PT on the Net Research

Encephalitis


Question

I am looking for any information on working with individuals who have had encephalitis and suffered permanent nerve damage to muscles of the lower body, resulting in balance, strength and flexibility problems.

Answer

This is a very tricky question to answer with only a small part of the story. First we must look at the onset of encephalitis. Encephalitis means enkephalos- or brain and itis- meaning inflammation. There are so many different types of encephalitis it is hard to give a cookbook approach. The first thing that must be determined is if it was an acute trauma or if it had come on from an illness. Is the brain still inflamed or are we working with the aftermath of something that has run its course? We will assume that the inflammation is down and we are working from what is left over.

We must go back to our knowledge of motor learning. We must look at the process of motor control, how the brain learns, and how we intend to improve your clients capacity to produce skilled movements. The sensory information, or input the brain receives must at first be very controlled and systematic. Always start your client with the most amount of instability he or she can handle. A common mistake many people do is overload the sensory input and give the client more information than he can assimilate at this time. His brain will use this sensory input to relearn movement patterns and balance abilities. If the sensory input is overloaded the movements will be jerky and uncontrolled. He must slowly create new motor programs which will be stored in his brain to tell him what muscles should work at what times to create an efficient movement pattern.

This process must be done on timeline specific to your client. The exercises should be done in a proprioceptively enriched environment and done in multiple planes. A good place to start is at the core. Practice diaphragmatic breathing and control of the TVA (transverse abdominus). This can at first be done in a 4-point stance. Place your hand on is umbilicus and ask him to pull “up” his abdominals and hold. Start with ten seconds and work up to thirty or more seconds.(reference Paul Chek’s article of Strong and Stable). When he is able to do that efficiently, try the same technique with him standing, lying, sitting, bent over, etc. When he is able to contract the TVA for at least 20 seconds or more, it is time to start the training. I would start with standing on two legs. Have him stand with a staggered stance and contract his TVA. You can then apply very small amounts of pressure to him from all directions and test his ability to stabilize. I have always liked to use manual resistance. You may choose to have them hold a resistance band and just pull and walk around him at different angles. From standing on two legs you can progress to one leg and a toe down. Try the same steps as mentioned above with adding resistance after he can balance on his own. This type of training is not glamorous and does not produce high amounts of muscle tissue. This slow systematic approach in a multi-planar, proprioceptively enriched environment is the way to improve your clients balance, coordination and eventually his ability to regain better function in society. Provided he is further along than possibly I assumed, please use this type of training to enhance what you are already doing. The key is to work in all planes of motion: sagittal, transverse, and frontal. The second key is to challenge the stability aspect. Try having your client do every exercise he is already doing on one leg or one leg with a toe and concentrate on the TVA. The load you are doing will go substantially down at first, but the other benefits will far outweigh what is lost in using a decreased load. Remember, all movement starts at the core! Stabilize the core first and all movements will be more efficient and you will be able to improve balance, strength, coordination and efficiency of movement.

Mike DeMora, BCET