Back Pain and Its effects on Balance and Neuropathy

Cynthia Allen with Chus Jimenez

Cynthia Allen: 

This is the Feldenkrais Awareness Summit®. And I’m very pleased to have Chus Jiménez here. She has a PhD, she has studied podiatry, physical therapy, and the Feldenkrais Method®. She is very curious about life and balance and has been exploring this whole package of cognition, emotion, sensitivity, and motor control in the body and how people develop and move throughout their daily life. She’s very dedicated to continuing to explore this arena, including doing research.

What is Peripheral Neuropathy and How can it be Improved through Sensory Motor Training and Feldenkrais Method?

Chus Jiménez: 

Right now, I’m doing research about peripheral neuropathy, the problems, and the deficit in sensory information related to the somatosensory part of our sensory systems. 

How can it be improved through sensory motor training? Peripheral neuropathy is a group of diseases affecting the large distal myelinated sensory fibers of the arms and the legs, mainly affecting the hands and the feet. As you can imagine, people who have problems with this kind of sensory information are not able to properly use their hands and not their feet. The point where I want to pay more attention is in walking. As you have said, I’m a podiatrist as well, and I love that research domain, the balance and the postural control while we are walking. And if you take into account that there are lots of people having problems in the sensory system, affecting mainly the lower legs and the feet, well, we can be aware that maybe it is necessary to do something. And we’ll talk about it. We will talk about it and both sensory motor training and Feldenkrais Method can offer something interesting in this domain.

Neuropathy from Lower Back Injury

Peripheral neuropathy is due to a toxic problem, not an impingement, not a mechanical problem. It’s an injury due to some kind of metabolic and toxic reasons. For example, there are two main causes, two main problems related with peripheral neuropathy. They are diabetes and neurotoxicity due to chemotherapy in cancer patients. The problem here is that there are changes in the peripheral nervous system and we can find strange branches in collateral branches of the peripheral nerves, so these people are not able to feel a simple touch and vibration. They have problems with proprioception as well, which is necessary for moving, for walking. But they are kind of numbness, kind of unknown sensations while they are pressing the floor. But there are a big group of population affected by peripheral neuropathy having pain with, for example, a light touch. So, they are not able to feel the normal sensation but there is strange sensory information related to pain. And it happens in the large fibers of the sensory system. It is not related to the spine or with some kind of radiculopathy.

This is bilateral. They tend to be bilateral. And, well, as I have said, it’s kind of a toxic etiology. Because of treatment and because of high levels of sugar in diabetes. So, the problem is there, located in the distal parts of the body and not in the spine or in the lumbar spine, not other parts.

Peripheral Neuropathy and Balance

Peripheral Neuropathy and Balance

So, what about balance? As an example, let’s say a boy dancing and able to move freely, choosing how he wants to land, to leave the floor. He’s controlling the manner of touching or leaving the floor in a soft, very delicate way. Well, he has control. That’s the point. But, well, he’s a very skilled boy and he has trained a lot. But not everybody has this kind of skilled sensory motor system. So, what’s necessary to have postural control? In order to have balance to control our postural control, our motion, we need to have sensory skills, motor skills, and we have to take into account as well the executive functions, the cognitive functions. Let’s start by the sensory skills and, above all, the somatosensory system, that system mainly affected by peripheral neuropathy. With the somatosensory system, we have the cutaneous stimulus touch. We cannot properly feel what’s happening in our skin. 

As I have said, the feet are very damaged due to peripheral neuropathy, so I’m not able to feel if I’m affected by peripheral neuropathy. I’m not able to feel the contact with the floor properly, I’m not able to feel vibrations or by some kind of variations in the contact with the floor. And not only the cutaneous stimulus but also the proprioceptive system fails. So, I’m not sure about how my ankle is located in space or whether my foot is related to my lower leg. So, I’m not safe while I’m walking. This is quite hard. It is not easy to maintain balance with the somatosensory system affected by this kind of neuropathy. And it happens with both groups of people affected by peripheral neuropathy, with diabetic population, and with people suffering chemotherapy treatment due to cancer. But, with diabetes, having the blood sugar high, we can find a lot more systems, a lot more tissues affected by toxicity of sugar in blood. For example, that’s the case of the vestibular system. It’s another sensory system related to balance. It helps us to maintain our gaze stable despite having our head moving. And, well, it is related as well with the head position in space. But it is affected in a 70% higher probability, it is affected in diabetic population. And it happens as well with vision. Retinopathy, these vision problems related to high levels of sugar in blood. Hyperglycemia due to diabetes. So, in type one diabetes, 80% of people have retinopathy. In the end, with diabetes, these sensory systems are suffering some kind of damage. But it happens as well with motor skills. People having peripheral neuropathy tend to feel weak. There’s a delay in their motor activation of the muscles. They have some kind of atrophy and the tendons are thicker.

