Chapter 7

Neuropsychomotor Training and Benefits of Exercise

Neuropsychomotor training is a term my son and I came up with (all by ourselves) only to find out that neuropsychomotor is a word that’s already being used, primarily in connection with infants and preschool children to characterize the relationship between neuropsychomotor development and auditory processing (Guedes-Granzotti1, 2018). But that’s ok because the term, neuropsychomotor training nicely describes what you learned in the previous chapter about neuroplasticity and retraining this extraordinarily complex structure known as the brain.

At the beginning of the book, we mentioned that everything in the human body is connected. Your brain, skeleton, nervous systems, muscular system, limbic system, visual and vestibular systems, and every system is connected to all other systems. Every system is a player in this orchestra that makes up our bodies, our humanity, and allows us to think, move, feel emotions, make decisions, and exist.

Figure 7a illustrates how all systems are connected and play vital roles in the quality of movement and life we experience.


Figure 7a

In the diagram, psychological refers to brain function. This includes cognitive (executive function, memory, language, attention, and visuospatial function), behavioral (actions, habits, and reactions), and affective (motivation and mood). The brain, in conjunction with the central and peripheral nervous systems work harmoniously to feed and execute our movement and motor skills.

Movement professionals (and everyone): if you didn’t previously realize or understand the important connections between all systems, you’ve done nothing wrong. You can only train your clients the way you know how to train, knowing only what you know at any given point in time. The learning curve is a constant for me. I’m always seeking to learn as much as possible and literally every day, I learn something new that allows me to be a better trainer. Sometimes, the slightest bit of new information leads me to trying something new or different in our workouts, often leading to significant improvements in movement for the client.

Before we get into discussing the benefits of exercise, I implore you to keep a few things in mind that will help you to help others better:

• Be open to new information, techniques, and strategies. Always be open and try not to get stuck in that rut of thinking you know all you need to know. I promise – you don’t know all you need to know, and neither do I
• Always be seeking to learn all you can. You can wait to hear about new things that will help you or, you can seek it out. My guess is, you’re a seeker. Why? You’re reading this book. Enough said.
• Seek out professionals who have more experience than you or have a niche you’d like to learn more about. Ask them if you can shadow them and spend time with them while they’re working with patients or clients (providing the patient doesn’t mind and patient privacy isn’t compromised or considered violated in any way).
• Use your knowledge and skillset but be creative and experiment with things. You will have epic fails here and there, but don’t let that stop you. Adjust based on your client’s ability. Keep trying new things. This will be good for both you and your patient
• Maintain good communication with your client during sessions. If they’re not telling you how they feel about a particular exercise challenge, ask them how they’re feeling. Feedback is everything and
• you’ll want as much feedback as possible to keep your client safe while challenging them appropriately.

Benefits of Exercise

Mood and emotional state

Friends, I begin with a story about how learning one simple strategy helped my friend Angeles to instantly go from feeling completely defeated to completely optimistic, hopeful, and unstoppable in a matter of minutes.

It was Wednesday, April 18, 2018 and I had just finished delivering a 90-minute presentation to a large audience at a Parkinson’s symposium in Monterrey, Mexico. Next on the schedule was a 45-minute workout, which I was to lead.

I ran from the stage to an empty room to get out of my suit and tie and put on workout clothes, and at the same time trying to decide what type of workout I should lead. This was my first time in Mexico and while everyone made me feel very welcomed there, I was nervous and wanted to deliver impactful techniques in this short workout session. There was no room for disappointment.

I returned to the conference room where approximately 55 people were waiting and ready to begin the session. At the very last second, I decided to do a workout I refer to as, “The Floor is our Friend.” I was mentally crossing my fingers hoping they would like and benefit from this session. “The Floor is our Friend” is designed to help a person get back to safety in the event of a fall. It also includes a number of foundational movement patterns which help to develop strength and more optimal movement. You’ll learn all about this in part four.

I started the session by having everyone lay down on their backs on the floor. It’s not uncommon to hear of a person with Parkinson’s who has difficulty or is unable to roll over. Imagine waking up in the morning and encountering rolling over in bed as your very first challenge. That’s not a good way to start your day.

So, we now have 55 people on their backs and our first movement involves a specific strategy to leverage your body and roll from your back (eyes looking at the ceiling) to front, (facing down). Next – we use another specific strategy to leverage and roll from front to back. Then, we roll in the opposite direction from back to front, and then roll back to starting position.

