Let it Flow: How Fashion Can Help You Move and Feel Lighter

By Erica DeMarch - June 14, 2019

I just had an incredible session today with my client and wanted to share what I learned.  She ended the session smiling, telling me she felt lighter, less fearful of moving, and fluid.  This was a huge transformation considering she started the session by telling me she’s depressed and not motivated to exercise or move and fearful of falling.
I asked her,  “What do you love? What makes you happy?”
Her immediate response was, “Fashion.” 
So then I decided that our session would start in her closet; I told her she needs a new workout outfit. An hour later, we found ourselves in a completely different place than where we started. I would never have guessed that a new shirt and skirt could change how someone moves so much. (Please note that this may not work for all. Remember: she loves fashion and it’s important to her.)
This brings up an important discussion of really listening to our patients. I’m currently reading Alex Ferguson’s book, Leading, and in the first chapter, he discusses listening. He states, “There’s a reason that God gave us two ears, two eyes and one mouth. It’s so you can listen and watch twice as much as you talk.”  I’ve been really paying attention to the cues, feedback and instructions I provide to my patients to help them move better and I think this quote explains how much we can learn from our patients by listening and watching. 
After she put on her new shirt with bellowing, flowy sleeves and a beautiful skirt, she was ready … but what now?  She laughed and said, “This isn’t a workout outfit!” My first instruction was then to show off the sleeves.  I wanted to see her sleeves flow, swing, move and float in the air.  She started to move her arms out to the side, up and down, twisting and in diagonal patterns.  She started to shift her weight to move her sleeves more. Actually, she wouldn’t stop moving! Then she started to walk. She even was trying to continue to move the sleeves, which improved her arm swing that has been affected by Parkinson’s disease.
I noticed her turns were not as fluid as I wanted them to be as she took extra steps backwards.  I asked her to start her turn showing off the sleeve, almost like a matador, which improved the fluidity of her turn. Then she went onto doing the twist, swinging her dress left and right, concentrating on the amount of movement in her skirt.
She laughed and told her husband, “Erica told me I can buy new exercise outfits if I keep using them to help me exercise!” For her, this was the motivation she needed; to start by wearing a new outfit that makes her feel good and then let her fashionable outfit drive her movement patterns. The visual cue (seeing the movement of the sleeves and feeling it move in different directions) helped her move bigger and more without thinking of every movement or fear of falling. 
We ended with the excellent PD Warrior move called “Tah Dah” (click to read more about this exercise) to show off her outfit. (She used the sleeves on her shirt as a variation instead of the scarves.)
I didn’t have to tell her to lift her arms up as high as she could, twist or swing her arms - seeing and feeling her sleeves and skirt were her cues to move. Hearing her say, “I love fashion,” made all the difference.  Listen to your patients or listen to yourself. What do you love and how can you incorporate it into your life to make you feel better and lighter?

P.S. My fashionista friends, now I’m thinking we need a class for YOU that combines fashion and movement with the outfits we are wearing to drive our movement … and end with a great fashion show! What do you think?  

A Good Reminder to Listen to Your Patients and Apply the Task Oriented Approach to Motor Control

