PD WARRIOR MODULE 1. Copyright PD Warrior 2012

Transcription

1 PD WARRIOR MODULE 1 1

2 PD WARRIOR STATIONS 1 OVERHEAD BALL THROW 2 SQUAT AND STOP 3 SCARF SNATCH 4 LADDER STEP & ARM BURNER 5 DOUBLE STEP TAP 6 BIKE SPRINTS 7 PARTNER BOX 8 BALL SLAMS & BALANCE 9 HELICOPTER PARTNER CLAP 10 TAHDAS 11 BOX STEP 12 SKY REACH 13 GUN SHOT 14 OVER THE RIVER 15 BANDED SIDESTEP 16 SIDE TAP OVER STEP 17 POWER SWIVEL 18 SWISS BALL BOUNCE 19 PENQUIN WADDLE DEGREE CUP CHANGE 21 RIVERSTONE CLOCKFACE 22 PARTNER KICKS 23 SCARF THROW 24 POWER LUNGE 25 PUSH STEPS 26 PARTNER BALL PASS 27 TRAVELLING LUNGE STEP 28 FLOOR KNEEL 29 TWINKLE TOES 30 BALLOON TENNIS 2

3 WEEK 1 WARM UP 1 OVERHEAD BALL THROW STOP AND SQUAT 2 SCARF SNATCH LADDER STEP & ARM BURNER 3 DOUBLE STEP TAP BIKE SPRINTS 4 PARTNER BOX PARTNER BOX 5 BALL SLAMS & BALANCE HELICOPTER PARTNER CLAP 6 TAHDAS BOX STEP 7 SKY REACH GUN SHOT 8 OVER THE RIVER BANDED SIDESTEP COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR SCARVES ARM BURNER LADDER STEPS BIKE BOXING PADS & SHIELD BALANCE FOAM HURDLES AGILITY DOTS RESISTANCE BAND 3

4 WEEK 2 WARM UP 1 OVERHEAD BALL THROW STOP AND SQUAT 2 SCARF SNATCH LADDER STEP & ARM BURNER 3 SIDE TAP OVER STEP POWER SWIVEL 4 PARTNER BOX PARTNER BOX 5 BALL SLAMS & BALANCE HELICOPTER PARTNER CLAP 6 TAHDAS BOX STEP 7 SKY REACH GUN SHOT 8 OVER THE RIVER BANDED SIDESTEP COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR SCARVES ARM BURNER LADDER STEP BIKE BOXING PADS & SHIELD BALANCE FOAM HURDLES AGILITY DOTS RESISTANCE BAND 4

5 WEEK 3 WARM UP 1 OVERHEAD BALL THROW STOP AND SQUAT 2 SCARF SNATCH LADDER STEP & ARM BURNER 3 DOUBLE STEP TAP BIKE SPRINTS 4 PARTNER BOX PARTNER BOX 5 SWISS BALL BOUNCE POWER SWIVEL 6 TAHDAS PENGUIN WADDLE 7 SKY REACH GUN SHOT 8 OVER THE RIVER BANDED SIDESTEP COOL DOWN EQUIPMENT REQUIRED SOFT BALL X1 CHAIR X2 SCARVES ARM BURNER LADDER STEPS BIKE BOXING PADS & MITTS SWISS BALL HURDLES AGILITY DOTS RESISTANCE BAND 5

6 WEEK 4 WARM UP 1 OVERHEAD BALL THROW STOP AND SQUAT DEGREE CUP CHANGE RIVERSTONE CLOCKFACE 3 DOUBLE STEP TAP BIKE SPRINTS 4 PARTNER KICKS PARTNER KICKS 5 BALL SLAMS & BALANCE HELICOPTER PARTNER CLAP 6 TAHDAS BOX STEP 7 SKY REACH GUN SHOT 8 SWISS BALL BOUNCE POWER SWIVEL COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR X2 SCARVES ARM BURNER LADDER STEPS CUPS X 10 BIKE BOXING PADS & MITTS SWISS BALL HURDLES AGILITY DOTS RIVER STONES 6