We continued practicing this technique for a few minutes and as I’m walking around and helping people, I notice a lady who is performing the movement very well, but she is crying. I asked if she was okay and she said, si – todo bien (yes, yes, all good).

During my presentation prior to the workout, I had noticed Angeles sitting in the audience. She didn’t look happy, but I couldn’t determine for sure how she was feeling.

Fast forward to the same evening, I was back at the hotel and had a notification on Facebook of a new comment from a post I put up during the workout. The comment was from Angeles. It said something to this affect: I didn’t want to attend the workshop because I felt hopeless and defeated. I had been to so many workshops and nothing helped me. My husband dragged me there to attend and today, for the first time in 5 years, I rolled over all by myself! I went from feeling defeated and hopeless, to being a fighter and feeling unstoppable, all in a matter of about 5 minutes.

Well, folks – I sat in my hotel room and I cried – for quite a while. It took some time to wrap my mind around the idea that Angeles, who I learned had been mostly bedridden for an entire year prior to this workshop – had gone from feeling hopeless and defeated, to feeling UNSTOPPABLE solely because she rolled over all by herself! Can you even imagine how this would feel? … rolling over without assistance for the first time in five years?

Angeles credits me with something I’m not comfortable with (but am happy about at the same time) – giving her life back. Really? I didn’t give her anything other than a strategy to get her rolling over by herself. I delivered the technique which I learned from Dr. Perry Nickelston. All I did was modify it slightly into a functional strategy to help her roll over.

I delivered the technique and Angeles did the work and made it happen! I have countless stories of this nature where one seemingly tiny tool or technique causes immeasurable improvements in movement and changes the mindset completely.

In July of 2018, I traveled to San Luis Potosi, Mexico and worked for five days at a wonderful physiotherapy clinic owned by my friends, Dany and Jess. They filled my schedule with appointments to work with people with PD. More specifically, we would have each person come into the clinic and allow us to video record and assess gait.

With each patient, we started outside, having them walk in their normal footwear. I had a predesignated pathway set up for them to walk. As they walked away from me, I recorded a posterior view of gait. At the end of the walkway, we had a support person positioned at the point of turning around in case they needed assistance making the rotation. As they returned to the starting location, I video recorded an anterior view of gait.

Next, we went into the clinic where I had cameras set up to do simultaneous lateral and posterior video recording as they walked on a treadmill – still wearing their normal footwear.

Without telling them what we were doing or what to expect, we instructed patients to take of their shoes and socks. We placed Naboso textured insoles in their shoes and had them put the shoes back on, but without wearing socks. From there, we started all over again, heading back outside to walk the same pathway they walked previously, and then returning to the treadmill.

This is where it got very interesting. With nearly every patient, we saw an instant improvement in gait including improved stride length and symmetry, posture, head position, reciprocal arm swing, and velocity. Rotations improved as did their level of confidence in their ability to move. Most patients felt safer, more stable, and secure. Some started running. One gentleman took off running and didn’t stop! He ran to the end of the block, took a left turn and I lost him. About ten minutes later, he showed up at the clinic coming down a different street and from a completely different direction. He hadn’t run for years! We were in tears because he was in tears. Happy tears.

I have another story for you. It’s a beautiful one and is one of my favorites.

At the end of the week in San Luis Potosi, I taught a full day workshop at a wonderful fitness facility. We had about 60 people in attendance, most of whom I had met with at some point during the week to analyze their gait. It was at this workshop where I met Maria Celinda, a PD fighter in her mid-40’s who had been living with Parkinson’s for over 15 years.

There was a large area just outside the seminar room perfect for walking. As gait re-education is a part of our live workshop program (and something you’ll learn about in detail in part four), we did gait training exercises in the large, open area, first in normal footwear and then, with Naboso insoles.

In normal footwear, Maria Celinda was unable to walk without assistance with use of a walker or from another person. After placing the textured insoles in her shoes, it was like magic happened. Maria almost immediately started walking without assistance – and that’s just the beginning. Not only was she walking unassisted – she was walking with an almost normal gait, heel to toe, symmetrical stride, improved posture, and swinging her arms.

But the story continues to get better. Soon, she started running! In fact, we were far past the time of having to get back into the seminar room to continue the program, but I wasn’t about to ask her to stop running! She ran and ran – her running stride improved, her arms were swinging perfectly, and she was smiling! In the end, she ran up to a group of us, completely in tears, and explained how she felt a renewed sense of hope and optimism. She used to be a runner, and this was her first time running in over 15 years!

Well – needless to say, we were all in tears as we had witnessed something so beautiful, amazing, and life changing.