By Erica DeMarch - March 1, 2019

This theory highlights the importance of context. In other words, how you control coordinated movement to achieve a goal or task will vary depending on the person, the task and environment. For example: put me in a large walk-in closet and when I’m reaching, I can stagger my stance and shift my weight to reach. Now, change my environment and put me in a small closet, and this tight space changes my base of support and my strategy. Similarly, if the task changes, it may increase or decrease the difficulty of its balance component. For example, if a person needs to reach high, they may need to stand on their tiptoes, challenging their balance rather than reaching for it lower or at eye level.
I discussed this approach in my class today after listening to my clients in their home or in a class setting discuss their goals for how and where they wanted their balance to improve.  One client with PSP told me he wanted to develop his sit to stand when he gets up from his desk chair. The small space changed his strategy of his transfer and his balance in standing. I was lucky to observe this in his actual environment; if I tested his sit to stand in an open wide environment, his balance control was good.  In a closed, tight space, it changed his movement patterns and strategy and he would lose his balance backwards because he didn’t shift his weight forward.  A simple change of position of the chair and external focus of attention, bringing his hips forward toward the table at the end of the transfer, improved his stability tremendously. 
Next, I taught him one side step and then a 90-degree turn to leave his desk. That sequence was his first exercise in his home program: rise up and at the end of transfer, focus on his belt buckle forward towards the table, next take one step to the side, keeping hips forward (or cue belt buckle towards table) and then eyes initiate the turn in the direction he is turning, followed by head turn, trunk and step to the right to complete the 90-degree turn. Repeat 10-20x.
This was also a concern of a client in my class.  He said, “I can get out of a chair fine, but when I need to turn and walk from that chair, I feel unsteady.” We practiced as a group getting up from the chair, sidestepping, turning in each direction and also in tight spots. One client even grabbed two weights and dual-tasked, holding weights while transferring and stepping.  This was a good reminder that the task, environment and individual are all important in order to achieve a goal, especially when assessing and treating.  
We also discussed how the “eyes are the window of the souls”. Imai et al.  observed that when participants were asked to move in a straight line and turn 90 degrees, a saccade was made in the direction of the turn. A similar observation was made by Hollands et al. in which healthy participants made saccades in order to position their gaze in line with the endpoint of the required travel path. Clients were asked to pay attention to initiate movements with a saccade, then head, trunk and foot. Some clients were shocked at how much easier it was. 
The next time a client tells you they have trouble getting out of a chair, or if you are a client telling your healthcare professional you are having trouble, please elaborate …
Is it from all chairs (high, low, toilets)?
It is only in tight spaces?
Is it perhaps in the dark at night while trying to go to the bathroom?
Does it occur maybe only when you are rushing and moving faster than your comfort level? 
Is it when you are carrying something? 
These are only a few examples, but remember, the importance of content - meaning how you control coordinated movement to achieve a goal or task - will vary depending on the person, the task and environment.  

Hollands MA, Patla AE, Vickers JN. “Look where you’re going!”: gaze behavior associated with maintaining and changing the direction of locomotion. Exp Brain Res 2002;143:221-230.

Imai T, Moore ST, Raphan T, Cohen B. Interaction of the body, head, and eyes during walking and turning. Exp Brain Res 2001;136:1-18.
Srivastava, Anshul & F Ahmad, Omar & Pham Pacia, Christopher & Hallett, Mark & Lungu, Codrin. (2018). Relationship between saccades and locomotion. 10.14802/jmd.18018.

Woollacott MH, Shumway-Cook A. Concepts and Methods for Assessing Postural Instability. Journal of Aging and Physical Activity, 1996,4,214-233 O 1996 Human Kinetics Publishers, Inc

New Year / New Habits: Laying Down a ‘New Trail’ in 2019

By Erica Demarch - December 31, 2018

I wanted to share an inspiring post I read from Anna Louise-Bouvier on LinkedIn.  I think it’s quite fitting as we all reflect on our goals for the New Year. 
She wrote: “I always find it fascinating to explore the relationship between the ‘habit’ research and the ‘addiction’ research. The path to laying down new positive habits is so relevant to understanding the paths we lay down to change bad habits. Whilst they are different in many ways there are also some commonalities.”
Below is a beautiful analogy that relates to someone trying to stop drinking, but you could also relate it to building any new habit. As health professionals, we understand how important it is to help people lay down new hiking trails in their brains ... whether it’s exercising, mindfulness, sleeping, eating or any of the other positive health behaviors we try to build.

