Goal: 0 Percent Dorsiflexion (Adventures in Neurorehabilitation)

Today marks Day 1 of a 2-week exploration of neurorehabilitation at The Kennedy Krieger Institute in Baltimore – one of the nation’s premier spinal cord rehabilitation centers. (Multiple sclerosis is, in case you’re wondering, considered a spinal cord injury).

Most people with my functional ability would be happy with the mobility they have, especially after living almost an entire adulthood with multiple sclerosis. I am not most people. I don’t want good function. I want to get back every shred of lost function… and also to be able to do press up handstands (which wasn’t something I could do… or tried to do… pre-MS).

At times, it’s hard to walk. There have been times where it has been harder than it is currently. There are also days where it is harder than other days. That’s pretty much the nature of MS.

Over the past several years, I have done hundreds of hours of work to try to strengthen and stretch the muscles surrounding my ankle to try to get my leg to work better. And I have maintained the function I recovered from when it was “worst” to “now.” Actually, it improved a lot, but it’s been about three years since things were at their worst, and about 2 years since things have been better and stable. I work almost every day to keep things at my current ability. But I want more improvement than I’ve been getting.

For those of you who have taken my course, you know that one of the most challenging things to work around is spasticity, and it’s my number one problem. Spasticity is abnormal muscle tone that’s common in neurological diseases. When one muscle is incredibly tight, it makes it nearly impossible for the opposing muscle to function correctly.

I came into Kennedy Krieger assuming I would see a lot of my friend, the goniometer. It reminds me of the protractor we used in geometry (my least favorite math subject ever!) and it’s used to measure range of motion of joints. It also measures how soon an active spasm kicks in to limit mobility.

To walk properly, you need about 10 degrees of dorsiflexion of your foot (meaning you can lift your foot up – toes towards your shin 10 degrees off of the floor). When I am lying down on my back, I have -25 degrees of active dorsiflexion (meaning how much I can make my foot move to my shin). So, I’m about 35 degrees from proper function. For me, the main reason for that immobility is that I have so much tightness in my calf muscles, my Achilles’ tendon, the fascia (we think), and there’s also probably some stuff going on with the joint capsule itself. I know from previous MRIs that I have chronic joint effusion (water on the ankle joint) and inflammation of the synovial sack (that makes that fluid). Whether those problems are from the improper movement or contributing to it is a mystery. Perhaps I’ll solve it this week.

First, my PT for the week, Kristen, strength tested all of my leg muscles (scores are from a 0-5, with 5 being perfect). My left leg dorsiflexors are a 3. Most other muscles are a 4 or a 5. I have spasticity in my left calf and quad (which I knew).

Next, we did a 6 minute walk to see how far I could go (1,360 steps). That’s pretty slow. The faster I walk, the more my calf tightens up, so you’ll never see me speed walking. Kristen noticed that my feet like to pronate (roll in) and that my dorsiflexion worsened over the course of the walk. I will say that today was/is a good walking day, so my leg wasn’t showing off it’s neurological issues as much as it could. Often my left leg will also hyperextend when I’m walking (that’s quadriceps spasticity), but that didn’t want to show itself today.

After the stroll, she strapped a belt around my waist that was attached to a computer to measure my gait – it measured pelvic stability (mine is pretty much perfect- thanks Pilates!), stride length, stance time, push off, etc. from one side to the other. My push off was much better on my right leg (stronger calf) and my stride length was longer on that side. When I added in my Walk-Aide (an electrical stimulation device that helps lift my foot into dorsiflexion at the exact right time during gait), I had a more even stride length AND I had a better push off of my left foot. This seemed weird because the device is stimulating the opposite muscle to the one that pushes off, but makes sense when you realize that the left foot has a better heel strike and opportunity to roll through the foot and use more of the force available in the plantar flexor (calves) to walk.

We did about 7 different walks- barefoot, shoes, shoes with orthotics, shoes with different orthotics, shoes without orthotics and with Walk-Aide, and shoes with orthotics and Walk-Aide. The last one yielded the most even gait, so makes sense for me to (continue to) incorporate in my gait training that I’ve been doing. Evidently, I also slightly posteriorly tilt my pelvis when I’m walking (probably to make it easier for my weak left hip flexor to lift my leg). In standing, my pelvis is slightly tilted the opposite direction (anteriorly).

