Neuromuscular re-education consists of manual techniques (PNF-proprioceptive neuromuscular facilitation), activities for balance and core control (Bosu exercises and Therapeutic Ball exercises) and other therapeutic exercises that are designed to re-develop normal, controlled movement patterns. The goal of neuromuscular re-education activities is to re-train a body part to perform some task that the body part was previously able to do.
When is Neuromuscular Re-education Employed?
Neuromuscular re-education techniques may be applied in a range of situations. In our setting, the need to re-establish normal kinesthetic sense and proprioception of the Cervical, Thoracic, Lumbar spine and Appendicular skeleton is critical to eliminate many of the symptoms that a patient presents with during their treatment time. When these neurological characteristics are not functioning properly, a patient cannot maintain proper posture and many of the muscles of the involved area do not function properly.
A range of techniques may be used to “retrain” the nerve signals and rebuild muscle memory through repeated, movement patterns. Multiple muscle physiology and strength training journals agree that neural adaption precedes a strength change in the form of hypertrophy or hyperplasia of the muscle cells. The patient experiences increased strength in the first 3-4 weeks based on this neural adaption. It is referred to as an enhancement of neurological “communication” with the motor end plate and the number and frequency of neural impulses is increased within a particular motor unit. This helps to re-establish and re-educate the “normal” neural control that is needed for a patient to experience movement patterns that do not have abnormalities, which can lead to musculoskeletal conditions.
Anyone who has spent any time in the out-patient orthopedic physical therapy setting has witnessed the loss of neuromuscular control in an involved body part. Pain, inflammation and swelling due to surgery or traumas like rotator cuff injuries can lead to loss of neural muscular control and abnormal movement. Healthcare professionals can attest to the fact that in these situations the muscle cannot perform any action without a neural impulse.
A denervated muscle (the nerve cannot transmit a neural signal to the muscle) can be stimulated with an exterior direct electrical current, but is 100% non-functional (paralyzed) if the nerve is not capable of delivering the electrical impulse to stimulate the motor end plate and begin the contraction process. Any reduction in neural input to that muscle’s motor end plate(s) will have a negative effect on the muscle’s ability to function properly.
Many of our patients have general tenderness, hypo-mobility and decreased motion of a joint(s). It is necessary for a joint(s) to have full motion to be fully functional. If the joint does not articulate through its full range of motion via muscle contraction, there will be weakness and functional limitations that will develop over time. This time period is different for every patient, but several weeks to months is not out of the ordinary when the symptoms are not treated properly. Any loss of motion and strength needs to be addressed to eliminate the patient’s symptoms and correct the “problem.” Re-education of the nervous system must occur prior to developing enough strength and motion to regain full function. Without the neuromuscular re-education process, there is no way that the “normal” movement patterns can be re-established.
Neuromuscular re-education plays a major role in the out-patient, orthopedic Physical Therapy setting. If the proper techniques, activities and exercises are not performed on an injured body part, an acute injury can develop into a chronic situation. Most of the active rehabilitation treatments that occur in the acute and sub-acute phase of healing are truly re-educating the nervous system more than dealing with the muscles and other soft tissue. Re-developing normal movement patterns and functional capabilities can only occur if the nervous system is in control of the musculoskeletal system.
After Stroke Rehabilitation
Stroke is the number one cause of serious adult disability in the United States. Stroke disability is devastating to the stroke patient and family, but therapies are available to help rehabilitate patients after stroke.
For most stroke patients, rehabilitation mainly involves physical therapy. The aim of physical therapy is to have the stroke patient relearn simple motor activities such as walking, sitting, standing, lying down, and the process of switching from one type of movement to another.
Another type of therapy to help patients relearn daily activities is occupational therapy. This type of therapy also involves exercise and training. Its goal is to help the stroke patient relearn everyday activities such as eating, drinking and swallowing, dressing, bathing, cooking, reading and writing, and using the toilet. Occupational therapists seek to help the patient become independent or semi-independent.
