Defining when rehabilitation should start seems straightforward.
As soon as an individual is medically stable, evidence shows that it is beneficial for rehabilitation to begin. Starting at this earliest opportunity helps to minimise the effects of deconditioning and inactivity and reduce the risk of pressure sores and contractures. Defining the length of rehabilitation, however, and when it should ‘end’ is more tricky and continues to be subject to debate.
Over the years, guidance has been suggested for the timeframes of rehabilitation. With spinal cord injury, it has been said that the greatest recovery happens in the first six months following injury. It is also commonly cited that after two years it is unlikely for further recovery to occur. However, medical advances and breakthroughs in research are changing this. New and emerging technologies such as spinal cord stimulation are demonstrating that even in chronic injury, the nervous system has the ability for neuroplasticity long after two years post-injury.
Goal setting is a commonly used and exceedingly popular method of guiding length of rehabilitation. This ensures that interventions are guided towards achievements that are meaningful both to the individual and the service provider. However, alongside the physical and psychological needs of the individual, there are many other factors that can impact on the length of rehabilitation, such as their geographical location and circumstances. Service availability, financial constraints and family responsibilities can also all impact on someone’s rehabilitation journey.
Lessons from lockdown
Experience from the Covid-19 pandemic too has given a greater insight into the impact of disruption to rehabilitation.
At Neurokinex, we shut our doors in March 2020 for just over three months when the first UK-wide lockdown was announced. This meant a temporary curtailment to the rehabilitation of all the individuals with whom we worked. When we resumed our activities in July 2020, it gave us first-hand insight into the impact of suspending rehab.
We are well aware of the many consequences of being inactive, but following the lockdown, what we noticed in our clients was wide-ranging. Unsurprisingly, many clients had lost some of their fitness, stamina and endurance and, like a large proportion of the population, many reported that it had been difficult to keep their weight under control.
Alongside this and more worryingly, we saw losses in hard-earned function that had been gained over preceding months and a reduction in confidence with activities that are vital for independence in daily life. This was all despite the fact we provided virtual exercise programmes to follow at home during the lockdown period.
Reflecting on the impact of the temporary halt to rehabilitation influenced our decision to keep our doors open with strict Covid-19 measures in place during the second and third lockdowns. Our clients were hugely relieved by this as many wanted their rehabilitation to continue.
The enforced period of closure also made us think about the challenge faced by individuals with neurological conditions throughout their lives.
Those living with such a condition have, effectively, to commit to life-long rehabilitation in order to manage their symptoms and maintain the gains that they achieve. Even just maintaining a steady level of function requires a significant level of commitment and motivation.
With a neurological condition, individuals need to ensure that they stretch sufficiently to manage spasticity and avoid developing contractures that can limit their function. They need to dedicate time to moving their body into positions which alleviate pressure and allow muscles to be stretched for longer periods of time, such as lying prone. They also need to maintain sufficient shoulder strength and control in order to deal with the increased demands on their upper limbs as a result of their injury without developing shoulder injuries which could have knock on effects on their independence and function.
Fitness is also key to be able to push a wheelchair or walk when a proportion of your muscles aren’t functioning fully and reduce the risk of developing cardiovascular disease or diabetes. Then, there’s the need to regularly practice activities that are more challenging so that the confidence and ability to perform these tasks when needed isn’t lost.
All in all, it’s an awful lot for anyone to manage, in addition to the challenges that daily life throws at us. As such, we realise the value of rehabilitation services lies not just in helping individuals to achieve their goals, but also to develop the right mindset and confidence to manage these challenges throughout their life.
For those commissioning services, my message would be quite simply that rehabilitation for neurological conditions should never ‘end’. Lifelong support and follow-up are vital to helping individuals stay on top of their symptoms, optimise their function and independence and minimise the impact that their condition can have on their lives.
NeuroBall™: enabling progress in rehabilitation
An expert’s view of the rehab technology.
What impact can the NeuroBall™ have on rehabilitation? Claire Everett, neurophysiotherapist at PhysioFunction, shares her insights into its benefits
What are the main benefits of NeuroBall™:
- For your clients/patients?
- For your clinic?
The main benefits to the clients are improvements to hand and upper limb function; working with the NeuroBall™ can assist with integrating the hand and upper limb into the whole body recovery.
We have also utilised the NeuroBall™ in therapy to assist with balance – e.g. training in both sitting and standing.
The NeuroBall™ allows the client to work at home independently following assessment and recommendations of a NeuroBall™ trained therapist.
Having a means of independently exercising can be empowering for the client and facilitates a more intensive rehabilitation programme.