Just as a path becomes smoother and simpler to navigate with each use, newly formed habits get easier and more natural with time. It’s simply a matter of continuing down that path we wish to travel until it becomes clear.
What habits do you hope to clear a path for in 2019?
It’s so important for us to lay down new “hiking trails” in our brains ... be it exercising, mindfulness, sleeping, eating or any of the other positive health behaviors we try to build. It may be a difficult or slow path in the beginning, but the more we do it, it will become more comfortable and easier.
As I reflect on 2018 and look forward to 2019, I am planning to start new exercise habits, one step at a time. My first step in this plan is to add daily stretching.
Make a Habit of Stretching
We all know stretching is good for us, especially if we have postures such as sitting for a long time at a desk, carrying a child, participating in a recreational activity or sport like biking or running, etc.  We know there are so many benefits to stretching; it increases blood flow, flexibility and range of motion, and even reduces stress. If we are more flexible in our spine and legs, we also have better balance and can use our equilibrium strategies (ankle, hips and stepping) more efficiently.
We know how important it is for us to add stretching to our daily routine, yet why aren’t many of us doing it? Our lives get so busy that we end up skipping this important and quick step. How do we make stretching a habit?
I’m a physical therapist and even I’m guilty of omitting a good stretch. I watch my young children and even my dog stretch before they get up, but why don’t I do the same? Most mornings, I am in such a rush to get my day and my family’s day started that I just dive right in. Do you do the same? (Perhaps you do stretch right when you wake up, and if so, CONGRATS – you are one step ahead of me!)
Charles Duhigg, the author of The Power of Habit talks about the framework of forming a new habit:
• Identify the routine • Experiment with rewards • Isolate the cue • Have a plan
Let’s use this framework to start a habit of stretching:
Identify the routine: You can start by trying some of the exercises in this video of stretching in the doorway. 
Video of stretching in the door frame
Experiment with rewards: This may be different for each of you. It may be as simple as you feel better/more balanced, maybe you perform better at a sport, or you look better with improved posture.
Isolate the cue: The cue is a reminder to do stretches. Perhaps it’s every time you walk through the doorway of perhaps your bedroom or bathroom. I like to start after a habit I already do, such as after I brush my teeth or while I’m waiting for my morning coffee.  There you have it - my plan is to stretch while I’m waiting for my coffee in the am and after I brush my teeth at night!
Have a plan: When are you going to stretch? Let’s start today! My plan is: every morning and night, waiting for my coffee and after I brush my teeth, I will do my doorway stretches (extend, sidebend and rotate). The doorway provides feedback on foot position (wide or narrow stance will change your stretch) and can help you deepen your stretch by reaching higher or moving your hips to the side to touch the doorframe.  

Please comment and share your plan for a new healthy habit!


How Balance Matters Can Help Train Sit to Stand

By Erica DeMarch - November 2, 2018

How Balance Matters Can Help Train Sit to Stand
Improve the timing and amplitude of weight shift to decrease loss of balance backwards
No plopping - improve control of stand to sit
I recently listened to a great podcast called "The Therapist Who Said Too Much" from Senior Rehab Project, sponsored by the Academy of Geriatric Physical Therapy.  It really struck a chord with me.  After it was over,  I continued to reflect on the cues and feedback I provide to my patients during our sessions together.
While helping a patient with sit to stand, you may have used the cue “nose over toes” to help shift their weight forward. If you have, you know that sometimes it works and other times you need alternate cues or feedback. I tend to explain A LOT. I have even explained the definition of balance (center of mass over base of support) with the hopes that my patient would shift his weight forward better. I have learned through experience though that sometimes less is more.
Is there a way to help provide simple processing with less verbal instruction? Have you ever tried auditory feedback?
When we use our voices, we can say the same word in different ways, expressing different emotions or meanings each time. When using auditory feedback, the click sounds the same every single time it is heard; its meaning never varies. When you hear “click-click” while using the Balance Matters system, you know you performed a movement correctly, motivating you to do it again. 
Training Sit to Stand:
Using multi-sensory feedback using the Balance Matters system will improve an individual’s awareness of their starting posture and transitional postures. The auditory feedback in the footpads helps promote improved timing and sequence of the task. Sometimes, an individual’s body awareness is poor due to various reasons and they are unaware of their body position prior to a transfer; this sets them up for failure. Feedback can help engage the patient during all phases of sit to stand transfers (preparatory/ starting alignment, transitional movement and the final standing posture.)   
  1. Verbal Cue: “Activate the back clicker in the footpad.”
    • This will improve starting alignment by putting weight on the heels with improved anterior pelvic tilt and weight through the legs, activating the quads.
  2. Verbal Cue: “Activate the front clicker in the footpad and stand.”
    •  This improves the next phase of forward weight shift during sit to stand.
  3.   Verbal Cue: “When standing, keep all clickers quiet.”
    • At the end phase of standing, all clickers should be quiet. (If there is an increased sway in one direction, the auditory feedback will provide the individual with which way to shift their weight.)
  4. Verbal Cue: “Sit and keep all clickers quiet.”
    • During stand to sit, try to keep all clickers quiet until they touch the seat with their bottom. This is effective for the temporal (timing) part of the transfer so a “plop” doesn’t occur. This can happen if timing of weight shift is the issue and they shift their weight to their seat too soon and do not keep their COG over their feet. 
Simple instructional cues:
Sit to stand:  Activate back clicker, activate front clicker while you stand, keep all clickers quiet during standing. 
Stand to sit: Keep all clickers quiet until bottom is on the seat.
Progressions and intervention ideas to consider depending on patient goal:
  • You can perform part practice (only one phase of the transfer).
    • Preparatory phase: Work on good starting posture, activating back clicker to promote anterior pelvic tilt and increased weight bearing through the legs.
    • Transitional phase: Reach forward with arms and activate front clicker to promote anterior weight shift.
    • Transitional phase for stand to sit: partial squats to sit down keeping clickers quiet to improve the timing of weight shift and decrease a “plop”.
  • You can progress by using foam footpads to activate the vestibular system or sit to stand with staggered stance and step to work on step initiation.
  • You can also perform eyes closed to improve balance in dimly lit environments.
    • This is important when standing up from bed to walk in order to go to the bathroom at night. An article “Effect of Sitting Pause Times on Balance After Supine to Standing Transfer in Dim Light” mentions that the risk of falling for older adults increases in dimly lit environments. The results of the study suggest that longer sitting pause times may improve adaptability to dimly lit environments, contributing to improved postural stability and reduced risk of fall in older adult women when getting out of bed at night.  This is an important topic on how the speed or timing to adapt in different environments (dim lit or uneven surfaces) can change our overall balance and postural control and should be integrated into balance exercises and goals. 
  • The starting stance position (feet parallel versus a slight staggered stance) makes a difference during sit to stand transfer speed and initiation of gait. 
    • Kawagoe et al. demonstrated that forward displacement of CoG during standing up was significantly longer in normal foot placement when compared to posterior foot placement, which was referred to 10 cm behind the normal position
    • Posterior foot placement in combination with augmented arm position associates with faster FTSTS times in individuals with chronic stroke (Kwong et al 2014)
    • It may be more desirable for persons with stroke to place the affected foot behind the unaffected foot when performing STS to increase affected ES and GM muscle activation. (Nam et al 2015)
    • Translating the swing limb ½ foot length backward appears to enhance the interaction between posture and locomotion, which may have therapeutic potential for improving gait initiation performance. (Dalton et al 2011)