So, we collected some data over a couple of hours. But the dilemma of the tightness remains.

Kristen introduced me to the Galileo, a vibration plate that is used for many neuromuscular issues, as well as to improve strength, balance, and bone density. The Galileo is actually the reason I wanted to come to Kennedy Krieger in the first place. I’ve tried a LOT of things for my left leg over the past decade. I have not tried this.

When people think vibration plates, what generally comes to mind is the Power Plate. They’ve pretty much cornered the market in fitness, but when you’re looking at neurorehab, the Galileo and its types and frequency of side-to-side oscillation have many more scientific studies backing them up. I’m not saying the Power Plate can’t be used for it or won’t work. I have no idea – never been on one. If you have – let me know!

After I used it (3 sets of 2 minutes – 1 standing, 1 standing doing squats, and 1 standing on my left leg only), we immediately measured my active dorsflexion, which had improved from -25 degrees to -18 degrees. Cool! The issue is that this change in spasticity is not shown to be a lasting change… BUT, the question is whether you can use that temporary improvement to work on exercises and stretches in a new, better range of motion that will ultimate improve mobility.

So, Kristen set our goal of getting my foot to an active 0 degrees of dorsiflexion by the end of the next two weeks. Which, honestly, is super ambitious and will be pretty unbelievable if we get there. Some of the things she wants to look at are splinting my leg at night (been there, done that), dry needling (done that, too), aquatic therapy (never tried that one), and joint capsule manual mobilization (haven’t done that one).

Tomorrow, I’m told I’ll have to do running, skipping, jumping tests. I can tell you in advance that I will suck at these. Did I ever mention I was a straight A student. Failure is not fun for me…

On that note, I forgot to mention that my proprioception is pretty much perfect. I do a lot of Pilates.

In health,

Mariska

Neurological Medications and Their Impact on Exercise

Most neurological clients are on multiple medications, both to manage symptoms and in the cases of chronic diseases such as MS and Parkinson’s disease, to slow disease progression.

What does that mean for you as a teacher?

First, you need to understand that many of the medications for neurological symptoms cause… wait for it… neurological symptoms. That’s right – dizziness, confusion, depression, tremors, and more can all be symptoms of these drugs. So, knowing someone’s medications and the side effect profile for them is important.

In terms of some interesting specifics, anti-spasticity medications such as Baclofen and Zanaflex are spinal muscle relaxers which relax all of the muscles in the body – those that are in spasm and those that are not. They causes dizziness, similar to having had a couple of drinks. Plus, muscles that are in spasm appear to be toned when they are actually quite weak. When someone takes a spinal muscle relaxer, you will be able to see the true strength (or rather, weakness) of the muscle you otherwise might confuse as being stronger. That means you WANT them to be taking the medication before you work with them so you are seeing how strong they actually are.

Some clients may be on a Baclofen pump, which delivers the medication to the intrathecal space directly to the spinal cord. This enables a lower dose of the medication, but it also has an internal pump that limits flexion and rotation.

Steroids, which are commonly used for MS relapses and other inflammatory neurological diseases, are notorious for causing bone weakness, including osteopenia and osteoporosis. So, if you’re working with a client with a history of steroid use, you will want to know if he or she has had a bone density test, and adjust your workout accordingly, following osteoporosis protocols as needed.

Finally, many of the MS drugs are injectables, and a common side effect is injection site reaction, causing painful welts and bruises. Putting pressure on these spots (often the outer hips) can be quite uncomfortable. So you would have to modify side lying positions.

My best advice? Get a run down of your client’s condition AND their medications, and do some research. Make a plan around both their condition and the medications that accompany it.

In health, 
Mariska

Improving Dizziness with Exercise

Improving Dizziness with Exercise

October 6th, 2015 by mariska

If a client comes to you and says the word “dizzy,” that should be your cue that there is something amiss with either the vestibular system or the nerve pathways that send its information to or from the brain.

The vestibular system is one of the three neurological keepers of balance (the other two being vision and proprioception).