The facility is able to remotely monitor use of the NeuroBall™ and adherence to an agreed exercise plan assists the therapist in managing a client’s therapy programme.
How do you decide which clients/patients are the best candidates for NeuroBall™?
A trained NeuroBall™ therapist who has experience is the best person to identify clients who will be good candidates for the NeuroBall™.
It is best practice to have identified patient goals and identified problems from a detailed assessment.
Clients need to be able to follow the instructions to engage with the therapeutic games and this forms part of the suitability assessment.
The NeuroBall™ can assist in those with both high and low tone in their hand and upper limb, however regular input either face to face or via Telerehab is required to maximise the client outcomes and ensure good technique and patterns of movement in the arm and hand are achieved.
Challenges: The size of the client’s hand to fit in the NeuroBall™ must be at least 15 cm long with a palm at least 8 cm wide so that may prevent some smaller or paediatric clients from using NeuroBall™. I’d also like to have more games to work on hand opening.
What expectations do you set with clients about:
- How often and for what length of time they should train with NeuroBall™?
- What improvements in activities of daily living they should see if they follow your recommendations?
Length of time and intensity of training is tailored to the individual and monitored and adjusted by the experienced NeuroBall™ Therapist.
Improvements in daily living activities will be individual and personal goals are set in liaison between client and therapist.
Expectations are best managed by a thorough assessment, an individualised training programme and regular input with a trained NeuroBall™ Therapist. In general, our clients have enjoyed the games and the feedback on their progress. Clients have reported that using NeuroBall™ benefits their hand function and balance.
How have you used telehealth in your NeuroBall™ home program?
We have integrated the NeuroBall™ into our extensive Telerehab offering. It has had the most benefits in those clients who have regularly engaged with 1:1 sessions with an experienced NeuroBall™ Therapist.
What have you heard from your clients about how NeuroBall™ has impacted their rehab and their lives?
Our clients have given a variety of feedback, some found whilst using the NeuroBall™ their hand was more engaged with their body, and they noted improved hand function. Some also noted improved balance.
Some clients experienced minor discomfort with use and others felt over time the games became less engaging and motivating. However, with further input from an experienced NeuroBall™ therapist, adjustments to improve comfort and suggestions on how to keep the games engaging usually addresses these issues.
For more information on the NeuroBall™, visit here
The value of strength and conditioning in neurorehabilitation
Strength and conditioning is a field of exercise science specialising in the optimisation of human performance.
Along with other closely related disciplines – such as physiotherapy, biomechanics and physiology – strength and conditioning is an established support service in sport but rarely applied within neurorehabilitation, despite holding evident value.
Within sports, a strength and conditioning specialist works collaboratively with a multidisciplinary team that has been collectively tasked with optimising the physical resilience, development and performance of athletes. An integral part of their specific role within such a team is to maximise the technical training opportunities of athletes by ensuring they can withstand the unique physical demands placed upon them by their respective sport, training environment and competition format.
This role is fulfilled by methodically appraising and addressing the physical abilities and limitations of athletes in alignment with specific outcomes associated with sporting success. In doing so, distinct movement patterns (eg running), physiological systems (eg cardiovascular) and architectural properties of muscles (eg cross sectional area), can be effectively and repeatedly targeted for adaptation and maintenance as required.
Contributor to success
Strength and conditioning is recognised as a key contributor to the sporting success of athletes and teams competing at the highest level, with a reported 93 per cent of Great Britain’s Olympic and Paralympic medal winners receiving this support service in the lead up to the last Olympic games in Rio 2016.
Despite the undeniable success of such an approach, the field of neurorehabilitation has yet to recognise the value that this specialism can bring to the long-term recovery from and ongoing management of neurological conditions and associated issues. This is a missed opportunity – especially within a community-based setting, where access to services supporting this population in completing a recommended level of exercise and exploring potential for functional recovery is limited.
In part, this can be attributed to a level of ambiguity regarding the exacting role that such a specialist can fulfil within the existing team of professionals who work together to support this population’s exercise needs and ongoing recovery. Typically, these teams comprise consultants, occupational therapists, physiotherapists and case managers who are likely to associate strength and conditioning with fitness instructing and personal training.
While both of these disciplines have a place within neurorehabilitation, professionals qualified to deliver such sessions are only required to complete relatively short courses which don’t cover the range and depth of knowledge regarding how their skills can be applied in support of those with neurological conditions. This is compounded by the apparent ambiguity surrounding the skills possessed by strength and conditioning specialists.
In contrast, a Bachelor of Science degree course will cover an array of relevant topics and necessitates the completion of several vocational placements, as well as an undergraduate research project, before aspiring strength and conditioning specialists are eligible to acquire and maintain accreditation with a well-governed professional body. This means that such specialists are equipped with a more pertinent foundation of knowledge and greater level of professional practice than a fitness instructor or personal trainer.
