Training in
neurorehab

Training in neurology

and geriatrics

Using various neurological and geriatric clinical pictures and symptoms, we want to show how an effective training scheme can be designed. In this series, we will consider stroke, multiple sclerosis (MS) and Parkinson's disease as the three most common diseases in neurology and, with the exception of MS, also in geriatrics. In a further instalment, we will deal with the importance of training for older people.

Text: Sabine and Hans Lamprecht

An important finding in recent years in the field of neuro- and geriatric rehabilitation is that training and training principles should be applied to achieve sustainable success.
Training does not always have to take place with devices – training without equipment can also be effective. Devices help to make the training easier to compare and to present objectively, as well as allowing patients to train at their individual performance limit. Increases in performance can be clearly documented and often help motivate the patient to continue training.

If the devices are additionally combined with visual or acoustic feedback, the training effect is often clearer and motor learning is easier. The training motivation is increased if the devices have games in which the patients can earn points, for example. In such cases, patients often do not notice that they are training on the device for much longer periods, and therefore reach a significantly higher performance.

Everyone likes to play – whatever their age

When patients achieve success, the important neurotransmitter dopamine is also released, which brightens their mood and helps with motor learning.

These effects can also be achieved without equipment, but therapists or relatives must then provide the necessary framework conditions. A fun and encouraging atmosphere, plenty of praise and a little competitive spirit are all helpful for the motivation of neurological and geriatric patients. The therapists should offer a lot of praise to the patients undergoing training, and report back to them clear improvements based on figures. [6]

The first instalment in this series deals with stroke, the most common neurological disease in our society.

The prevalence of patients with stroke (CVI = cerebrovascular insult) will continue to rise in the future due to demographic developments and will thus remain a very common clinical picture in both neurology and geriatrics. [3]

The cause of a stroke is either ischaemia, which can often more easily be treated medically – the stroke units provide a valuable contribution in such cases – or, in a significantly lower proportion of patients (approx. 15 to 20%), bleeding, in which case lysis treatment is not possible and more severe progressions can often be seen.

Since the site of the damage is often located in the bend of the middle cerebral artery, hemiplegia of the contralateral side occurs, mainly affecting the arm. It is important to mention this here, because we have stroke patients who cannot move the arm, or can hardly move it, due to the damage site alone. A stroke causes damage to the upper motor neuron (upper motor neuron syndrome, UMNS). This means that patients show a more or less pronounced weakness, while spasticity only develops over the course of time. [4] The more patient activity can be achieved in the early phase, the less spasticity will develop. In the upper extremity, however, flaccid paresis can persist for years.

Effective training for stroke patients

Intensive walking exercises should be started as early as the acute phase [2]. Aids such as walking frames or rollators (with lower arm rests on which the affected arm can be easily supported if necessary) should be used. Often acute wards and stroke units have no gait trainers, but are instead equipped with movement exercisers or a bed bicycle. These should be used for intensive cardiovascular and endurance training. Since a stroke immediately leads to negative symptoms of upper motor neuron syndrome (UMNS), it is absolutely necessary – if possible – to begin training with resistance. In the case of the upper extremity, the arm should be fixed with appropriate aids so that it can be moved.

If weakness occurs when subluxation is present, the patient must be fitted with a shoulder orthosis [5]. Unfortunately, the guidelines state that stroke patients only need a shoulder orthosis if they are able to walk, but this does not correspond to everyday life. If the patient has a painful shoulder or the therapist notices pronounced subluxation, the stroke patient must be provided with a shoulder orthosis at least during training and, if the shoulder is painful, also while in a wheelchair.

In summary, stroke patients need to walk intensively with the help of aids, even in acute rehabilitation, and must also intensively practice gripping. Mobilisation should not only take place in the wheelchair, and patients should not practise while sitting – and certainly not while lying down – if they are able to walk.

More intensive training is necessary in rehabilitation. This is where gait trainers and treadmills come in. For the upper extremity, movement exercisers such as tigo or balance trainers – including those with balancing and step triggering functions – can be used in addition to training of the distal functions.

Stroke: general training principles

There are many indications in studies that training in the aerobic range, for example, improves the cardiovascular situation. The load control should be based on the training control for heart attack patients.