To understand working with vestibular disorders, you first need to understand how the vestibular system works. The vestibular complex is located in your inner ear, and it’s made up of the otolith organs (utricle and saccule) and the semicircular canals. Sense receptors located within them tell your brain if you are moving, how fast, and in which direction. When something goes wrong, you will feel dizzy, like you are on a rocking boat. You might even get sick to your stomach.

For serious vestibular disorders, you need to work with a physical therapist or Ear, Nose, and Throat doctor who specializes in the vestibular system. But for mild vestibular weakness, you can see great improvements, just by adding head turns to your exercise.

Why?

When you move your head, you literally “shake up” the vestibular system. And if you’re prone to getting dizzy, this actually desensitizes you to that sensation, ultimately making the dizziness lessen and your balance improve. In the Pilates environment, the reformer is also a great tool, since it adds forward/backward movement to most exercises. Add a head turn on top of it, and you’re working the otolith organs and the semicircular canals all together.

An easy exercise is to do footwork on the reformer, turning your head to the right as you press out, then center as you return the carriage. Then turn your head in the opposite direction. Repeat several times.

A (much) tougher exercise is to do lunges on the reformer or leg presses on the chair, adding a head turn as your knee comes in, and turning your head to center as it presses away.

No reformer? If your gym has a treadmill, try walking on it holding on to the rails and turn your head to each side, up and down, up to the right and left, and down to the right and left. For most people who have vestibular problems, one direction is going to be worse than others. So, do that one the most.

If you don’t feel a difference, definitely head to a doctor to find out if there’s something more serious going on.

In health,

Mariska

To learn more about all of the aspects of balance, you can check out Wobbly: A Balance Workshop on Pilates Anytime. Not a member of Pilates Anytime? Sign up here for a free 30 day trial! (That’s plenty of time to watch the workshop at a discount and check out all of their wonderful content!)

Understanding Fear of Heights (and Falling)

You stand perfectly well on the sidewalk, but if you’re up on a box or ladder, you start to feel wobbly. Ever wonder why?   The fear of heights is a common one. Actually, fear of heights is slightly different than the true fear most people have – the fear of falling. The fear of falling is hard-wired. It’s one of the only fears you are born with (the other is the fear of loud noises).

When you’re working with clients in exercises that challenge balance, there will be the natural fear of falling. The best way to fix that fear is to practice with progressions that make people feel more secure.   Move from positions that have four points of balance (such as long stretch on the reformer) to a more challenging (less balanced) four points like standing splits on the reformer with both hands on the footbar. From there, create three points of contact, such as with standing splits with one hand reaching forward and the other on the footbar.

How else can you create three points of contact? For exercises like lunges on the reformer, simply push the forward knee into the footbar. That extra feedback into the shin will help you feel more secure until you feel balanced enough to have just two points of support (your feet). If you have a standing platform, use it to create a more stable base for the forward foot.

Three points of support is actually nothing novel. Look at rock climbers. They usually have three points (hand, hand, and foot; or foot, foot, and hand) attached at any time. By only letting one limb go at a time, they feel more grounded (or attached to the mountain, in this case).

But what about the fear of heights? What’s that about? And how does it affect a workout?

Fear of heights is linked both to fear of falling and to the disorientation you feel when things don’t look the same as you’re used to seeing them.

Let’s say you’re doing Going Up Front on the chair. The Wunda chair isn’t a terribly high surface upon which to be standing, but the world does look different from up there. If you’re 5’6” tall, you’re accustomed to seeing things from either your standing, seated, or supine height. You are hardly ever higher than that. Even doing a side plank on the mat and turning your head to look up can be disorienting (or it might throw you off balance if your vestibular system needs some work).

As a teacher, don’t discount people’s fears. But encourage them to face them with smart progressions. Know that neurologically, overcoming a fear will give your client a burst of dopamine that is a happy “brain drug” that helps create neuronal pathways that will help the memory of that accomplishment stick, making it easier to do the challenging balance exercise over time.

In health,

Mariska

Want to learn more about balance, fear of heights, and neuroscience? Check out Wobbly: A Balance Workshop on Pilates Anytime, come to one of our workshops, follow Pilates for MS on Facebook, or sign up for our newsletter!