In another blog, I will discuss how to use auditory feedback while training to step at different speeds, stepping to various surfaces and turning.  An individual may have good postural control stepping or turning at one speed but not another; it is important to assess and then train appropriately.

EG Johnson et al. Effect of Sitting Pause Times on Balance After Supine to Standing Transfer in Dim Light J Geriatr Phys Ther. 2017 Jun 01
Podcast: “The therapist who said too much” from Senior Rehab Project sponsored by the Academy of Geriatric Physical Therapy
Cacciatore TW, Gurfinkel VS, Horak FB, Day BL. Prolonged weight-shift and altered spinal coordination during sit-to-stand in practitioners of the Alexander Technique. Gait & posture. 2011;34(4):496-501.
Hirschfeld H, Thorsteinsdottir M, Olsson E. Coordinated ground forces exerted by buttocks and feet are adequately programmed for weight transfer during sit-to-stand. J Neurophysiol. 1999;82(6):3021–9. [PubMed]
Brunt D, Greenberg B, Wankadia S, Trimble MA, Shechtman O. The effect of foot placement on sit to stand in healthy young subjects and patients with hemiplegia. Arch Phys Med Rehabil. 2002;83(7):924–9.
Kawagoe S, Tajima N, Chosa E. Biomechanical analysis of effects of foot placement with varying chair height on the motion of standing up. J Orthop Sci. 2000; 5(2):124-33.
Kwong PWH, Ng SSM, Chung RCK, Ng GYF. Foot Placement and Arm Position Affect the Five Times Sit-to-Stand Test Time of Individuals with Chronic Stroke. BioMed Research International. 2014;2014:636530. doi:10.1155/2014/636530.
Nam I, Shin J, Lee Y, Lee MY, Chung Y. The effect of foot position on erector spinae and gluteus maximus muscle activation during sit-to-stand performed by chronic stroke patients. J Phys Ther Sci. 2015 Mar;27(3):571-3. doi: 10.1589/jpts.27.571. Epub 2015 Mar 31
Dalton E, Bishop M, Tillman MD, Hass CJ. Simple Change in Initial Standing Position Enhances the Initiation of Gait. Medicine and science in sports and exercise. 2011;43(12):2352-2358


Listen! Why Use Auditory Feedback?

August 3, 2018


It is important to listen in order to improve the
 speed, timing, symmetry and rhythm of movements

Tell me and I forget. Teach me and I remember. Involve me and I learn.
Benjamin Franklin

• How effective is the feedback you provide to your clients when helping them learn new movement patterns?

• What is your style of intervention? Telling, teaching, or involving?

• What type of feedback do you provide? Visual, auditory, tactile, or a combination?

• Is your feedback immediate or do you decrease and fade it as a patient progresses?