Taking it one step further – six weeks later upon arrival at the San Francisco airport, I checked my phone to find a message from Maria Celinda with a video attached. She has a PhD in chemistry, taught at a university and had been out of work for quite some time.

Her video showed her in her lab coat, in the chemistry lab while walking and carrying a hot cup of coffee. Maria was BACK TO WORK! Now THAT is something to think about. Just imagine how that must have felt for her.

So, friends – can you see why I put mood and emotional state first in this chapter? Something as simple (or maybe not so simple) as regaining the ability to roll over, walk without assistance, or starting to run again has the potential of changing a person’s life! Hence another reason for why I am always learning and teaching and trying to help. One little technique or strategy has the potential of making a HUGE impact! When we move better, we feel better and our mood improves. When our mood is good, we move better. It’s a cycle where movement and mood feed each other.

Let’s take this a step further. There is almost always a positive ripple effect when someone learns or regains a skill or an ability. Angeles can now roll over by herself, relieving her husband or anyone else of having to help her. Maria Celinda is walking without assistance and running again, relieving her caregivers to a large degree. Caregivers have a rough deal and aren’t recognized nearly as often as they should be for what they do. When a person with PD regains a skill, the caregiver usually gets a break, too. This is part of the positive ripple effect and it is huge!

Exercise categories and modalities and their benefits

Strength, cardio, and flexibility are the most commonly known exercise categories. While we will examine these categories and benefits of several modalities within them, we’ll also look at numerous other categories, techniques, tools, functional movements, and their benefits including: stability, agility, gait, multi-tasking, yoga, reflexive stability, anticipatory stability, posture, reactive training, hand-eye coordination, crossing the midline, mobility, foundational movement patterns, foundational breathing patterns, mindfulness, dance, music, art, group fitness classes, and overall movement and functionality.

Balance / Stability

In general, regular static and dynamic balance stability training transfers to activities of daily living, helping to improve movement and reduce falls and fall risk. It has also shown to reduce fear and increase confidence with respect to movement.

Agility

Agility training is a highly effective in helping to improve movement and fall recovery. Integrating a variety of agility training strategies yields benefits that transfer to activities of daily living.

Dual task & Multi-tasking

While dual and multi-task training is one of the most challenging modalities, significant benefits can be gained. Dual tasking increases fall risk and leads to more falls. Frequent and regular multi-task training in the gym helps to transfer to multi-task activities outside the gym and reduce the risk of falling.

Perturbation balance training (PBT)

Any type of perturbation balance training presents unique challenges. Whether performed on or off a treadmill, perturbation training will challenge balance and movement and benefits will transfer to activities of daily living.

Stretching and flexibility training

Rigidity is a common motor symptom which can cause postural issues, pain, and a multitude of movement challenges. People with PD find flexibility training to be beneficial in helping to temporarily relieve some of that rigidity, improve posture and gait, and feel better. Some never experience rigidity, but still find stretching and flexibility training to be beneficial.

Strength and Foundational Movement Patterns

Stronger is better. There’s no question about that. But what kind of strength? There are a multitude of strength training modalities, i.e.: weight machines, free weights, suspension (TRX), resistance bands, bodyweight, etc. With the goal of transferring strength benefits to activities of daily living, we also use an important technique known as foundational movement patterns. Part four will deliver foundational techniques such as rolling patterns, getting onto all fours, crawling, getting up to kneeling position, standing up from the floor, and getting down onto the floor. These movements involve a multitude of fascial and muscular firing patterns which help greatly to develop functional strength, especially in the event of a fall when the patient needs to navigate back to a safe place.

Posture

Optimal posture helps improve gait and movement, and generally reduces fall risk. Other benefits may include less wear and tear on joints and the spine, a reduction in pain, improved performance of internal organs, and improved breathing capacity.

Gait Training

Most people aren’t taught how to walk with optimal form. For example, if a patient with PD experiences diminished arm swing, they may not even notice. A gait assessment allows the trainer to observe gait issues. Gait training will educate the client on gait biomechanics and specific cueing will help the client to work towards restoring optimal gait.

Vestibular

Vestibular assessment, reset, and training has shown to help improve movement, gait, and hand-eye coordination.

Hand-eye coordination / Visual

A visual assessment, reset, in addition to hand-eye coordination training has shown to be helpful to temporarily improve depth perception. This makes it easier to throw and catch a ball or other object during training sessions. This will help to better distinguish how far away an object is upon approach (chair, couch, curb, step, threshold, etc.).