The third part related with executive functions, with Cognition is very important as well and sometimes we don’t pay attention to this point. Because, if I want to keep balance and I want to move properly, attending to what’s happening around me, someone is talking to me or there’s some kind of motions, some cars or bicycles or a dog, as you will see in a moment, I need to react, I need to process that kind of unexpected information properly. And diabetes, once again, several studies have shown that we have the cognitive functions affected as well. There is damage in the white matter of the sensory nervous system and a delay in the processing of information. So, we are facing a problem quite completely involving balance in people with peripheral neuropathy because, as you can see, the sensory nervous system is affected as well.

What are the Effects of Peripheral Neuropathy?

Effects of Peripheral Neuropathy

  • Loss of confidence                      
  • Fear, co-contraction
  • Sedentarism 
  • Health decline
  • Lower quality of life
  • Several body representations in the brain
  • Low accuracy
  • Affected by peripheral neuropathy

The consequences of all these scenarios are people having peripheral neuropathy, as I have said, there are other systems as well affected, and have loss of confidence. They are afraid of moving very often and as you may be aware, when we are afraid, When we don’t feel safe, there is a body reaction related to core contraction. All the muscular systems react and create a stiff posture. Sadly it is very frequent that people affected by these kinds of injuries stay at home, becoming Sedentary. To stay at home watching TV on the sofa. There will be a very decline, a very loss in physical function. It will decline as well and it is affecting the quality of life of course. So, if you don’t use your body, you’re going to lose your body image. And something like this in the feet of people affected with peripheral neuropathy. Sometimes it happens as well with the hands but mainly in the feet. When time passes by it’s more difficult to recognize my own body if I’m not able to feel it. I cannot feel it, I cannot move it properly, so the image, the body representation, disappears.

Walking with Peripheral Neuropathy

Walking with Peripheral Neuropathy

How do people with peripheral neuropathy walk? They have actually a slower gait, a wider base of support, longer double support time. It’s not easy to lift the foot off the floor. And when something new is happening they are not able to prevent the possibility of falling down. They are not able to react to new circumstances. Usually they tend to fall down. It is said that they are up to 23 times more likely to fall down than healthy people.

Research: Diabetic, Peripheral Neuropathy and Gait

Research: Diabetic, Peripheral Neuropathy and Gait

Currently working on this research. It has been developed in two hospitals here in Madrid. So it’s quite interesting because it’s a multicentric study. People tend to be old and they have certain problems with their balance. And they are at risk of falling down. We have measured that because there are several Proofs and several tests. In fact there is one very easy to perform, this is the up and go test.

What we’re trying, they are in a risky situation but still they are able to go to the office, to the hospital, the center and receive the lessons we are preparing for them. And the objective is to see if they can improve. If their nervous system has the ability to recover. There are two targets. One of them is to recover the damaged tissue, the peripheral nervous system affected by peripheral neuropathy. And the other strategy is based on compensatory strategies. And as I’ve said here, attention is key. It’s very important. Because we are not only talking about one foot, or the lower leg of a person with some kind of injury. We are talking about the whole human, and the central nervous system as well. And here, the brain, the cerebellum can help the peripheral part to compensate for the damage.

What is the Purpose of the Research Study?