Speech therapy helps stroke patients relearn language and speaking skills, or learn other forms of communication. Speech therapy is appropriate for patients who have no problems with cognition or thinking, but have problems understanding speech or written words, or problems forming speech. With time and patience, a stroke survivor should be able to regain some, and sometimes all, language and speaking abilities.
Parkinson’s Rehab
It’s well-known that exercise of all kinds is beneficial for patients with Parkinson’s disease. But physical therapy, in particular, is key. Why? A professional can guide you through the right moves to increase mobility, strength, and balance, and help you remain independent, says Denise Padilla-Davidson, a Johns Hopkins physical therapist who works with patients who have Parkinson’s. Here are things a therapist may work on:
Note: Please discuss any exercise program with your physician/neurologist and get a referral to a physical therapist or trainer with expertise in Parkinson’s disease before starting any specific program.
Amplitude Training
A specific form of physical therapy for Parkinson’s disease is called LSVT BIG training. (LSVT is Lee Silverman Voice Treatment. LSVT LOUD is therapy to amplify the voice.) “It’s meant to help patients with Parkinson’s increase what we call ‘amplitude of movement,’” says Padilla-Davidson. In LSVT BIG, you make overexaggerated physical movements, like high steps and arm swings. It’s a way to retrain the muscles and slow down the progression of hypokinesia, the increasingly smaller, more shuffling movements that happen with Parkinson’s. Ask your doctor or physical therapist about LSVT BIG.
Reciprocal Patterns
Reciprocal movements are side-to-side and left-to-right patterns, such as swinging your arms while taking steps as you walk. Parkinson’s disease may affect these patterns. Your therapist may help you reinforce reciprocal patterns by the use of a recumbent bicycle (a stationary bike in which you sit in a reclined position) or elliptical machine (in which you use your arms and legs). On your own, says Padilla-Davidson, “Practice walking, keeping in mind the swinging of your arms. It may help to chant or sing to keep the rhythm.” Dance classes and tai chi are also useful.
Balance Work
Normal balance, explains Padilla-Davidson, is an interplay among what you see (visual feedback), your inner ear (which helps you orient yourself) and how your feet sense the ground beneath them. Parkinson’s disease can affect this balance system, making your gait (how you walk) unstable, which in turn may make you fearful to be in public or crowded spaces. Gait training (practice walking) can help. Exercises that aim to improve balance should be guided by a physical therapist, who can work with you to understand any issues with balance and teach you ways to compensate.
Stretching and Flexibility
It’s common for patients with Parkinson’s disease to develop tight hip flexor, hamstring and calf muscles. To counteract that stiffness, it’s best to stretch at frequent intervals throughout the day, rather than just once, says Padilla-Davidson. Ask a qualified trainer or therapist who specializes in Parkinson’s to show you how.
Strength Training
Muscles naturally weaken with age, so strength training is important for everyone. But research suggests that muscle weakness is a bigger problem for patients with Parkinson’s disease, says Padilla-Davidson. Depending on what stage of the disease you are in, a therapist might have you do resistance exercises with light dumbbells or a resistance band (a kind of thick rubber band). Pool-based classes, using the water’s resistance to strengthen muscles, can also be a good fit, she says.
LSVT
What is LSVT, and How Does it Help Parkinson’s Disease?
As Parkinson’s Disease progresses, patients start to lose their ability to walk, talk, and complete activities of daily living. The Lee Silverman Voice Technique (LSVT) is a proven therapy that helps patients with Parkinson’s Disease, a neurological condition that affects nerve cells in the brain responsible for body movement. Patients learn to do things big and loud by exaggerating movements or talking a little louder.
Parkinson’s Disease Awareness Month
April is Parkinson’s Awareness Month! Physical and occupational therapy can help and includes specialized programs such as LSVT LOUD and LSVT BIG, which help patients manage symptoms and improve their quality of life. PT includes general conditioning exercises, functional training, and gait and balance training. Therapists also can offer strategies to safely transfer to and from the bed, in and out of the shower, and other daily activities.