Why use auditory feedback?

This is an interesting question that can be applied to people of all ages.  For example, watching my two young kids learning new physical skills, I have to decide when is it necessary to step in and when do I let them learn from their mistakes? What strategies help people learn faster and retain new movement patterns?

For our clients, we want to help them learn new movement patterns that are efficient, safe, and effective.  To achieve this, we must consider the type of feedback we provide. We need to connect with them on multiple levels:
  • Involving clients helps them to learn from their mistakes and problem solve to correct their errors/movement patterns.
  • Engaging them promotes cognitive awareness of movements that were previously automatic and unconscious.
  • Highlighting improvements results in better performance and outcomes.
  • Motivating them builds on the eagerness to perform more repetitions and practice! 3,4,6
When designing a program that incorporates feedback there are many influential factors to consider 6-8:

Today’s discussion will focus on modality, specifically auditory feedback and why you may use auditory vs visual or tactile feedback.  I have used feedforward cues such as a metronome but a limited amount of auditory feedback within my practice due to the limited resources. Audition, the sense of hearing, enables the perception of rhythm and speed. Auditory feedback provides temporal information such as speed and timing. It improves step symmetry and enables the perception of periodicity, rhythm, and cadence.

The study of Ronsse et al. (2011) 5 highlights the importance of choosing the right modality for the intended goal. Two groups of participants acquired a new bimanual coordination pattern. Performers had to continuously move both wrists back-and-forth while maintaining 90°-out-of-phase (a quarter of the cycle) using visual input reflecting coordination as well as auditory pacing to integrate the timing of both hands. Behavioral findings revealed that the visual group became dependent on this augmented feedback performance, whereas the auditory group performed equally well with or without augmented feedback by the end of practice. Functional magnetic resonance imaging results corroborated these behavioral findings. The visual group showed increased neural activity in sensory-specific areas during practice which is indicative of reliance on augmented feedback. Conversely, the auditory group showed decreased neural activity in areas specifically associated with cognitive/sensory monitoring of motor task performance.  This study is one of many that explains the benefits of using auditory feedback for the timing of movements.6 Visual feedback is important for the acquisition of a skill but it is important to gradually decrease visual feedback for effective long-term retention.  Visual feedback also may be better to improve spatial parameters of movement vs temporal parameters (timing of movements).6

The following video demonstrates how auditory feedback (in the forefoot and rearfoot) from the Balance Matters system improves the timing of movements. The individual is blind and could not stand tall with good posture without falling backwards.  He appears to be looking down but his flexed posture was actually stabilizing him. Initially he worked on standing upright using auditory feedback from the footpads under him.  If he started to lose his balance backwards he shifted his weight forward faster to activate the front clickers to prevent a fall.  Once he was able to stand with good posture he progressed with head motions and arm motions and standing on various type of footpads to maintain good postural control. He then progressed to dynamic stepping. Watch as he achieves improved stability and posture after six weeks as he receives auditory feedback to quickly shift his weight forward and improve the speed and timing of his lateral weight shift to sidestep. Although he has improved, he still has goals to continue to improve his postural control and sensory orientation.


Reflecting on the verbal cues I provided, it may have been more effective to increase his external focus of attention as I mentioned in my last blog. Instead of “shift your weight to your toes or front part of your foot” being more specific by instructing “when you hear the front clicker of the pads, push through it to make it quiet”.  I could have used another cue to increase his awareness to the sound of the clicker to improve the speed of his weight shifting to discourage losing balance backwards.  I believe our instructions, cues and feedback still needs to be researched further to achieve optimal outcomes in various stages of rehab.
I love how learning is a two-way street and that our clients also teach us how to become better clinicians. This client’s blindness brought to light the degree to which I rely on visual demonstration.  I realized how important auditory and tactile cues are in helping to change movement patterns. Try Balance Matters to improve the timing and symmetry of movements. Stay tuned for another blog and video demonstrating how to use auditory feedback for the timing of weight shifting during sit to stand and stand to sit transfers and how to prevent “plops”.

