Motor control elements and cognitive elements
Author. Maite Tubía Tejada
Musical Body Rhythmics proposes for the functional re-education of movement in brain injury-hemiparesis, the learning of rhythmic sequences and of steps and figures typical of ballroom dancing.
This learning and practice is carried out in two stages:
- Firstly, steps are learnt in isolation in the exercises of the rhythmics programme (walking, lateral displacements, balance, etc.) because they are rhythmic sequences that establish a harmonic dynamic for the control of movement.
These dance steps help to find the right supports for weight loading, body perception and spatial orientation.
- At an advanced stage of the training, the steps and figures that the patient manages to master in an spontaneus choreography of dance in couple are joined. The patient learns how to chain steps and figures to achieve fluency. The patient learns to follow and, if he or she wishes, also to lead.
How, when, why to introduce in the functional re-education programme of movement in hemiparesis, steps and figures of ballroom dances.
First stage
All rhythmics sessions, during the whole training period, begin with a walking exercise to the rhythm of the music. The patient is familiarised with the gait exercises and all the elements that need to be corrected in order to make the gait as organised and symmetrical as possible in terms of posture, weight distribution, step rhythm at the appropriate speed, stride length, leg and foot orientation.
The first thing to establish is the rhythm of the steps and that these are safe. If a person has a rhythm in his steps, it means that he supports the weight equally on one leg and on the other.
The legs alternate in the weight load. If he do not keep the rhythm in the steps, it means that there is an asymmetry in the distribution of the weight: one of the legs is overloaded and the other does not perform its function correctly.
There are people with hemiparesis who without any control to correct gait can go 76-82 steps/minute. This is not their gait mastery speed if they do not load their weight correctly on the affected leg and drag it, backward affected hemibody, there is no rhythm in the steps, the stride length of both feet is unequal, the affected arm adopts a protective attitude. The aim is not for the patient to walk the maximum number of metres but to organise the gait. In rhythmics, we will slow down with the help of a piece of music, for example: to 60 beats/minute (which translates into 60 steps/minute) and this will allow the patient to start consciously correcting the elements that go wrong. The patient will stop as many times as he loses the minimum organisation he is able to maintain. This period requires patience from the therapist and the patient because we will have to stop every few steps. However, all the conscious corrections will make the gait become automatic. When the patient manages to maintain the organisation of the gait for 3 songs in a row, it will be good to remind him of the stage when we stopped 5 times in a single song.
For the young man we will see in video 1 of this article, with congenital hemiparesis and intellectual disability, his minimum rhythmic speed at the start of training was 58-60 steps/minute. At this speed he could concentrate on trying to overcome his difficulties, which were as follows:
-the right foot was dragging
-leg and foot were in external rotation
-the right knee did not flex
-spasticity in the ankle and no mobility in the right foot
-backward right hemibody
-right leg did not load the weight correctly and when standing in the static position remained in external rotation.
The speed of the music in the video of the young man practising a partner dance is 104 beats/minute.
A large number of complementary exercises form part of the walking exercises in the rhythmics programme. They consist of introducing rhythmic sequences and arm-hand coordinations into walking.
Lateral steps are also started to be learnt at the beginning of the training. Once the patient has improved in the simple lateral displacement exercises, the first rhythmic sequence he learns is – Rhythmic sequence in parallel lines articulating lateral displacements with forward displacements.
The next rhythmic sequence to learn is the basic rumba step to improve the weight load on the paretic leg and to control the stopping of the movement on said leg. Once the basic rumba step is learned, the patient practices it on the place without advancing to master it.
Subsequently, within a marching exercise to the rhythm of the music, the rumba step should be interspersed every two steps. This should be practised with both legs.
Description of the basic rumba step when performed with the right foot:
00: Starting position. Striped foot: right foot (RF). Blank foot: left foot (LF)
1 RF: step forward (simultaneously the left foot is lifted a little).
2 LF: it marks (step without moving) (at the same time the right foot is lifted slightly)
3 RF: step backwards (simultaneously the left foot is lifted slightly)
4 LF: it marks (simultaneously the right foot is lifted slightly)
Repeating the sequence by stepping with the left foot and marking with the right.
Learning this rhythmic sequence requires cognitive work, a mental effort to master the body.
The basic rumba step has the following elements of movement control when interspersed every 2 steps:
– Stopping the walking with the affected leg
– Bringing the body weight backwards with a step backwards with the affected leg.
– Resuming walking with the affected leg without losing the rhythm.
– Marking: the sound foot is lifted and step after each weight load on the affected leg.
Second stage
This is a stage in which the patient has progressed and has managed improvements in motor and cognitive control of walking exercises, lateral movements, arm and hand exercises, etc.
Each exercise of the rhythmics method is in itself a test. If the patient passes an exercise, it means that a qualitative aspect of movement control has improved.
The selection of exercises in the total rhythmics exercises programme is adapted to the individual patient’s motor and cognitive difficulties.