7 WEEK 5 WARM UP 1 OVERHEAD BALL THROW STOP AND SQUAT 2 SCARF THROW 180 DEGREE CUP CHANGE 3 POWER LUNGE PENGUIN WADDLE 4 CHALLENGE TASK CHALLENGE TASK 5 BALL SLAMS & BALANCE TOE WRESTLING 6 BANDED SIDESTEP RIVERSTONE CLOCKFACE 7 PUSH STEPS SWISS BALL BOUNCE 8 OVER THE RIVER POWER SWIVEL COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR SCARVES CUPS X 10 RIVERSTONES SWISS BALL BOXING PADS & MITTS BALANCE FOAM HURDLES AGILITY DOTS RESISTANCE BAND 7

8 WEEK 6 WARM UP 1 PARTNER BALL PASS TOE WRESTLING 2 DOUBLE STEP TAP BIKE SPRINTS 3 SKY REACH GUN SHOT 4 PARTNER BOX PARTNER BOX 5 POWER LUNGE PENGUIN WADDLE 6 TAHDAS HURDLE CLICKS 7 PUSH STEPS BANDED SIDESTEP 8 POWER SWIVEL OVER THE RIVER COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR X2 HURDLES ARM BURNER LADDER STEPS BIKE BOXING PADS & MITTS BALANCE FOAM CLICKERS AGILITY DOTS RESISTANCE BAND 8

9 WEEK 7 WARM UP 1 PARTNER BALL PASS TRAVELLING LUNGE STEP 2 STOP AND SQUAT HURDLE CLICKS 3 DOUBLE STEP TAP BIKE SPRINTS 4 PARTNER BOX PARTNER BOX 5 SWISS BALL BOUNCE POWER SWIVEL 6 BANDED SIDE STEP PENGUIN WADDLE 7 FLOOR KNEEL ARM BURNER OVER LADDER 8 HELICOPTER PARTNER CLAPS TOE WRESTLING COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR X2 CLICKERS SWISS BALL STEPS BIKE BOXING PADS & SHIELD BALANCE FOAM HURDLES AGILITY DOTS RESISTANCE BAND ARM BURNER LADDER 9

10 WEEK 8 WARM UP DEGREE CUP CHANGE HURDLE CLICKS 2 SCARF SNATCH FLOOR KNEEL 3 BIKE SPRINTS BOX STEP 4 PARTNER KICKS PARTNER KICKS 5 HELICOPTER PARTNER CLAPS TWINKLE TOES 6 GUN SHOT STOP AND SQUAT 7 RIVERSTONE CLOCKFACE DOUBLE STEP TAPS 8 BALL SLAMS & BALANCE PARTNER BALL PASS COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR X1 SCARVES HURDLES CLICKERS STEPS BIKE BOXING PADS & SHIELD BALANCE FOAM RIVERSTONES AGILITY DOTS CUPS X 10 10

11 WEEK 9 WARM UP DEGREE CUP CHANGE HURDLE CLICKS 2 SCARF SNATCH FLOOR KNEEL 3 SIDE STEP OVER STEP ARM BURNER OVER LADDER 4 PARTNER BOX PARTNER BOX 5 HELICOPTER PARTNER TAPS TWINKLE TOES 6 PENGUIN WADDLE POWER LUNGE 7 TRAVELLING LUNGE STEP TAHDAHS 8 PUSH STEPS POWER SWIVEL COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR SCARVES ARM BURNER LADDER STEPS BALLOON X 2 BOXING PADS & SHIELD BALANCE FOAM CUPS X 10 AGILITY DOTS HURDLES CLICKERS 11