  1. Chiviacowsky, S., & Wulf, G. (2007). Feedback after good trials enhances learning. Research Quarterly for Exercise and Sport, 78, 40–47
  2. Dozza M, Horak FB, Chiari Auditory biofeedback substitutes for loss of sensory information in maintaining stance.Exp Brain Res. 2007 Mar; 178(1):37-48.
  3. Huang, H., Wolf, S. L., & He, J. (2006). Recent developments in biofeedback for neuromotor rehabilitation. Journal of Neuroengineering and Rehabilitation, 3(1), 1–12.
  4. Molier, B., Van Asseldonk, E., Hermens, H., & Jannink, M. (2010). Nature, timing, frequency and type of augmented feedback; does it influence motor relearning of the hemiparetic arm after stroke? A systematic review. Disability and Rehabilitation, 32(22), 1799–1809.
  5. Ronsse, R., Puttemans, V., Coxon, J. P., Goble, D. J., Wagemans, J., Wenderoth, N., & Swinnen, S. P. (2011b). Motor learning with augmented feedback: Modality-dependent behavioral and neural consequences. Cerebral Cortex, 21(6), 1283–1294. 5. Sigrist, R., Rauter, G., Riener, R. et al. Augmented visual, auditory, haptic, and multimodal feedback in motor learning: A review. Psychon Bull Rev (2013) 20: 21.
  6. Sigrist, R., Rauter, G., Riener, R. et al. Augmented visual, auditory, haptic, and multimodal feedback in motor learning: A review. Psychon Bull Rev (2013) 20: 21
  7. Tzetzis, G., Votsis, E., & Kourtessis, T. (2008). The effect of different corrective feedback methods on the outcome and self confidence of young athletes. Journal of Sports Science and Medicine, 7, 371–378
  8. Wulf, G., & Shea, C. H. (2002). Principles derived from the study of simple skills do not generalize to complex skill learning. Psychonomic Bulletin & Review, 9(2), 185–211

Train to Take Longer and Faster Steps with Trunk/Leg Coordination Using Multi-Sensory Feedback

June 22, 2018

Exercise Example: Step forward or backwards with trunk extensions and rotation

The first goal of these exercises is to coordinate head, trunk, leg movements. The second goal is to target hip extension and push off to help with forward progression, foot clearance of swing leg and increase walking speed.


Visual feedback
Improve spatial parameters of movement
by promoting increased trunk extension and rotation.

Auditory feedback
Improve temporal parameters of movement by
promoting faster and symmetrical stepping.

Tactile feedback
Improve spatial parameters of movement
by promoting awareness of step position (length and width)
eyes looking at laser for trunk motion rather than looking down for foot position.

Walking requires us to move the hip 10-15 degrees beyond normal
extension in standing in order to achieve propulsion from the leg and foot.

Without Feedback
Decreased hip extension, push off
and trunk rotation
Decreased dissociation of hip/trunk
With Feedback
Improved hip and trunk extension,
push off and trunk rotation
Improved dissociation of hip/trunk

In this exercise feedback may help someone who:

  • Stiffens their trunk to hold upright when increasing speed or length of steps
  • Unable to dissociate head and trunk or trunk and leg while stepping
  • Heavily relies on vision for walking and requires increased proprioceptive training
Substitutions can occur if the hip won’t extend (I.e. Hyperextension of the lumbar spine).

If there is limited hip mobility then after mobilizations and stretching this exercise can help train a new pattern of using the new range of hip extension.

To replace a poor pattern (i.e leaning forward at the trunk to bring leg behind) this exercise will help a client to move in a new pattern (trunk erect and hip extended). Movement is the only way the CNS gets information. For anyone who has ever lost work on a computer you know you need to save it frequently to maintain it. To maintain a new movement pattern with new range of motion you have to continue to exercise and then use it in function (i.e. walking).


What's your focus? Improving Motor Performance

The Importance of External Focus of Attention

By erica demarch - May 24, 2018

I just reread a great article on the OPTIMAL theory of motor learning and decided to apply it to my class for people with PD this am and was impressed with the results.  I had the attendees focus on external focus of attention rather than internal focus of body movements.  For example, during the warmup, I said “reach toward the ceiling and push through the floor” to improve posture extending their hips and knees as they pushed through the floor and extending their trunk, elbows and fingers as they reached toward the ceiling.  Reflecting on my past cues, at times I emphasized more on the internal focus of body movements, such as spread your fingers, shift your weight to your left foot etc. The research shows changing just one word or focus can change a movement pattern.  Yoga and Tai Chi and some sports do this well, but do we do this in everyday movement training? 

Try today to use an external focus of attention and see if it improves performance. 

The article I read is “Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning” by Rebecca Lewthwaite and Gabriele Wulf.  It states “Evidence has amassed for the advantages of concentrating on or adopting an external focus of attention on the intended movement effect (e.g., motion of an implement, striking a target, exerting force against an object) relative to an internal focus on body movements.”

