I have a client who is recovering from a viral attack six months ago, which left her with sensory nerve damage to her femoral nerve on the right leg, particularly affecting the knee and ankle. She currently walks with a stick, and her goals are to build up her mobility and strength in the right leg. In addition to walking on the treadmill and using the bike (including single leg to work focus on the movement on the right leg), I'd be grateful for any other exercises you think would be appropriate.
This is quite an issue you are being presented with. Before I can give you some recommendations, I have some questions that need clarification. I am asking you now, but you should be asking yourself these questions in order to dive deeper into this situation of healing your client.
- How do you know she has lost sensory innervation to her lower extremities (LE) in those areas? Is this per the MD’s or PT’s evaluation? Have you done any dermotomal testing?
- Of course, there are myotomal issues as well. Have you done a myotomal test for the LEs?
- What type of virus did your client have? This can help us with additional referrals, nutritional work, lab testing, etc. I have seen it damaged through compression, adhesion, tumors, diabetes, pelvic injuries and from issues with the psoas muscle. So knowing what virus would be another great piece to the learning puzzle.
- You say it affects her knee and ankle... how? Is she locked in a certain movement, is there a lot of hypomobility in these joints, are they hypermobile, are they flaccid, do they have edema and so forth?
- Have you done any other physical, movement, length-tension, primal pattern, inner unit, outer unit, SIJ tests, etc. with this client?
What other practitioners is she working with and what info can they present that may help dictate your recommendations and treatment?
As you can see, there are a lot of questions and missing information for us to provide a comprehensive/individualized recommendation. What I always tell my students when I teach or lecture is this: “You can’t treat dysfunction if you don’t understand function. If you can’t find it, you can’t fix it. Everything we are provided with is a ‘branch’ to your client’s tree. We need to ask the WHY questions in order to get to the ‘root.’”
From my point of view, nutrition and lifestyle principles are the foundation for everyone’s healing. “You are what you eat,” as Paul Chek says in most of his programs. I would start with the basic nutrition and lifestyle principles in order to create a foundation for facilitative healing.
THOUGHTS: Everyday you wake up, the first thing that is turned on is your thoughts. If you follow the Law of Cause and Effect (thoughts -> words -> deeds), then it should all make sense. If you begin the day with good thoughts, then your words and deeds for that day will be positive and lead to success. Within the process of healing, you are what you think by having become what you thought!
BREATHING: After you wake up and have a thought, the second thing you do is breath. Most of us yawn, as well as have an increase in respiratory rate secondary to the release of Cortisol (a stress and awakening hormone). The average person breaths 20,000 times a day. If you are stressed or you are a chest breather, you breathe 40,000 times a day. It has been shown that 70 to 75 percent of most visits to the MD are all related to incorrect breathing patterns. Something simple as breathing can create upper quarter dysfunction (neck and shoulders), which will snake its way through the body. This can inhibit any healing or realignment below.
HYDRATION: Most of us wake up and race for the coffee. What you should do and need to do is go for WATER! You have been dehydrated for eight hours, and coffee will just exacerbate the dehydration, leading to headaches, constipation, decreased concentration and performance. Water helps to stimulate digestion, eliminate toxins and hydrate the body.
FOOD: The next thing most of us do is think about food. This is simple: focus on the quality (organic vs conventional) and quantity (do you eat or skip meals? what are your ratios of protein, carbs and fat?). But most people wake up late and are too lazy to cook a meal, so they grab a bar. Our nerves are surrounded in myelin, which is a proteolipid layer (protein and fat), so the higher quality the food your client is eating, as well as the more protein and fat in relation to carbs, the better the chance of her CNS healing.
EXERCISE: This is the most confusing area for many. Some people work out too much, and some don’t work out at all. As a society, we work, sit and eat more but move less! Whether it is Qi Gong, Yoga, Tai Chi or just plain old exercise, get out there and move!
CIRCADIAN RHYTHMS: This is a fancy word for sleep. I would have to say the most common complaint of all my clients is that they are fatigued and want more energy. A great place to start is with sleep. When you sleep, you release hormones to repair and regenerate. Up to 24 percent of the population falls asleep at the wheel each year.
When it comes to her rehabilitation, I can give you some general recommendations. I don’t know too much about your client, so to give you extensive individualized recommendations is not possible. I am going to give you some brief areas to look into, and you can do the leg work from there.
With this type of injury, the myelin sheath and nerve cells tend to become damaged. Nerves tend to take up to five times longer to heal than muscles, so keep this in mind when creating your plan with your client. This is not going to be a one month deal. She has to be in it for the long haul.
The main goal is improving or maintaining function and mobility. This can be done by referring out or working along with her PT and OT.
You should refer her out initially to get a brace for her LE. This will help create functional mobility until she starts to gain back some LE control. Most people with this dysfunction have issues with LE extension, so walking, getting up stairs, etc is quite a task. The brace will help to create some stability and also mobility.
When it comes to training your client, remember that you have to train her software, not her hardware. As Bobath states, “The body knows nothing of muscles, it only knows movements.” So if you train your client on machines or try to isolate muscles, you will only create a beautiful muscle. But this will do nothing to train her software or CNS. Doing single leg work, for example, is quite advanced to start with. I can see your train of thought, but if she has difficulty standing on two legs, is lacking intrinsic stability and global muscle coordination, standing on one leg will help her to create compensations.
You have to begin to think of what movement patterns your client is required to do in her everyday life (i.e., push, pull, bend, twist, lunge, walk, squat, rotate). These are what are considered a primal standard, but what is her primal standard? As well, you can still begin with these patterns but in a more regressed pattern. Example: A squat is a primal standard, so maybe for her do a SB with DB against the wall. If we regress it, we can go to a Gravity machine squat and then to a supine hip extension back on back. So you have to think of where she needs to start from in order to get her where she needs to be.
The only technique I have seen that actually trains the CNS is what is called DNS by Kolar. This is the work of Janda, Lewitt and Voijta out of Prague and Germany. It is the study of infant/ontogenic development and how CNS development through primitive reflexes, primal movements, stereognosis (recognizing objects through touch), somatognosis (body awareness), motivation and desire create morphology. This is done through palpating reflex locomotion points on a person’s body and using supine and prone infant positions to tap into the nervous system. This influx of afferent stimulation taps into the cortical level, rewiring faulty movement patterns. To learn more about this technique and to find a practitioner in your area, visit www.rehabps.com.
As for exercise, my best recommendation at this point, if you can’t find a DNS practitioner in your area, would be to find a CHEK Practitioner Level 4 or have your client work initially with a Feldenkrais Practitioner. All of these practitioners will work with regressed primal patterns and infant development patterns on the floor. They will increase body awareness by tapping into the CNS through sensory stimulation on the floor focusing on breathing, homologous, homolateral, contralateral and primal pattern movements.
You will see in most of my articles here I always talk about the healing totem pole. When people come to us, we might not be first on the pole. This is a good example. Keeping this client and doing machine work will do nothing but detrain the CNS. As well, just focusing on floor work with no plan or understanding of what you are doing will create and/or reinforce faulty motor engrams. You can learn a great deal from working with these practitioners. I know this might not be the answer you were looking for, but in the end, our goal is for the client’s healing. Good luck.