Examples of techniques for specific symptoms to normalise movement
| Symptom | Movement Strategy |
|---|---|
| Leg weakness | Early weight bearing with progressively less upper limb support, eg, ‘finger-tip’ support, preventing the patient from taking weight through walking aids/supporting surfaces |
| Standing in a safe environment with side to side weight shift | |
| Crawling in 4 point then 2 point kneeling | |
| Increase walking speed | |
| Treadmill walking (with or without a body weight support harness and feedback from a mirror) | |
| Ankle weakness | Elicit ankle dorsiflexion activity by asking the patient to walk backwards, with anterior/posterior weight shift while standing or by asking the patient to walk by sliding their feet, keeping the plantar surface of each foot in contact with the floor |
| Use of electrical muscle stimulation | |
| Upper limb weakness | Elicit upper limb muscle activity by asking the patient to bear weight through their hands (eg, 4 point kneeling or standing with hands resting on a table) weight bearing with weight shift or crawling |
| Minimise habitual non-use by using the weak upper limb functionally to stabilise objects during tasks, for example, stabilise paper when writing, a plate when eating | |
| Practise tasks that are very familiar or important to the individual, that may not be associated with symptoms eg, use of mobile phone, computer and tablet | |
| Stimulate automatic upper limb postural response by sitting on an unstable surface such as a therapy ball, resting upper limbs on a supporting surface | |
| Gait disturbance | Speed up walking (in some cases, this may worsen the walking pattern) |
| Slow down walking speed | |
| Walk by sliding feet forward, keeping plantar surface of foot in contact with the ground (ie, like wearing skis). Progress towards normal walking in graded steps | |
| Build up a normal gait pattern from simple achievable components that progressively approximate normal walking. For example—side to side weight shift, continue weight shift allowing feet to ‘automatically’ advance forward by small amounts; progressively increase this step length with the focus on maintaining rhythmical weight shift rather than the action of stepping | |
| Walk carrying small weights/dumbbells in each hand | |
| Walking backwards or sideways | |
| Walk to a set rhythm (eg, in time to music, counting: 1, 2, 1, 2…) | |
| Exaggerated movement (eg, walking with high steps) | |
| Walking up or down the stairs (this is often easier that walking on flat ground) | |
| Upper limb tremor | Make the movement ‘voluntary’ by actively doing the tremor, change the movement to a larger amplitude and slower frequency, then slow the movement to stillness |
| Teach the patient how to relax their muscles by actively contracting their muscles for a few seconds, then relaxing | |
| Changing habitual postures and movement relevant to symptom production | |
| Perform a competing movement, for example, clapping to a rhythm or a large flowing movement of the symptomatic arm as if conducting an orchestra | |
| Focus on another body part, for example, tapping the other hand or a foot | |
| Muscle relaxation exercises. For example, progressive muscle relaxation techniques, EMG biofeedback from upper trapezius muscle or using mirror feedback | |
| Lower limb tremor | Side to side or anterior-posterior weight shift. When the tremor has reduced slow weight, shift to stillness |
| Competing movements such as toe-tapping. | |
| Ensure even weight distribution when standing. This can be helped by using weighing scales and/or a mirror for feedback | |
| Changing habitual postures relevant to symptom production. For example, reduce forefoot weight bearing | |
| Fixed dystonia | Change habitual sitting and standing postures to prevent prolonged periods in end of range joint positions and promote postures with good alignment |
| Normalise movement patterns (eg, sit to stand, transfers, walking) with an external or altered focus of attention (ie, not the dystonic limb) | |
| Discourage unhelpful protective avoidance behaviours and encourage normal sensory experiences (eg, wearing shoes and socks, weight bearing as tolerated, not having the arm in a ‘protected’ posture | |
| Prevent or address hypersensitivity and hypervigilance | |
| Teach strategies to turn overactive muscles off in sitting and lying (eg, by allowing the supporting surface to take the weight of a limb. Cushions or folded towels may be needed to bring the supporting surface up to the limb where contractures are present) | |
| The patient may need to be taught to be aware of maladaptive postures and overactive muscles in order to use strategies | |
| Consider examination under sedation, especially if completely fixed or concerned about contractures | |
| Consider a trial of electrical muscle stimulation or functional electrical stimulation to normalise limb posture and movement | |
| Functional Jerks/Myoclonus | Movement retraining may be less useful for intermittent or sudden jerky movements. Instead, look for self-focused attention or premonitory symptoms prior to a jerk that can be addressed with distraction or redirected attention |
| When present, address pain, muscle over-activity or altered patterns of movement that may precede a jerk |
EMG, electromyography.