The guidelines of the American College of Sport Medicine and the American Heart Association recommend:

  • Training 3 to 5 times/week for 20 to 40 minutes
  • Training with 50 to 80 % of the maximum heart rate
  • Documentation of the results (10-metre walk test, 6-minute walk test, force test)
  • Strength training always with one leg
  • 10 to 12 repetitions, 3 series
    each with pause


The training should always be at the limit of the patient's performance and be carried out for at least 4 weeks before success can be measured. Many studies have shown that strength training in stroke patients leads to an improvement in the functions trained, with no increase in spasticity or pain. Even high-intensity strength training leads to an improvement in strength and functional abilities.

Training principles with the lyra gait trainer

Speed

At the beginning of rehabilitation, a high number of step repetitions is the goal. International guidelines recommend at least 800 steps. [1] For severely affected patients, these repetition rates can actually only be achieved with a gait trainer.

The walking speed must be set to as quick as possible. Often only a higher speed makes it possible to find the right gait rhythm, improving symmetry and thus making walking easier for the patient. The training is therefore more relevant to everyday life and walking becomes automatic. Even severely affected patients should reach a speed of around 1 km/h in the first sessions. Of course, this depends on the individual – but faster is easier!

Later on, specific attention must be paid to an increase in speed. The higher the speed, the easier it is to walk. For more experienced patients, the minimum speed can be increased to 2.6 km/h. Even the 4 km/h that the lyra goes up to is slower than we would normally walk, but is entirely sufficient for the patients. In general, the patient should not be assisted in any way, as this disturbs motor learning. Remember: if the focus is on speed, the patient can of course hold on to something for support. The patient may and should also look at their feet, as they can learn more effectively from the visual feedback.


Endurance

In addition to speed, the time for which the patient can walk is also a focus. It is important that the patient walks for as long as possible. They can also be allowed to sit briefly on the lyra to rest. The recommended endurance training is interval training at the fastest possible pace, but most importantly for the longest possible time. The metres walked are noted as the target parameter [7]. Step length can also be considered, but this is less important. The most important aspects of gait training are speed and endurance.

Even balance can be trained in the lyra. In this case, the patient should no longer hold on to anything – or only onto mobile objects such as Thera bands. Focus can now be placed on the patient looking right, left and upwards. This will help them train sensory balance. Of course, motor and cognitive dual-task training can also take place.

Weight relief should be minimal and should take place only when necessary, and should be dynamic so that the relief can adapt to the patient's gait. This enables the patient to support their own weight as far as possible.

Training principles with the movement exerciser

Upper limbs

During movement training with the arms, the focus can be either on endurance in the sense of cardiovascular training or on strength with appropriate resistance.

The affected hand should always be moved along with the arm, even if it has to be supported or fixed. If the therapist has concerns about the shoulder, a shoulder brace should be used. If the shoulder is painful, exercise should be carried out on a raised seat or while standing up, so that the arm is not flexed more than 60 degrees. If the focus is on strength, appropriate resistance must be used. In this case, instead of taking a hesitant approach, it is important to determine the patient's performance limit. This is the individual reference point for controlling the strength requirement.

Strength training

Yes. We know that strength is also essential in the upper limbs in order to reduce evasive movements and make activities possible. Damage to the upper motor neuron leads to negative symptoms, which can and must be alleviated with strength training. The DGNR guideline for "Motor Therapies for the Upper Limbs in the Treatment of Stroke" classifies arm pareses according to strength values and recommends strength training.

... even with spasticity
That's right – because the positive symptoms are sustainably reduced by activity or strength training. Functionally, the positive symptoms of UMNS are reduced to the extent that activity or strength is improved. Even with severe arm pareses, activity and individually adapted resistance loosen the arm both temporarily and permanently. If the arm gets tired, a temporary increase in the positive symptoms may be observed.

Limits of tigo training for arm motor skills

As therapists who focus on functional ability and everyday activities, we know that distal function is what makes arm activity possible in the first place. The grasping function must be accorded central importance in therapy of the upper limbs. Training with the tigo does not reach this function – however, the proximal musculature can be usefully trained.

Lower limbs

A movement exerciser allows targeted endurance and strength training of the lower limbs. It is up to the therapist to decide whether targeted endurance training is performed with the upper limbs to achieve the above effects or whether activation of the lower limbs is preferable. Since endurance training requires as much resistance as possible, as quickly as possible and – most importantly – for as long as possible, short breaks should be planned and exercises repeated up to three times.