12 WEEK 10 WARM UP 1 OVERHEAD BALL THROW STOP AND SQUAT 2 SCARF THROW LADDER STEP & ARM BURNER 3 DOUBLE STEP TAP BIKE SPRINTS 4 PARTNER BOX PARTNER BOX 5 BALL SLAMS & BALANCE TOE WRESTLING 6 TAHDAS BOX STEP 7 HELICOPTER PARTNER CLAP TWINKLE TOES 8 POWER LUNGE BANDED SIDESTEP COOL DOWN EQUIPMENT REQUIRED SOFT BALL X2 CHAIR SCARVES ARM BURNER LADDER STEPS BIKE BOXING PADS & SHIELD BALANCE FOAM HURDLE AGILITY DOTS RESISTANCE BAND 12

13 EXERCISE INFO OVERHEAD BALL THROW This exercise is designed to elicit force and power from the upper limbs. There is also an element of balance and control required. Have the person face a solid wall, with their feet apart to start. Give them the soft ball and have them throw the ball overarm, using both arms aiming for a target above head height. Ideally they should throw with enough force to catch the ball on the full. If someone is prone to back injury, have them throw underarm, you can even do this from a seated position. If someone has a pre-existing shoulder injury, have them throw underarm from a standing position Progression. To make this exercise more difficult, you can have the person step further away from the wall, stand in tandem or single leg stand or on a foam block. 13

14 SQUAT AND STOP This exercise focuses on power arms and legs as well as symmetry, weight shift and lower limb strength training. Start with the person standing in front of a sturdy chair with feet hip width apart and arms by their side with hands clenched. Have them sit quickly and lightly and then come back up to standing. When they are moving to the sitting position have them push their hands out into the stop position. As they come back up into standing have them bring their hands back down to their side with hands clenched. Make sure in the stop position they extend both arms symmetrically and they don t sit down heavily. If someone complains of knee pain, they can do half time stands, or half squats from a standing position. If balance is a concern, have a sturdy chair placed in front, but not obstructing the person. In the case of pre-existing shoulder injury, change the arm position to a sideways movement. Progression. To make this exercise harder, you can have them add a jump up as they return to the standing position. 14

15 SCARF SNATCH This exercise focuses on speed and timing in the upper limbs. There is a small balance component. Start with the person holding a scarf in each hand and their feet wide apart. Have them throw one scarf high into the air, as high as they can. As it floats down, have them snatch it out of the air as it reaches shoulder height. Repeat on alternate sides.. In the case of pre-existing shoulder injury, have the person throw underarm and bending the elbow to gain force. In the case of poor balance, place a sturdy chair in front of the client. Progression To make this exercise harder, you can have them increase the speed of repetition, number of reps on each side and number of scarves they throw at a time. Try catching two scarves from the same throw. 15

16 LADDER STEP AND ARM BURNER This exercise focuses on dual tasking activity by doing two different exercises with the arms and legs. Have the client start at the top of the ladder holding the arm burner. Walking with high knees they need to land with one foot in each rung while using the arm burner evenly between both arms. When they get to the end, they need to turn around and repeat the exercise If there are balance concerns, have the person set up near a wall or rail where possible. Progression To make this exercise more challenging, have the client miss every second step to increase stride length while continuing with additional upper limb task. 16

17 DOUBLE STEP TAP This exercise focuses on coordination and balance. If you do not have stairs, then use V2 four polystyrene cups set up on the step about hip width apart. V1. Have the patient face the stairs and ask them to tap the first step, then the second step and then the first step and then the floor. Repeat with alternating foot in the same pattern. V2. Have the patient face the step and ask them to tap two cups in turn and then return to the floor. Repeat with alternating foot.. Have a sturdy chair placed to the side within reach if there are balance concerns. Progression Increase speed of taps, include upper limb task which is flick, close. 17

18 BIKE SPRINTS This exercise is designed to force use and increase overall speed of activity. Keep the resistance as low as possible and aim for high revolutions per minute > 80 (RPM). Have the client start with a base line speed. Every 20 seconds they need to sprint as fast as possible for 10 seconds. Each time they finish a sprint they need to stay above baseline speed. If the client has a pre-existing heart condition, heart rate max needs to remain at sub max level*. If client has had a pre-existing knee injury or joint surgery, avoid extreme ranges of motion. Progression Encourage increase baseline speed or sprint speed. Increase length of sprint. 18