The minimum improvements that a patient with brain injury-hemiparesis, who is undergoing training in Musical Body Rhythmics, must manage in order to incorporate the learning of ballroom dance choreographies into his process of functional movement re-education are:
1 He walks to the rhythm of the music at the appropriate speed in a straight line and in an oval trajectory. He walks in a range of speeds: 70 steps/min…80 steps/min…90 steps/min…even 100 steps/min, without shuffling, keeping gait characteristics constant.
2 He performs simple lateral movements to the left and right
3 He has improved movement and muscle tone in the arms. He is familiar with certain arm exercises and already raises the affected arm above his head, although his posture is not yet correct.
4 He is familiar with certain proprioceptive sensations in partner exercises with the therapist. These sensations are:
– Leading and following: in a large number of exercises the therapist leads the patient so that he feels the movement well done and thus has a reference for the planning of the movement. The patient feels the movement well done by attuning to the therapist’s body so that both move in unison. The therapist can handle him with both hands.
– Unloading of the weight of the body with the hands as a point of support.
– Force nullification with the hands as a point of support.
– Bouncing with the hands
– Lifting and falling
– Tension-traction
5 He walks backwards
6 The mobility of hands and fingers has improved and he is able to correct the wrist flexion posture in the exercises of this rhythmics method designed for this purpose.
7 The patient already performs the simplest arm and hand-leg coordinations of the complementary gait and lateral movement exercises.
Progressive order in learning the dance steps:
1 Basic step of rumba:
It is the first dance step that a person with hemiparesis learns, due to the elements of movement control that this step has, which are:
– Stopping forward movement with the affected leg.
– Bringing the weight backwards with a step backwards with the affected leg.
– Lifting the foot of the sound leg and stepping at exactly the right moment.
– Resuming walking by articulating continuously for a whole piece of music 2 steps + rumba step → 2 steps + rumba step…
The basic rumba step allows to work on these 4 elements of movement control in a harmonic way and with the time reference of the music that will mark the optimal speed for the audio-motor coordination.
2 Marking: stepping without advancing
The patient finds it easier to move forward than to remain in place by lifting each foot to step.
3 Spatial articulations:
– Articulating fluently the change of direction of forward and backward steps.
– Articulating fluently the change of direction of side steps to the right and side steps to the left.
– Articulating fluently the change of steps to:
-side steps
-steps forward
-steps backwards
-basic rumba step
4 Leading and following:
We will practise with the patient a closed form of leading him and an open form.
Closed form: patient and therapist side by side.
When the patient is learning how to intercalate the rhythmic sequences of the gait exercises, we lead him in a closed way so that he can feel the movement well done. To do this, the therapist wraps his arm and hand around the patient’s lumbar waist and holds out his other hand in front of him (the patient places his hand on the palm of the therapist’s hand).
Open form: patient and therapist facing each other.
The therapist takes the patient’s hands and marks signs as in partner dancing, so that the patient feels that there is going to be a change of direction or a change to a rhythmic sequence and becomes familiar with these gestures of the therapist.
5 1st turn:
This is the most anatomical turn.
Patient and therapist face to face holding hands.
The therapist raises his left arm so that together with the patient’s right arm they form an arc. The therapist marks with his hand on the patient’s lumbar waist to pass under the arch and return to the position facing the partner (the arms also return to the starting position). The rotation in this turn is 360°.
Cognitive elements of this turn: path perception and spatial orientation.
Cognitive and motor difficulties that the patient will have:
– He may stand with his back to the therapist or to the side.
– He will lose the rhythm of the footsteps, but this does not matter. What matters is that he perceives and realises the trajectory of turning on his steps. The starting point is facing the therapist and the final position is also facing the therapist. The patient will have to orient himself in the planning of the movement and overcome the tendency to going off on a tangent.
– Motor difficulty: as the patient is attempting a complex movement of the whole body, spasticity will increase in the affected arm. It does not matter. We will let the patient know that the tension in the lifting arm increases, which flexes the elbow and lowers the head. With practice, the patient will be better able to control that spasticity does not increase.
The gaze in the turns
There is an important detail to be taken into account in the turns, that is the gaze.
We will ask the patient to look for us with their gaze and we will warn him to do so. When the therapist sees that it is the right moment, while completing the turn, he will say: Look at me!
6 Open step backwards of rumba:
Both feet alternate stepping backwards (in slight external rotation) and return to a side-by-side foot position. The bodies of therapist and patient will be placed in profile each other. Simultaneously, the therapist with his hand-arm signals the patient to change to this step. The patient will join the therapist’s hand-arm coordination and both will move in mirror. As the spasticity in the affected arm will increase, we will let the patient know this fact and, slowly, slowly, he will do the corresponding coordination, trying to bring the arm to a more natural muscle tone.
