A man in the middle stage of dementia has a tendency to wander with his gaze downward, which then makes his posture flexed and alters his balance. He also is not aware of his environment and does not pay attention to things above his waist. In order to improve his balance and posture, traditional physical therapy approaches would have focused on gait training using verbal instruction and manual cues. And this approach would have failed.
Conventional therapy approaches using verbal instruction have limited practical application for someone with Alzheimer’s disease because the temporal lobe, the center for language and memory, is damaged. We needed to find another way.
About ten years ago, there was a big push in the therapy community (physical, occupational, and speech) to shift conventional rehabilitation approaches to a more “habilitative” approach. This meant meeting the patient at their current level and working within the confines of his or her skills. These newer approaches paid considerable attention to modifying the environment to make Alzheimer’s patients more successful and independent. This notion still has terrific merit, as any technique that simplifies processes and compensates for deficits provides much more opportunity for success. But it is not enough.
The shift is now back to “rehabilitative”, using what we know about the Alzheimer’s brain to our advantage.
Alzheimer’s disease is a neurodegenerative disease and should be treated as such. Therapists need to view these patients the same way they would evaluate and treat someone with a stroke, brain tumor, or traumatic brain injury. We have so many tricks in our toolbox for treating neurological dysfunction- Neuro-Developmental Techniques (NDT), Proprioceptive Neuromuscular Facilitation (PNF), Sensory Integration (SI)… Alzheimer’s patients respond very well to these approaches because they don’t rely on declarative memory.
The trick to successful rehabilitation in Alzheimer’s is to allow people with Alzheimer’s the time to learn, and to imprint movement patterns through repetition. The expectation is not that the person will have the awareness of learning or have any insight into improved performance. The expectation is that motor learning will happen without any declarative awareness.
The book The Memory Cure by Majid Fotuhi, MD helps support that message.
By focusing on procedural learning, the same type of learning we use to learn how to ride a bike or throw a ball, we can bypass the temporal lobe and the hippocampus, and use other centers of the brain less affected by Alzheimer’s. Such a basic and obvious philosophy… but misunderstood by most.
So back to our example of the man who has poor posture, a downward gaze, and doesn’t look around the room…A physical therapist might focus treatment on getting the patient to take bigger steps and look up as he walks. Telling the patient to do it the right way will not work. Those centers of the brain are damaged. But, he might have more success by having the patient march to music and have him search the room for post-it notes scattered higher up on the walls. This may show great potential in improving gait patterns and posture, but the trick is getting these new patterns to stick.
The man who is repetitively reminded or motivated to look up will develop better posture. The more he practices bigger steps and movement patterns, the more often his brain and body will employ those patterns.
The same is true for a woman with Alzheimer’s who doesn’t notice barriers below her knee. She can be trained to look down to see chair legs and door jams by creating a visual interest and repetitively having her notice them.
You can train a person to be able to locate the bathroom, put on their shoes, and improve their balance through procedural learning. There may be a physical limitation that hinders performance, or a need for visual cues if there is not enough cognitive ability to sustain attention throughout a task, but the premise holds true.
The secret, according to Dr. Fotuhi and a healthy dose of common sense, is repetition, repetition, and repetition. Movement patterns do not require much from the higher centers in the brain. Learning how to move is a basic human function mastered through repetition and practice.
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