19 PARTNER BOX This exercise is to encourage full upper limb motion, speed, balance and coordination. Have each partner stand and face the other partner. One partner has the mitts on while the other partner has boxing gloves on. The partner with the mitts needs to stand with legs wide apart and ready to brace. The partner with the boxing gloves stands in boxing stance. They will continue appropriate boxing drills for two minutes and then swap with the partner with the mitts. Drills may include; jab, cross, upper cuts, hook, over head and any combination of the above. 10, 20, 30, 40, 50 This exercise is aiming focus on speed, not power.. Any pre-existing shoulder, elbow or wrist injury needs to be taken into consideration and the exercise modified accordingly. Ensure care is taken with hitting the pads that no contact is made with the person behind the pads and that the force is matched an appropriate for each pair. Ensure that the boxer does not lock the elbow when striking the pads, nor flex the wrist. If the boxer is very deconditioned please monitor closely for injury Progression. Increase speed and repetition of drills. Increase complexity of drills by changing combination. 19

20 BALL SLAMS This is a partner exercise encouraging coordination, balance and forced upper limb use. Each partner stands facing the other one. The first partner slams the soft ball into the floor to bounce once before reaching the other partner. The other partner then catches the ball and returns the bounce. To increase the level of difficulty have each person stand with a narrow base of support or on a wobble board or duradisc. If there are concerns about balance, have a sturdy chair, wall or rail placed near the client. Progressions. To make this exercise harder, have the client stand in tandem or single leg stance or on an unstable foam/unstable surface. The softer the ball the harder the slam to get it across to the other partner. 20

21 HELICOPTER PARTNER CLAP This exercise is designed to increase axial rotation, challenge vestibular balance and force upper limb use. Have your partners face each other with wide base of support and hands out by their sides at 90 degrees. Starting with their right arm leading, rotate until their hands meet in the middle. Have them clap, return to the starting position and then lead with the other arm. Encourage them to keep their shoulders down and back as they continue with the exercise. If there are concerns about spinal rotation, introduce a swivel or change the exercise completely to ant anterior clap. Progressions Introduce speed, accuracy, alternate combinations right, right, left, left etc. 21

22 TAHDAS This exercise focuses on amplitude and exaggerated movement of the shoulders, back extensors and stepping. There is a balance and coordination component. The client needs to start with legs hip width apart. Starting with the right leg, take a small step forward with high knees, at the same time both arms move out to the side. Both arms then come back into the middle as the leg steps back. Repeat with alternating legs. Ensure that both upper and lower limb movements are powerful going out and coming back, wrists and fingers are fully extended and chest is out.. Modify exercise as appropriate if there is pre-existing injury. If there are concerns about balance, place a sturdy chair close by and start with one side only, using the other hand for support. Progressions Use a foam block/hurdle as a target to step over to increase hip and knee flexion. Encourage high effort and motor output. 22

23 BOX STEP This exercise focuses on coordination, balance and high intensity. Place four dots in a square on the floor. Have the client practice stepping forwards and backwards on the dots; right, left, right, left. Once the client can achieve consistent timing and step accuracy, add upper limb task; hand flicks (right step) and hand clench (left step). on getting the feet right before introducing the hand flicks. If there are balance concerns have a chair located close by. Progressions Double time hand flicks, high knees, stepping on river stones. 23

