Table 44.1

Daily Training Session Sample

Figure 44.4

Timeline of combined training. Different functions can be exercised consecutively. There should be a minimum of 2 hours before repeating the same type of training.

In our studies, individuals are trained in the clinic initially for 1 to 2 weeks (Monday through Friday). As they improve, they are challenged with harder tasks in order to progress. After the clinical training period, they continue training at home, performing the same components of CN-NINM training that they learned in the clinic. Individuals return to the clinic approximately at weekly and monthly intervals to review training. They must receive frequent and progressive upgrades to the physical challenge in their training in order to improve and retain therapeutic benefit. The following sections illustrate the types of training and how each is progressed for training.

44.8.1. Movement Training

Movement training has two components: warm-up exercises and movement control exercises. Warm-up exercises are performed at the beginning of each training session. The goal of the warm up is two-fold. First, the warm-up prepares the system for work. The body responds best when the systems are primed. This is similar to an athlete warming up before tasking the body with physical demands. Second, the warm-up exercises are targeted towards areas of abnormal movement and physical limitations. The warm-up exercises help to “wake up” the body’s pathways and relieve stress on tight areas. This helps the body prepare to work toward maximum performance. The PoNS device is not used during the warm-up exercises. Focused attention is given to the quality of the movements. All exercises emphasize neutral posture and good alignment.

The second component of movement training is movement control exercises. Human movement occurs as a result of the synergy of three interrelated systems: the muscular system (soft-tissue structures; i.e., muscles, tendons, ligaments, and fascia), nervous system (recruitment of muscle synergies during movement), and articular system (functional joint motion) (Neuman, 2009). In an unaffected individual, structural alignment, neuromuscular control, and movement are optimal, as long as no impairments are present. When any of these is impaired, the result is abnormal movement. In people with neurological disorders, the movement synergies are affected. As a result, they typically present with abnormal movement patterns and often develop compensatory strategies. The movement control exercises are targeted towards the individual’s abnormal movements. A critical piece of the CN-NINM intervention is to properly challenge the individual’s movement control patterns in a manner specific to their needs.

The movement control exercises are designed to retrain movements for improved neuromuscular control, alignment, and mobility. This is achieved by:

• Isolating body segments

• Focusing on quality of movement

• Moving joints within normal range by balancing muscle contraction and relaxation

Sample exercises include chin tucks, shoulder circles, scapular circles, pelvic tilts, and pelvic figure 8s. Each exercise starts out simply and builds in complexity as the individual demonstrates mastery. To illustrate how to progress an exercise, we will use leg circles. The starting point may be standing on one leg while holding a support and making a circle in space with the other leg. The leg circle can be performed in front of the body, then in back of the body; progress by connecting the two circles and making a figure 8; the figure 8 progresses to a four-leaf clover. Further progress this exercise by turning the foot inward and outward (add greater internal and external hip rotation). Increase the challenge more by performing the exercise without holding a support. Each exercise can be developed in a similar fashion, progressing from single to multiple planes, and simple to more complex movements. The goal is to demonstrate coordinated and fluid movement through the maximum range of motion of the joints. Movement control exercises are performed with the PoNS device. The focus is on correcting abnormal movement patterns. Using a mirror when learning and practicing the movements facilitates visual feedback, which allows the individual to self-correct. The treating clinician helps determine which exercises are important to address the individual’s needs.