Chus Jimenez: 

The research  study has two goals. And one of the goals is actually wanting to reverse the tissue damage. There are several studies showing evidence related with the improvement in the speed, the sensory nervous transmission. You know, the intensity and the velocity of the nervous system after the training. It has been shown with yoga practice, with Tai Chi practice as well. And in a meaner way, but as well with aerobic training. But we have to pay attention to this point, to our aerobic training because once again people affected by this kind of pathology, usually they are not prepared to run or to use a bicycle or things like that. So we need to start with them in a very realistic and soft manner. And that’s why we want to receive people at a real risk and start, and find a starting point very adjusted to their current situation. So that’s the reason why sensory motor training could be more helpful than other types of training.

It has been shown that in the medial nerve in the hand and as well in the lower legs, twice as fast. And then the intensity increases as well. Another study showed that the branches in the skin, the sensory nerve branches in the skin increased as well. After the training, they have nervous system plasticity and recovery in that local part.

Balance Training for Neuropathy through Feldenkrais Method

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Feldenkrais Awareness Summit

Now, you need to start training balance with a very stable position, probably in a chair. You can progress in this kind of training using the standing up position but with a wall near you. And the kind of progress, the possibility of creating a progression here is to reduce the base of support. So, you start on a chair, standing up later with the feet in a natural position. But later with the feet together or in a tandem position or crossing the legs. Or even in a mono pedal position with only one foot over the floor. But always with a wall near you because this is challenging. But after having trained this kind of skills in a

progressive way, you can add something more. Related to the foot, with the intrinsic muscles and properties of the foot. In this specific part of the lesson, you should start, once again, on a chair. Seated on a chair. And feel your contact with the floor. The contact of your left foot, for example, with the floor. The heel touches the surface. The floor foot as well. Pay attention to each of your metatarsal packs of your left foot. And the pressure in the heel and in the forefoot as well. And start to shift the weight from the rear foot, from the heel, to the fore foot and back. How do you do it? Are you using your knee? Maybe your hip. What about your ankle? Is something happening in your pelvis? Okay, and stop. 

And try to do this using only your ankle. While you are doing this, try to feel the height of your vault, the vault of your left foot, sorry. The internal arch of your left foot. Sometimes it is very useful to feel posture in movement. The preceptors of the muscles, the spindle muscles are not the same when you’re moving and when you’re in a static position. So you perceive the height of your internal arch while you are moving. And now rest, please. And feel what’s the height of your vault on your left foot, now in a static position. How could you increase the height of your vault, in this foot, in the left one? Maybe you can try moving your knee and your hip, your ankle as well, of course. I’m going to ask you to keep touching the floor with your heel and with your path. Even the first one, the first metatarsal path. And try to increase the height of your vault. How can you do it? We’re going to explore at least two ways of doing it. Try to explore if rotating your shin bone is usable for you. Try to use your ankle and your tibia, and your fibula as well to modify the height of your vault in your left foot. Is something happening there? Remember you need to keep the contact of your heel and all your metatarsal paths, keep the contact of all of that with the floor. Now this is something quite unusual for healthy people as well. But with peripheral neuropathy this is really surprising. Sometimes you can help your students, your patients offering the kind of Functional Integration® during their own explorations. You can guide with your hands, with your own motion, because it is very meaningful for them.

But there is another way. Stop for a while and rest. Because now you have used your extrinsic muscles. You have used the lower leg, long muscles from your knees to your toes. But there is a concept very well accepted by researchers that we need to increase the core muscles in the foot as well. You know the intrinsic muscles on the foot, because they’re very important to maintain the stability of the foot. So try to move your knee, your hip, without moving your shin bone. Try to increase the height of your vault in your left foot with your intrinsic muscles. Use the distance between your heel and your forefoot. And try to maintain your toes touching the floor.

Can you feel the changes in your foot? People with peripheral neuropathy will usually feel their feet as if they were a piece of wood. And it happens as well in their brain representation. We are awakening this part of the body. And you can stop here, but I want you to be aware that these kind of exercises should be introduced, and should be used standing up as well. And even with only one foot over the floor. So, with a very reduced base of support. Okay? So that’s very important to create a functional training related to walking.

Source: This is a short excerpt from a longer interview held with Chus Jimenez during the 2019 Feldenkrais Awareness Summit. To see the entire summit offerings go to:   

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Cynthia Allen
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