Stay tuned for my next blog using auditory feedback to help with the timing and speed of movement. 


Making Changes...One (Sparkly) Step at a Time

By Erica Demarch - November 27, 2017

Making Changes … One (Sparkly) Step at a Time
“Fancy Nancy” is an uplifting, positive patient who has been such a pleasure to work with. She spreads sparkle wherever she goes … literally. Nancy put sparkles on her cane and sells similar ones to others to brighten their days. Just like it is with any of my patients, it was such a pleasure to see her finally reach her goal. This past week, “Fancy Nancy” walked into the clinic with a huge smile and was so excited to tell me that she had just returned from a successful trip to New Mexico with a friend, where she enjoyed hiking, walking, visiting all the galleries and dining out. She’s now planning a trip to Las Vegas with her son to see a show.  
Just a few months prior to this day, Nancy told me that she needs to stop traveling, something that she truly loves, due to her Parkinson's disease. Determined to get her back to her passion, we sat down and worked on a plan together to make sure that she could travel again.  While I was at a conference speaking, I received an email from her asking me to please call her ASAP. Nervous that something had happened, I contacted her immediately. I was so relieved to hear that she was calling because she wanted to tell me personally that she had just booked a trip; she was so excited and so proud. I am thrilled that this trip was such a success, and that she feels confident enough to book another one.
“Fancy Nancy” may think that I have given her a gift by helping her return to her passion. Sure, I may have helped to push her toward her goal, but I hope she realizes that the gift she has given me is equally as wonderful. Not only did she brighten my day every time she came for an appointment, her positivity and drive – and in turn – success, pushes me to keep going. I ventured into starting my own company and developed a product (Balance Matters) in hopes of improving people's balance. We are currently working on researching an approach, and there are definitely days where I need to turn to my patients for that extra push. These success stories and my determined patients help me continue to move forward so they can all reach their individual goals and enjoy life.
I hope this story inspires both patients and other health care professionals as much as “Fancy Nancy” has inspired me. Keep pushing forward and never give up on the big picture while taking the small steps necessary to reach your success.
Pleased to be keeping you “balanced” -
P.S. If you’d like more information on “Fancy Nancy’s” sparkly canes, please email Nancy at

Excerpt Written by Erica DeMarch in the Pathology Textbook

A Therapist's Thoughts: Parkinson's Disease

Every patient with PD should be educated on neuroprotection and neuroplasticity, and the earlier they are educated, the better.  In treating those diagnosed with a progressive disorder, you want to empower them on how they can change their brain and maximize the benefits of their exercise program.  The intensity, difficulty, complexity and specificity of exercises need to be explained and incorporated in their exercise routines.  Although they may consider themselves “active,” their intensity may not be at a sufficient level to promote the most benefits.  An easy way to access the intensity of their walking is to count their steps per minute and use a metronome to maintain their speed and/or increase it (100 steps/min would be considered moderate intensity).  Your role as a physical therapist is to increase the intensity level of practice beyond their self-selected energy expenditure.  Many of my patients reports therapists do not work them hard enough and give in to their complaints.  Make sure you always try to motivate and work your patient to their fullest ability; help them understand they are capable of moving more than they think. 

Besides the intensity of exercise, the quality of movement maintained during repetitive movements is very important.  One of the main movement problems due to basal ganglia disorder is the failure to automatically maintain an appropriate amplitude and timing of sequential movements.  Training should include awareness of complete muscle activation, attention to effort and amplitude of movement.  Use auditory cues (music or metronome while walking on a treadmill), visual or tactile cues (touching a target to maintain range of motion during calf raises) will immediately enhance the size and timing of their movement and therefore maximize overall performance.

You should become aware of your patient’s goals and interests (i.e. sports, hiking, dancing) and incorporate task specific exercises to help improve outcomes and compliance.  For example, if your patient plays tennis, incorporate the racket in your session during reaching and stepping exercises.  

Get the Book Here


How Well Do We Maintain Our Own Bodies for Balance?

“Life is like riding a bicycle.
To keep your balance you must keep moving.”

-Albert Einstein

How well do we maintain our own bodies for balance? As well as a rider would maintain their bicycle? If we want to keep both upright and moving forward, both our body and our bicycle need to be in good condition.  The need for a maintenance plan and for repairs of a bicycle are determined bya professional mechanic after careful analysis of its current condition. We should also see health care professionals for an individualized plan for our balance to ensure we continue to keep moving forward.  The better you maintain your bicycle, the less repair you will need.   If you damage a bicycle during a crash, your mechanics goal is to restore function for a smooth ride.  Similarly, if you fall, appropriate health care providers can help determine the cause, improve function and provide insight and education to prevent future falls.

