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
Where does rehabilitation start and end?
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.
Changing outlooks and redefining possibilities
Established using best practice in spinal cord injury therapy from around the world, the rehabilitation offered by Neurokinex is helping to redefine the possibilities for people living with paralysis. NR Times learns more about its neuroscience-inspired work
“We want to help change people’s outlook on life.”
Jane Symonds’ summary of the work of Neurokinex, and its approach to redefining possibilities for people living with paralysis, is a powerful one.
For aside from the work the rehab provider does with patients physically, using techniques to stimulate the whole body rather than only the functional areas, the impact its neuroscience-inspired approach has mentally is possibly even greater.
In enabling people who are paralysed to have hope that one day they may walk again or at least make significant gains in their mobility and independence – and being at the cutting edge of developments which could enable this – Neurokinex is inspiring patients from well beyond the geographical reach of its centres in Hemel Hempstead, Gatwick and Bristol.
Founded in 2013 by Harvey Sihota, now chief executive of Spinal Research who himself lives with spinal cord injury, not-for-profit Neurokinex was born from his extensive research into best practice and latest innovation in spinal cord injury therapies from around the world, to give hope and renewed confidence to those living with paralysis.
“I think the biggest thing is the difference in outlook,” says Jane, clinical lead physiotherapist at Neurokinex.
“Most people who come to us have been injured relatively recently, although some people have lived with paralysis for quite a long time. Some are elderly and we also work with children but whatever their age, the realisation of what they can do and can achieve is huge.
“We do have some tears when we see what can be possible, it’s very moving. To see people regaining their confidence during their time with us, so they want to go out again or feel they can return to work or get back to driving, is very special. We want people to live their lives to the full once again.”
Progress, particularly in terms of their outlook and expectations, is something the Neurokinex team is committed to supporting people to achieve, says Jane.
“The expectations are quite low among people when they first come to us, many of whom have just come out of hospital,” she says.
“Hospitals are really cautious in their approach, and don’t want to give false hope, which is understandable – but hope is so important.
“Several of our team are used to doing rehab with professional sports players. They take that expectation of what people can do with the right mindset, combine it with the power of encouragement that enables people to achieve, and applied it to what they do here.
“I worked in a spinal unit for eight years and found it quite frustrating that when people left, they were considered rehabbed and done. But they weren’t as fit and strong as they could be, their function wasn’t as good as it could be and with the right support they could do so much more.
“Often it can be the case that people leave their daily physio in hospital and then face anything up to an 18 week wait for their community provision to begin.
“Without the right support, it’s easy for people to go backwards, to lose any progress they had made and put on weight, experience pressure sores, and a whole host of other consequences. It’s very hard to regain what is lost.
“But with intervention, they can make great progress. Through working with our team, we can help make gains in their function, strength and endurance, which can have a hugely positive impact on people’s lives.”
And as part of its commitment to delivering the very latest innovation to its clients, Neurokinex is part of trials of technology developed by ONWARD, expected to commercialise as early as 2023, which is set to enable paralysed patients to regain movement.
“We’re really hopeful this will make a difference and it is very interesting to be part of this study. We are always looking to what can be done to change the lives and outlooks of people living with paralysis,” says Jane.
“Our approach is inspired by what Harvey created here. He constantly surprises us with what he achieves. He is so positive and to him nothing is impossible. That’s what we try to instil in the people we work with.”
Whilst striving to offer cost-effective services, part of the not-for-profit enterprise’s work is funded by the Neurokinex Charitable Trust, with fundraising activities helping to sustain its work.
One of its key initiatives in accessibility is the Step Up Scheme, which offers six free sessions following NHS referral.
“Through the Step Up Scheme, we underwrite the costs of those six sessions as we don’t want anyone to be excluded through cost, and we appreciate it is very hard for those who have to self-fund,” says Jane.
“Every year we are growing in numbers, which is fantastic, but we have to work harder to find ways to sustain that.
“With COVID, we were very worried about losing the scheme, but we had a big fundraising appeal which lots of our clients got involved with, and that raised over £50,000 which meant we could continue.
“Our paediatric area in Gatwick was also created through fundraising. It’s a lovely space which challenges kids while keeping them safe. That was a big project for us but one which is so well used and valued, and we’ll keep on developing what we can offer through generating the means to do that.”
Rehab specialist invests £500,000 in expansion
A rehabilitation specialist is expanding its offering through the opening of the first intensive neurotherapy centre in the south of England.
Hobbs Rehabilitation has invested £500,000 in its new Intensive Neurotherapy Centre in Bristol, which has given 2,000sq ft of space to more than double its level of technology available at its previous Bristol clinic.
It also gives the potential to deliver a six-fold increase in the intensity of treatment, all backed by data to chart patient progress and outcomes.
Through the creation of its new centre, Hobbs Rehabilitation Bristol is expanding its services beyond its core upper limb therapy to bring in lower limb specialism, with plans in place to develop an additional intensive speech and language therapy (SLT) service for aphasia patients.
A move into paediatric work is also being considered, as part of its ongoing development.
Four new people have already been added to the team based at the Intensive Neurotherapy Centre – two physiotherapists, one occupational therapist and a rehab assistant – with more set to be recruited as the centre continues to grow.
While its traditional client base has been mainly people with neurological conditions, such as stroke, the new centre is enabling it to work with growing numbers of spinal cord injury patients – with Ed Jackson, a former rugby union player who sustained such an injury in 2017, being one of its clients.
Bristol is the first Hobbs Rehabilitation centre with the entire Tyrosolution suite from Tyromotion, including the LEXO robotic gait trainer, having increased its provision from three to seven pieces of the high-tech equipment.
It is also the first independent provider in the UK to combine bespoke high-dosage physiotherapy, occupational therapy and speech and language therapy alongside the complete Tyrosolution and other assistive technologies such as the MyoPro.
“This new centre is a big expansion and investment and we plan to continue with this development of our services going forward,” says Ali Gomes da Silva, clinical lead at Hobbs Rehabilitation Bristol.
“We are looking to develop an SLT service with a specialist who used to work in aphasia rehab in Spain, and we are also looking to add a paediatrics service.
“One of our new additions to the team joined us from Glavic Clinic in Zagreb and has worked extensively in this area, so combined with the expertise we already have in the team and the equipment we now have, paediatrics is an area we are looking to expand into.
“We have added a number of people to our team already, and we’ll continue to recruit against the workload.”
While ongoing COVID-19 restrictions mean the centre can accommodate four people at one time currently, that will be raised to six in the near future as lockdown lifts, with more to be added in time.
And already the demand for such time is significant, says Ali, with referrals coming from therapists, case managers and patients themselves.
“We have done a lot of work with stroke patients to date through our upper limb service, but I think our huge increase in SCI is in large part through Ed Jackson being so vocal on social media,” she says.
“He’s been absolutely blown over by the advances in therapy practice we’ve made and how we can supply the data to support that.
“Through our new technology and equipment, we have made really good advances in both lower limb and upper limb, so are now even more able to support people with their therapy.
“We’ve fulfilled all the plans we had in place initially, but the expansion will continue as we go.”
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