This combination of attributes is perhaps most advantageous to individuals living with neurological conditions during the later stages of their recovery journey. Once a level of clinical stability and functional recovery have been reached following engagement in an initial period of intensive rehabilitation, many people struggle to meet their exercise needs after returning home thus unfulfilling their potential for further recovery of function.
A strength and conditioning specialist could safely apply an array of training methods underpinned by evidence-based principles and research to explore and maximise people’s functional capabilities. In addition, they can creatively overcome any barriers inhibiting them from reaching specific exercise intensities required to maintain health and evoke adaptations.
Integrating strength and conditioning into rehab
Here at Neurokinex, we hold strength and conditioning in high regard and integrate specialists into our team of multidisciplinary professionals providing a range of established and cutting-edge neurorehabilitation services.
The effective transfer and safe application of their skills is guided by the collective expertise of team members from more clinical backgrounds including physiotherapists, occupational therapists, exercise physiologists and sports therapists. It is not so unlike the process used when supporting the return-to-play strategies of athletes or managing any underlying health issues whilst they are training and competing in sport under the guidance of medical professionals.
Strength and conditioning specialists are required to learn the physical abilities of individual athletes and the unique sporting demands placed upon them before designing a programme to support them in optimising performance.
In the same way, our specialists also assess the goals and needs of clients whilst abiding to stringent medical guidelines. They first learn the functional capabilities of individuals living with a neurological condition and the specific movement patterns they are required to complete when performing daily livings tasks. Then they design programmes to help them become more independent through optimising performance of such tasks whilst understanding the limitations imposed by their condition.
By integrating such specialists within the Neurokinex team, we provide a significant additional dimension to the services we provide to the community we serve. Our hope is that the wider field of neurorehabilitation will also soon appreciate the difference this approach can make and look to apply strength and conditioning techniques to support those living with neurological conditions.
Why does exercise intensity matter?
Intensity is essentially the amount of work you do in a given period of time using these four components of exercise – Load, Distance, Speed and Time.
For example, with resistance training, this could be measured by how much load/weight you move, how far it is moved, how quickly it is moved and how long that weight was moved for. Using this understanding, a larger load moved more quickly will be recognised as being completed at a higher intensity than if one of those components was less.
Knowing the intensity a client can work at allows you to apply overload which is where you increase intensity to permit a physiological adaptation.
Tools to track intensity
- Metrics – measuring how much weight a person lifts, how quickly they push/run or how far/long they move, all provide comparable data to measure progression
- Rate of Perceived Exertion (RPE) – this is based on observing the body’s physical signs during physical activity. This can be tracked in a simple 1-10 rating scale. For example, if a client is at a very comfortable level of exertion during physical activity, they’d consider this a 4 or 5/10. However, if they are sweating a lot and feeling breathless, this might be considered level 8 or 9.
- Talk Test – this is a very easy test to figure out intensity – you just pay attention to how breathless your client is. If they can easily talk, they’re working at a light intensity. If they can talk, but it’s a little harder, they’re getting more into the moderate zone.
- Wearable technology – the heart rate will increase in proportion to the intensity of the exercise as a natural response. As heart rate monitors and fitness trackers are becoming more and more readily available, they can provide a more accurate way to measure intensity in real time, allowing you to adjust your client’s effort and measure their performance during the session/exercise.
How hard should you work?
That answer will vary greatly from person to person and the level of intensity should be tailored to the individual. While intensity can range from low to moderate and high, an estimate of a person’s maximum heart rate (MHR) can be calculated as 220 beats per minute (BPM) minus their age.
Target heart rate for moderate intensity activities is about 50-70% of MHR, while for vigorous physical activity it’s about 70-85% of MHR using this formula.
Understanding your client
Intensity has to be appropriate in terms of what your client can currently do, as well as matching with their goals.
Asking someone to perform something far beyond their current abilities could possibly have a negative effect on implementing progression in the future. You don’t want to be told “I remember when you pushed me too hard!”
Intensity requires a client’s understanding and trust in you as a trainer to use intensity to help them achieve their goals.
How exercise intensity helps those with neurological conditions
Intensity of exercise has been associated with benefits for individuals who have suffered a neurological injury including enhanced stepping for locomotion with individuals with incomplete spinal cord injuries and improved blood pressure control in individuals with spinal cord injury.
Overall, becoming aware of the intensity of exercise will help you to ensure that you are aligning your client’s health or fitness goals with exercises/activities to facilitate their progression going forward.
- For more information and insight on this topic, speak to the team at Neurokinex
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