00: starting position
1 RF: step backwards rotating the leg and foot outwards. The body faces to the right (simultaneously the left foot is lifted)
2 LF: marks (simultaneously the right foot is lifted)
3 RF: closes by placing next to the left foot
4 LF: step backwards rotating the leg and foot outwards. The body faces left (simultaneously the right foot is lifted).
5 RF: marks (simultaneously the left foot is lifted up)
6 LF: closes by placing next to the right foot
The gaze (and head) is maintained throughout the sequence towards the therapist’s eyes.
This step, by the dynamics it establishes with the weight, helps to find the appropriate supports when stepping backwards. This will have an impact on the patient’s natural movement when in everyday life he suddenly has to take a step backwards (when a door opens, if something throws him off balance, etc.). Conscious movements become automatic with practice and influence the reflexes to something unexpected.
7 Rumba side step:
RF: right foot (striped). LF: left foot (blank)
00: starting position
1 RF: side step to the right (left foot lifts simultaneously)
2 LF: marks (step without moving) (simultaneously the right foot is lifted up)
3 RF: closes by stepping beside the left foot
4 LF: side step to the left (at the same time the right foot is lifted)
5 RF: marks (step without displacement) (simultaneously the left foot is lifted up)
6 LF: closes by stepping beside the right foot
8 Spatial articulations:
The patient becomes familiar with changing from the basic rumba step to the open backwards step and with changing to foot steps on the spot.
Cognitively, keeping in mind, the ability to change movement and sequencing, as well as the kinaesthetic memory of each step and figure are worked.
The patient also becomes familiar with the proprioceptive sensations of the signs that the therapist makes with his hands and arms to indicate that a change is about to take place. The patient will feel the two parts of a sign, which are impulse and gesture.
9 Rolling and unrolling
The patient learns the figure of coiling and its sign (tension-traction) that the therapist makes to lead him to do it.
The turn is 360°, both when rolling up and when unrolling.
10 Turn of catching between the arms
This turn will be used to guide the patient in planning the movement in figure 11, which is the turn to change places.
11 Turn to change places
It is the most complex figure of all, but also the most attractive to the patients.
Patient and therapist exchange places, alternately passing under the arches they form with their raised arms.
Cognitive difficulties: the cognitive elements that the patient will work on are:
-spatial perception and orientation
-Audio-motor coordination: when changing to a turning trajectory, the patient will lose the rhythm of the steps. He will have to make a conscious cognitive effort to keep the rhythm. In this way the maintenance of the rhythm will become automatic. Conscious movements become automatic with practice.
Coordination of the arms: this turn involves both arms in an alternation of movements. Each arm separately goes up and down and remains at rest and then the other arm does the same while maintaining the rhythm.
Entering on time: patient and therapist alternate turns. When one turns, the other waits and each has to enter on time at the moment it is their turn to turn.
Control of eye movement: the gaze
In this turn to change places, the turn of the body is 180°. At the end of the turn, the gazes meet again. We will help the patient to be aware of the gaze by letting him know at the moment he has to look for the therapist’s gaze.
Motor difficulties: on learning this figure, spasticity will increase when lifting the affected arm.
On being attempting the patient a complex whole body movement, spasticity will increase in the affected arm. It does not matter. We will let the patient know that the tension increases on lifting his arm, that he flexes the elbow and lowers the head. We will slowly, slowly make the turn, placing the therapist his hand on the patient’s armpit when he begins to lift the arm and at the instant that the spasticity appears, we will ask him to relax the arm calmly and stretches the arm more. The patient realises that he can improve this fact and with practice he will control better that spasticity does not increase.
As long as that the type of injury and its location allow it, the procedure described in this article is focused on improving motor and cognitive difficulties resulting from cerebrovascular accidents (stroke) in the territory of the left or right middle cerebral artery and resulting from traumatic brain injury (with main damage to the frontal lobe), with the aim of recovering movement control. The procedure is the same for congenital brain damage with hemiparesis and intellectual disability. In this case, the patient has no previous experience of movement control, so the aim will be to develop movement.
The development of rhythmic movement and dance skills is a maturation of the human motor control system. Movement and intellect are linked. For a person with intellectual disabilities, learning ballroom dancing will contribute to a better understanding of his body and what is a mental effort to master his movements. He will also get to know the interaction-communication that takes place between two people in partner dancing.
In video 1 we can see what a young man with congenital hemiparesis and intellectual disability has managed in learning partner dancing after 3 years of training in the Tubía method of musical body rhithmics.The motor difficulties he had at the beginning of the training are described at the beginning of this article. The minimum rhythmic speed in the walking exercises at the beginning of the training was 58-60 steps/minute (the speed of the music 58-60 beats/minute). The speed of the music in this video is 104 beats/minute.
Learning to dance with a partner is a cultural activity. Knowing how to dance brings harmony, expressiveness, beauty, joy, increases self-esteem, favours communication, interpersonal relationships and participation in family and social parties. A person with an intellectual disability who also has hemiparesis, feels motivated to improve their difficulties with rhythmic exercises because he themselves appreciates what they is managing in the movement of their hands, their legs, in doing activities they had never done before and discovers the capacity they has to learn to dance and enjoy.