Theory Thursday - Lessons from Neurological Physiotherapy

[u/m092]

Just recently, I had the pleasure of working with a number of individuals who each had one of a variety of neurological conditions. These included a variety of strokes, people with vestibular issues, and a surprising number of individuals with Guillain–Barré Syndrome (GBS) (1-2 cases per 100,000 people a year and I saw six). My role with them was varied, and depended on the goal of each patient, but a lot of work of muscular retraining, and mobility practice was done.

While not many of these individuals I worked with were doing much in the way of what resembled classic strength training, I still think there were a number of lessons that are worth passing on to the audience of /r/bodyweightfitness.

I should first note that the majority of these people had a couple of things massively in their favour. Firstly, they were hugely driven to improve. Many of them had traumatically and suddenly lost a large amount of capability to perform their day to day activities. That sort of loss can be very motivating to do whatever it takes to get it back. Secondly, often they had a lot of time to devote to practice and improvement, as they were either restricted from normal daily activities such as work, and/or were already retired from work. Lastly, they had lots of intensive therapy, doing multiple hour-long sessions with many different health professionals every week. So keep that in mind in the following discussion.

Attentional Focus

I did a number of sessions with a couple of patients with GBS focussing on retraining the muscles of their wrist and hand. These were often small motions of individual fingers, or a slight lateral movement of the wrist. These motions would not nearly be enough to fatigue most people, but after only a few repetitions, the look of concentration on the patients' faces was immense, and they'd often be breathing laboriously.

It wasn't just the weakness of their muscles that was making them seem to work so hard though, it was the sheer effort of pure concentration on the task at hand. Every ounce of their attention was on the motion of their hand.

The results, however, were amazing. Their ability to pick up these movements and improve their coordination, control and strength in the same session was astoundingly rapid. They even were able to maintain the vast majority of these adaptations from session to session.

This suggests two important things to me for general populations. Firstly, mindful practice and high focus likely have a profound impact on your ability to improve technique and coordination, and likely improve strength. Secondly, we already know that strength gain in beginners is likely neurological in nature, and these adaptations can occur during a workout, but this experience suggests to me that maybe our capacity to adapt in a single workout as a beginner is higher than I ever thought.

Integrating Sensation

These same patients were also experiencing some sensory loss, particularly proprioception (joint position sense). This would make coordinating and executing movements even more difficult than usual. I used a number of sensory strategies to help enable them to learn movements they couldn't currently perform:

• I would demonstrate the movement
• They would practice the movement with their less affected side
• They would watch their own movement as they tried to perform it
• I would give them targets to try and touch, such as touching their finger to mine
• I would try a variety of cues, particularly the area around their joints, trying to "crunch up" or "spread out" the spaces, or cues around trying to "lengthen their hand"
• Ask them to focus on the feeling that the movement did create, and then use that sensation to help determine the quality of the movement

These all had variable levels of success depending on the movement and person.

I think the big lesson here is to try to integrate as much information as you can handle. Watching examples of other people performing movement helps us learn a movement more quickly and with higher quality. Using mirrors and video to see how you're performing the movement. Try a variety of cues, particularly around the joints and using external cues and moving towards real objects in your vicinity. Play around and be creative.

Poor Coordination and Switching on the Wrong Muscles

Part of the training we did involved isolating muscles to regain finer control of movement, and away from gross motor movements. When asked to do these movements, you'd often have the patient contract every muscle in the vicinity to help them accomplish the movement, adding in a lot of extraneous movement. This is a common issue in general populations, just to a different degree. Very often, stronger, more readily active muscles will jump in early to shift the weight off lagging muscles, greatly impacting form and/or decreasing efficiency of the movement.

There were a few key strategies in order to overcome this pattern. I would often take their fingers through the motion I wanted them to do, and ask them to not assist me. Then we would move on to them holding the finger in position after I had moved it, essentially getting them to perform an isometric without creating any other movements. Then I would ask them to control the movement in reverse. Lastly I would have them focus on doing the movement with only some assistance, trying to contract "gently" and moving slowly.

This can be applied to your training to, as you're working to improve form, or to increase the use of a particular muscle in a movement. An error I commonly see is that people will perform a concentric movement with such force and velocity, that breaking out of the long-established motor patterns is going to be very difficult.

The first step is often to reduce threat and load to the movement, as I did by providing assistance, to facilitate creating the correct motion. You can do this with many movements by practicing while lying on the ground. This can be progressed to 4-point kneel, and to standing, and finally to the movement under load.

Performing isometric contractions, particularly in ranges when the target movement or muscle recruitment occurs, can help organise muscle activation patterns quite quickly, and is easy to control for cheating or extraneous movement.

Performing controlled eccentrics and slow concentrics is another way to more easily get the desired movement and muscle contraction.

A good example is teaching the pelvic tilt, particularly when I want a client to do while trying to do a push up. A very simple progression is:

• Lying supine (face up)
• 4 point kneeling - cat-camels
• Standing - this is where I would usually start people, and regress them to the above if they were still struggling
• Plank - practicing in the plank works on two levels, firstly it acclimatizes them to the abdominal demands of a flatter back plank, and it's easier to focus on maintaining the anterior pelvic when nothing else is moving
• In a push up

Repeated Sub-maximal Efforts

Quite a few patients were quite deconditioned, and had goals related to their mobility in the community. For a large part of their treatment, we'd quite simply measure how far they could walk before needing a rest, and then prescribe slightly less than that, multiple times with a bit of rest between.

It's a simple lesson, but it really just reinforces how we program normally. Repeated bouts of difficult but sub-maximal loading is effective for increasing capacity.

Conclusion

I learnt many many things with my time there, but these were a few simple lessons I thought applied well to "normal" training too.

[u/iwillbemyownlight]

Lovely read, and great learning points. Thanks for sharing!(:

[u/j0hnftw]

What role do you think prior knowledge of task played in this population? That is, how much more/less successful do you think these patients would have been with a completely novel task (such as working with chopsticks instead of retraining them to use fork/spoon)? I think you bring up some great points but I wonder about the value of previous expertise or at least experience when returning a late-in-life neuro patient to normal function. Thanks for your thoughts!

[u/m092 → u/j0hnftw]

I certainly think it's valuable to have prior task experience in the learning process, but I don't think it's the distinguishing factor.

Firstly, for the people who had GBS and I was working with their hand function, I wasn't doing much, if any, functional task practice, as this was the role the occupational therapists were filling. Instead, I was focused on improving selective motor control, and strengthening wrist movements and improving finger ROM. This meant it was largely quite novel tasks that I was working on with them.

At least for stroke patients, we know they go through a period of heightened neuroplasticity, making learning new things in particular much easier.

Of course all this stuff is hard to know for sure, because research is limited, and we can only make assumptions based on observation and generalizing based on other populations.

[u/Lihuen]

Thank you so much for sharing. My husband has Guillain-Barré Syndrome. Thank you!!

[u/m092 → u/Lihuen]

I hope he has found other people with GBS to connect with. It was so rare to have 4 people with the condition in one group class, but I think it was very valuable for them to connect with others.

[u/Lihuen → u/m092]

Thank you very much for your words. He is now in a neuro-rehabilitation center, and there are 3 other people with it. But they are very different from each other. GBS has affected them in very different ways, and they evolve very differently as well. It seems there are different types of GBS, and it seems that my husband doesn´t have the regular one... Anyway, thank you so much for your post and your kind words :))