work to improve femoral head position with circumduction, flexion/extension, and medial/lateral glide, and be sure to incorporate these patterns to gait-specific standing exercises.
Strengthen the Spine
People with chronic illness tend to slouch. If you trip, have a fear of falling, or have bad balance, then you might tend to spend a lot of time looking down when you walk. In this position, breathing capacity is diminished, which causes a critical loss of oxygen to the brain and motor system. A strong spine improves posture, breathing, balance, and gait.
Address Pelvic Floor Muscles
Bladder and bowel problems are common in those with neurological illnesses or injuries. Pelvic floor muscles can also be affected from poor hip stability and weakness. It is important to refer all patients to a pelvic-focused PT that will address the pelvic floor and how it responds to movement.
Of course, you already know you should praise your client. But in terms of neuroplasticity, praise can actually help new motor learning “stick” by boosting dopamine – a key neurotransmitter that makes you feel happy and helps to consolidate brain map changes.
Good Homework Exercises Are a MUST
Recovery takes time, and a home exercise program is the key to recovery. A good home exercise program should include any exercises that a patient can successfully complete during the session and that can easily fit into their day. While exercises should be specific to certain areas, it is also a good idea to choose an exercise that challenges as many new movement patterns as possible without confusing the client. Using a unique scientifically backed, studio-tested program like TheNeuroStudio.com can free up more time in your sessions to reach goals. It is an online platform that provides patients with exercises specific to neurological symptoms such as foot drop, spasticity, weakness, gait, and bladder/bowel. It also provides shorter workouts that can be layered to create a full-hour workout to supplement what is being done in the clinic. PTP
Meghann Koppele Duffy, MA, NCP, is a renowned Pilates educator who conducts workshops internationally that have educated physical therapists, Pilates teachers, and personal trainers with a focus on neurological diseases including stroke, multiple sclerosis, Parkinson’s disease, and common neurological conditions and injuries. She has a master’s degree in applied physiology from Columbia University and is a co-founder of TheNeuroStudio.com, an online education tool for people with neurological conditions. For more information, contact PTPEditor@medqor.com.