LSVT therapy is an effective, evidence-based approach to treating Parkinson’s disease. LSVT treatment programs have been scientifically and clinically proven to improve the balance, walking, and general movement and speech patterns of patients. Through targeted and repetitive exercises, the therapy takes advantage of the brain’s ability to adapt and form new neural connections. This neuroplasticity enables people to create new motor skills and language memories and apply them in real-world situations.
Four Common Symptoms:
- Tremors
- Limb and trunk stiffness
- Bradykinesia, or the slowing of movements
- And weak balance or coordination
PD symptoms progressively get worse over time and patients can have difficulty with daily tasks such as getting out of a chair, getting dressed, and even walking, talking, and swallowing.
LSVT Big Therapy vs. LSVT Loud Therapy
LSVT therapy has two distinct treatment types, namely LSVT Big and Loud. LSVT big treatment is a form of physical therapy that addresses a patient’s motor function. Meanwhile, LSVT loud therapy is a form of speech therapy that helps Parkinson’s disease patients speak louder by stimulating their voice box muscles.
LSVT LOUD leads to functional improvements by addressing the internal aspects of symptoms, particularly impaired voice and swallowing function. Certified LSVT practitioners help people “recalibrate” their perceptions to know how loud or soft they sound to other people and maintain improved speech patterns and volume. An LSVT program trains vocal loudness in order to “enhance voice source,” and use vocal loudness for improved articulation, vocal quality, intonation, etc.
“LSVT LOUD trains people with PD to use their voice at a more normal loudness level while speaking at home, work, or in the community,” according to the LSVT website.
With LSVT BIG, patients learn how to use their bodies more normally through exercises that involve large and exaggerated movement patterns. Larger movements help patients move better, with more confidence and safety, whether that involves small motor tasks such as buttoning a shirt or maintaining balance while walking.
What Happens After LSVT Treatment?
Studies show that for LSVT LOUD, the sooner the treatment is completed, the more benefits the patient gets from it. Vocal loudness after completion can last 2 or more years with continuous daily practice after one month of initial treatment.
LSVT BIG treatment spans at least a month or more and includes daily practice and exercises. After your initial treatment, you’ll continue your exercises at home at least once daily for 10 to 15 minutes. However, LSVT is a continuing life journey for people with Parkinson’s Disease. Recommended additional exercises and treatment include:
Periodic “Tune-Up” Sessions – Tune-up sessions are recommended so your physical therapist can provide you with a reassessment and offer motivation and feedback on your progress. This is done to maintain the benefits of initial therapy.
Join Exercise Groups – Patients are encouraged to join and be active in community-based exercise groups of people who have completed LSVT.
Homework videos – Allows patients to practice their home exercises daily.
Fall prevention
Falls and fall-related injuries, such as fractures, are a growing problem among older adults, often causing longstanding pain, functional impairments, reduced quality of life, and excess healthcare costs and mortality.
These problems have led to a variety of single-component or multicomponent intervention strategies to prevent falls and subsequent injuries. The most effective physical therapy approach for the prevention of falls and fractures in community-dwelling older adults is regular multicomponent exercise; a combination of balance and strength training has shown the most success.
Home-hazard assessment and modification, as well as assistive devices, such as canes and walkers, might be useful for older people at a high risk of falls. Hip protectors are effective in nursing home residents and potentially among other high-risk individuals. In addition, the use of anti-slip shoe devices in icy conditions seems beneficial for older people walking outdoors.
To be effective, multifactorial preventive programs should include an exercise component accompanied by individually tailored measures focused on high-risk populations. In this Review, we focus on evidence-based physical therapy approaches, including exercise, vibration training, and improvements in safety at home and during periods of mobility. Additionally, the benefits of multifaceted interventions, which include risk factor assessment, dietary supplements, elements of physical therapy, and exercise, are addressed.