Reactive training

The faster we can react to an object or situation, the better. Training for faster reflexes will only help to reduce fall risk. Reactive training and perturbation training offer movement specialists the opportunity to be creative and implement a multitude of techniques to help the patient to improve reaction times.

Anticipatory stability

When we have the option to perform a movement such as a leap or a jump, we have the opportunity to prepare. Perhaps it’s during a training session and we’re jumping through an agility ladder. We look at the rung we’re about to jump over and assess the energy it will take to clear the rung and go the distance required. Before we perform the jump, we’re thinking about the landing. Then, we jump and land successfully. We anticipated the landing and the amount of control and stability it would take. This is called anticipatory stability.

Reflexive stability

Have you ever walked somewhere and stepped into a hole you didn’t see? Or you come upon a bump, curb, or step you didn’t see? In order to stabilize, stay upright, and keep moving, your reflexes must fire fast enough to avoid a fall. This is called reflexive stability.

Crossing the midline

When we perform movements that involve the arms or legs crossing over the midline of the body, the two hemispheres of the brain fire up and work better together. This is a powerful way to get both hemispheres working together and firing up new neural pathways. The more neural pathways we create, the better chances of improving movement and reducing fall risk.

Foundational Breathing Patterns

As we learned in part one, breathing issues are of high concern for people with PD. Exercising foundational or three-dimensional breathing helps to expand the rib cage and increase lung capacity and efficiency. Deep breathing opens up the lobes, fills the lungs with blood and oxygen (this will improve circulation), and helps to reduce the risk of complications such as pneumonia. \

Music / Rhythm

Whether someone has PD or not, rhythm and music have powerful effects on the brain. Use of a metronome or playing music while walking to the beat can help to create a more symmetrical and rhythmical stride. While experts are still studying the music-brain connection, it is well known that music can help with learning and memory. And try giving your brain a workout by listening to new music rather than what you always tend to listen to.

Drumming

Drumming, whether using a drum set, hand drums or a table-top engages the entire brain and makes for a good brain workout. When drumming, and especially using both hands and feet, both hemispheres of the brain are activated, neural connections between sides become stronger, and more coordination is developed.

Dance

When we’re dancing, we’re moving! Many factors come into play when dancing such as cross body patterns, rotations, cognitive skills (knowing the next move and where to step next) and sticking with the rhythm of the song. Plus, it gets the heartrate elevated which we know causes the brain to create BDNF.

Group Fitness

Parkinson’s group fitness sessions can be highly beneficial for a number of reasons. For example, if a person with PD likes to socialize but is self-conscious about tremors or concerned about falling in public, they may gradually start withdrawing from society. This can lead to depression and a less active lifestyle. Group fitness offers a safe zone, of sorts. The people in attendance share something in common – Parkinson’s disease! In our experience, group classes have been a wonderful way to get people with PD out of the house and into the gym for a workout – all while making new friends and having FUN!

Yoga

Yoga can be very helpful in many respects. Besides the temporary reductions in motor symptoms that are realized by many, other benefits include the opportunity to socialize (if doing a group yoga class) in addition to a relaxing, mindfulness experience depending on the type of yoga class.

Art

Art is therapy for many people and there are so many forms of art. A friend of mine in England does pottery and ceramics. When he’s spinning clay into the desired form, his bilateral tremors disappear completely. Another friend uses a lathe for the beautiful woodwork he creates, and his tremors diminish significantly. Painting, drawing, knitting, and other creative outlets can have positive temporary effects on symptoms.

Vibration

In part four, we’ll demonstrate many ways that vibration can be helpful including the temporary reduction or relief of:

  • Tremors
  • restless leg syndrome
  • cervical dystonia
  • abdominal dystonia
  • foot dystonia
  • menstrual cramps
  • constipation
  • myofascial release of overactive muscles

Fine Motor Skills

In addition to vibration, practicing and exercising fine motor skills is helpful in improving numerous tasks, such as: writing, texting, using silverware/eating, drinking from a cup, buttoning buttons, using a zipper, applying makeup, etc.

Mindfulness

This is an area that took me quite a while to get involved in and find useful. Now, after learning how to practice mindfulness effectively (for myself), I feel this is an underutilized relaxation technique. In fact, it has proven to be so beneficial for people with PD that I now lead mindfulness and relaxation classes. More about this in part four.

Chapter Summary

Research is being done constantly and examining countless ways that exercise can be beneficial. New data is coming out on a daily basis. In this chapter, we’ve hit on a few very important categories and modalities. For resources and supporting data on much of the information listed in this chapter, please refer to Appendix B.