Table 3

Examples of techniques for specific symptoms to normalise movement

SymptomMovement Strategy
Leg weaknessEarly 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 weaknessElicit 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 weaknessElicit 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 disturbanceSpeed 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 tremorMake 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 tremorSide 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 dystoniaChange 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/MyoclonusMovement 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.