Note: For all parameters, the patient's performance limit should first be determined and the training should then be individually adapted.

Strength training with the movement exerciser

During training with the tigo, the lower limbs as well as the muscles important for walking (dorsal flexors, calf, quadriceps and hip flexors) are activated. For this reason, resistance training with the tigo is a very sensible supplement to gait training for patients who have suffered a moderate to severe stroke. Here too, it is important to train at the patient's performance limit and to make sure that the affected leg is activated.
The tigo movement exerciser can generally be used for targeted endurance and strength training of both the upper and lower limbs.

Training principles with the balance trainer

The balo balance trainer can simply be used as a standing frame for severely affected patients. It is especially important for severely affected patients to stand during the early phase when walking is not possible.

We know that alertness plays a major role for patients with neglect, so it is better to carry out optical stimulation, gripping exercises or mirror therapy to treat the neglect while the patient is standing up, as they will have a higher degree of alertness than when sitting.
With pusher syndrome, the best approach is to move forwards and backwards with the balo along with visual feedback and games, and then gradually switch from the sagittal to the frontal plane.

Balance training

The patient can practice actively shifting their balance at all levels and thus train proactive balance.
Thanks to the spring resistance, the right side is activated more when moving to the left side and vice versa. If a patient has a hemiparesis on the right side, there should be more movement to the left side. The balance must be actively shifted by the right side. It is also important to work with the spring resistance. If lower spring resistance is set, the balance shifting must be adjusted more finely. This means that the demand on the patient's coordination is higher.

Strength training

And it is thanks to spring resistance that the balo provides an effective and targeted means of training strength.

Generally speaking, step triggering also needs to be trained more frequently during balance training. The balo, when appropriately secured, provides the ideal opportunity for this. Its spring resistance also enables heavier patients to use it for active strength training on a regular basis.

 

 

At a glance - Summarised

  1. Sustainable and effective training in neurological and geriatric rehabilitation should be based on certain training principles in order to achieve long-term success. With the help of equipment, training at the patient's performance limit is easier to achieve and more convenient to compare.
  2. Praise, a certain competitive spirit, and success during training all help to elicit feelings of happiness, increase patients' motivation and aid motor learning. Games also provide more motivation and significantly better performance during training.
  3. Stroke patients, in particular, should undergo intensive training as early as the acute rehabilitation stage – preferably with the use of aids. Both endurance and strength should be trained – at the patient's performance limit if possible.

Literature

[1] Dohle Ch. et al. (2015). S2e-Leitlinie Rehabilitation der Mobilität nach Schlaganfall (ReMoS). In: Neurologie und Rehabilitation 21.

[2] Bernhardt J., Churilov L., Ellery F., Collier J., Chamberlain J., Langhorne P. et al. (2016). Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT). In: Neurology 86 (23), S. 2138-2145.

[3] Foerch Ch. et al. (2008). The projected burden of stroke in the German federal state of Hesse up to the year 2050. In: Deutsches Ärzteblatt international 105 (26), S. 467-473.

[4] Gracies J.-M. (2005). Pathophysiology of spastic paresis. I. Paresis and soft tissue changes. In: Muscle & nerve 31 (5), S. 535-551.

[5] Nadler M., Pauls M. M. H. (2017). Shoulder orthoses for the prevention and reduction of hemiplegic shoulder pain and subluxation. Systematic review. In: Clinical rehabilitation 31 (4), S. 444-453.

[6] Rosenzweig M. R. (1966). Environmental complexity, cerebral change, and behavior. In: The American psychologist 21 (4), S. 321-332.

[7] Wieduwild E. (2012). Ausdauertraining nach Schlaganfall. In: neuroreha 4 (02), S. 88-92.

Authors


Sabine Lamprecht passed her physiotherapy exam in Berlin in 1982. Since then, she has completed various further training programmes. In 2006 she obtained her Master of Science degree in Neurorehabilitation at Danube University Krems, Austria.

From 1983 she worked as lead physiotherapist at Neurologische Klinik Christophsbad where she helped to set up the Physiotherapy Department.

 


Hans Lamprecht has also been working as a physiotherapist since 1982. He founded the Kirchheim regional group in the Baden-Württemberg Association of Physiotherapists.

In 1987, Sabine and Hans Lamprecht opened their own practice together.