24 SKY REACH The focus of this exercise is on trunk rotation and big shoulder and arm movements. This movement helps to improve range of movement in the upper back, trunk as well as in shoulders and hands. It will also help with powerful functional reaching. Have your client take a seat and use one hand to support themselves by holding on to the chair. While seated, take a wide supportive stance with your legs. When ready have them reach down and across the body with the free hand aiming to touch the floor on the outside of their foot. Bring them back up into tall sitting and continue reaching their hand diagonally in the opposite direction and up to the sky. They should feel a powerful stretch across the chest, upper back and into your arm and hand. If they find it difficult to reach all the way to the floor and across your body have them stop at their opposite knee. Progress down the shin as they feel more comfortable with the movement. Progressions Increase the amount of power in the movement. Each part of the movement should look and feel crisp and distinct from the other parts. 24

25 GUN SHOT The focus of this exercise is to work on trunk rotation. Many people with Parkinson s develop stiffness and loss of rotation through the trunk which can affect walking, turning and impact on balance as well. There is an element of balance indicated in this exercise, especially during the changing direction. Start with their feet wide apart, wider than your shoulder width. Clasp both hands together in a trigger grip, with arms straight in front, about shoulder height. Move both hands around to one side, about 90 degrees from the front. Ask the client to swivel at the opposite foot. Hold that position for one second and then return to the front. Repeat this move to the other side; again, stop about 90 degrees to the side. It is important to keep hands together and to swivel on the opposite leg to protect the back. If prone to back pain then start with a smaller rotation; perhaps only moving to 45 degrees. It may also be easier to keep eyes and head focused on the hands as you they turn to maintain balance. If that is too difficult, then have them focus on a point directly ahead of them as their body turns from side to side. Progression Start to consider putting more power into the turn and swivel, try moving as far round as they can. Remember, the ideal effort level is working at 80%. 25

26 OVER THE RIVER This exercise is excellent for helping to coordinate big strides with big powerful arm swings. It also helps with stepping and 180 degree turns. Start by placing the hurdle on the floor in front of your client. Have them take a big step over the hurdle. If leading with the left leg, have them swing the right arm forward with power and the left arm back well behind them. Keep the hands wide and open. When they have stepped over the hurdle cleanly have them turn around to face the hurdle again. The turn should be crisp and ideally achieved in four to six steps. When ready have them step over the hurdle again, leading with the opposite leg. Make sure to have them focus on swinging their arms with power and full range and bringing their knees up high as they step over the hurdle. If the turns makes them dizzy then slow them down and have them take more time with the turns. If they have trouble with knees or lower back, make the step smaller as they step over the hurdle. Progression They can try leaping over the hurdle. Aim for height, rather than distance. Make sure they have a large arm swing coordinating with the opposite leg at the same time, especially the back arm swing. 26

27 BANDED SIDESTEP This exercise focuses on posture, coordination and upper limb resistance. Start with the client holding the resistance band ends in each hand. As they step sideways, stretch the arms out fully resisting the resistance band and pushing the chest out. Hold briefly and then bring both arms back into the chest and repeat down the length of the gym. At the end reverse direction and repeat the banded arms. If there is shoulder injury, keep the arms low and avoid full resistance. Progression To make this exercise harder, use a higher resistance band and increase speed of sidesteps. To make this exercise easier, have the band run across the back of the client 27

28 SIDE TAP OVER STEP This exercise focuses on large amplitude lower limb side stepping combined with a large amplitude upper limb exercise. Place a step down on the floor so that it is running vertically to the patient. Have them step up on to the step from one side, making sure they leave enough room to get both feet up on the step. Both hands should be clenched and brought tight into the chest. Then have them bring the other foot up so that they are standing with their feet together. Then have them step off the step, taking a wide step out. When they step off have them stretch out with powerful arms and strong open hands. They can repeat the exercise coming up the other side. Knee, back and shoulder problems need to be considered. If you are concerned about balance then have them start on the floor or only to one side using a chair for support. ProgressionsHave them get some height as they leap off one side of the step and then back onto the step. 28