Balance Maintenance Tips 101

1. Tune up services: Meet with your health care team!

  • Check and review your medications with your MD
  • If you experience lightheadedness, dizziness or vertigo check with your physical therapist and MD to assess the cause: low blood pressure, BPPV…
  • Constipation or urinary incontinence can become the cause of a fall.Straining for a bowl movement can cause a vasovagal (drop in heart rate) response or decreased blood pressure resulting in dizziness or falls or rushing to the bathroom especially at night can cause falls
  • Have your vision checked including:
    • Visual acuity
    • Sensitivity to contrast (color and brightness): may have problems with night vision, fail to see that you need to step down from a curb onto similarly colored pavement
    • Dry eyes (decreased blinking)
    • Mobility of the eyes may be slower with smaller movements decreasing available visual field.
    • Convergence of the eyes may be impaired resulting in inefficient depth perception or double vision
    • Problems associated with aging: glaucoma, cataracts, macular degeneration
  • Be screened for a peripheral neuropathy, a condition that can decrease sensation in your feet and cause poor balance
  • Have your balance evaluated by a physical therapist specializing in balance
  • Discuss with your MD disturbed sleep, fatigue, exhaustion, stress
  • Have your cognition checked: executive function (task-switching, planning, working memory).  Impaired cognition can lead to inattention causing increased risk for falls 

2. Equipment and proper fitting

  • Shoewear:
    • Do not wear rubber soled shoes because they grip the floor and may cause you to fall forward if your foot catches
    • Wear orthotics if needed and well fitted shoes
  • If you need an assistive device (cane, walking stick, walker) or wheelchair have it checked for proper fitting and use 

3. Prepare and know your surroundings

  • Make your home safer
    • Avoid clutter, throw rugs, tight spaces
    • Install grab bars and use non-slip surfaces in the bathroom if needed
    • Use of adequate lighting and contrast colors especially on stairs-     
  • Outdoors
    • Be aware of the terrain: uneven surfaces, hills, inclines, curbs
    • Know the distance and your speed to get from point A to B 

4. Train for the Ride - Exercise!

  • Improve your Biomechanics/ Alignment
    1. Alignment: Keep body centered
      • Stretch and strengthen trunk for mobility
      • Make your base stable and safe
      • Wear proper shoes
      • Control dystonia with botox or physical cues
      • Decrease pain in feet and toes
      • Improve flexibility and strength of ankle/foot/toes
    2. Improve functional strength
      • Learn and practice correct technique to rise from a chair and from the floor to a standing position
      • Perform rhythmical reciprocal movements 
  • Starting
    • Don't let your feet get stuck to the floor during walking, turning, negotiating small spaces or approaching obstacles; overcome freezing by shifting weight from side to side like you are dancing, count 1, 2, 3, and then step forward, try another movement or step in another direction, use a visual cue: pretend to step over something or point a laser light and step on or over it, march in place, don’t fight the freezing and try to step harder, shift your attention to move your arms rather than legs 
  • Stopping / Check your brakes:
    • If you need to stop abruptly but feel like you will continue to move forward (festination): Stop, do not continue to try to move forward. Stand tall head over your feet, if your head is forward your feet will try to catch up to your head 
  • Changing gears / Dual tasking
    • Switching tasks and/or performing tasks simultaneously can alter your quality of walking and increase your fall risk.  
  • Turning radius
    • When turning try to make wide turns and shift your weight to the outside leg
    • You may need to step backwards or sidestep to change directions; practice every day! 
  • Use your senses to manage your wobbles
    • Over reliance on the visual system for balance can cause falls when in dim lit areas, turning your head to scan your environment, or crowded areas.   It also changes your posture as you look down.  You need to make good use of your vestibular system walk on inclines and uneven ground
    • Keep your foot from catching when walking thinking of stepping while lifting your toes
    • If you experience a loss of balance do you step quickly enough, use your hips and/or ankles appropriately?
  • Speed:
    • Using devices that keep a rhythmic beat, such as a metronome or music may help to walk faster and take longer steps and decrease fall risk 
  • Improve confidence: Fear of falling increases your risk!

Erica DeMarch, PT and Kenda Fuller, PT
South Valley Physical Therapy