29 POWER SWIVEL This exercise focuses on balance, trunk rotation and power arms. Have your patient start with a wide base of support and their hands splayed on their thighs. Get them to swivel to the right so they end up with a very narrow base of support. At the same time, have them push away with powerful arms to the front and to the back. After a short pause they should swivel back to the front with their hands coming to land back on the legs. Repeat in the other direction.. Knee, back and shoulder problems need to be considered. If you are concerned about balance then have them start on the floor or only to one side using a chair for support. Progressions As they swivel and push forward you can get them to come forward onto the front leg introducing some weight shift. 29

30 SWISS BALL BOUNCE This exercise is designed to focus on repetitive and powerful arm movements, with or without travelling. Have your patient start with a wide base of support. Get them to start bouncing the swiss ball with one hand. Make sure that the ball bounces back up to shoulder height and the client doesn t stoop to keep it bouncing. Encourage even, consistent bouncing. After a designated time you can have them swap hands or do a combination of alternating hands. Shoulder, neck and back issues need to be considered. Progressions. Have the client bounce the ball while dribbling around cones or cups on the floor. Keep them changing the leading hand. 30

31 PENGUIN WADDLE This exercise focuses on weight-shifting and is a powerful way to practice stepping. It is a really helpful tool to teach clients if they have mild episodes of freezing during gait. Set up 4 dots at least 1 foot apart in a square. Have your client stand on the back two dots facing forwards. Have your client practice shifting their weight from one dot fully to the other dot. If they are doing this correctly you will be moving from one leg, right over the other leg and then back again. Once your client has the hang of the weight shift, start them weight shift stepping around the box in a clockwise fashion. Once they have done one box then stop and reverse and go in an anticlockwise direction. Each time they step they should be moving location and alternating between left and right leg. If they get dizzy from going in a single direction or from the movement itself then please pause after each box rotation or change direction more regularly. You might also want to place a chair at either end of the box. Progression You can add arms to increase the complexity of the exercise. Add double arms up in front and then double arms out to the side alternating movement with each step they take. 31

32 180 DEGREE CUP CHANGE This exercise focuses on trunk rotation, coordination and amplitude. Set up two stations opposite each other about 1.5 metres apart and at least waist height. On one station, place 10 cups. Have your client stand in the middle of the two stations. Their job is to transfer all the cups from one station to the other only using one hand. This will mean that they need to increase axial rotation and reach sideways to pick up each cup. If you are concerned about balance have your client stand next to a rail or wall. Progressions. Have them stand with a narrow base of support or you can move the stations further apart so they have to travel between each station. 32

33 RIVERSTONE CLOCKFACE This exercise works on accuracy of movement, timing, sensory feedback and weight shift. Set up six riverstones with four in a row and two in front. Have your client stand on the two middle riverstones on the back row. Ask them to tap the riverstone in front, back to the middle and then out to the side and back to the middle again. They can repeat this move or swap to the alternating side to increase the weight shift. Try and get the patient to keep time to a beat as they step. Rolling off the riverstones is to be avoided. If you are unsure about stability then use the dots. Progressions Add additional arm challenge such as push forwards, push to the side 33

34 PARTNER KICKS This exercise focuses on balance, coordination and high effort repetition. This is a partner exercise where one partner is seated holding the boxing pads while the other partner stands in front. Once ready, the standing partner kicks the corresponding pad with the top of their foot (right foot, right pad), then alternates with the other leg. If there are concerns about balance, place a sturdy chair next to the standing partner. Progression To make this exercise easier, the kicking partner can repeat kicks on the same leg before touching the floor as well as speed up kicks. 34

35 SCARF THROWS This exercise focuses on powerful arm movements, weight shift and axial rotation. Have your patient stand with a wide base of support holding a scarf in the right hand. Ask them to bend down and across with the scarf to the left ankle, come back up and throw the scarf out to the side. If you have the space you can have the patient actually throw the scarf away. It might be a good idea to have a few scarves available if you want to do this. Be careful or any back and shoulder problems and modify accordingly Progressions You can add a side step travel as well as throw and catch. 35

36 POWER LUNGE This exercise focuses on lower limb strength training, balance and axial rotation. Have your patient stand with wide base of support holding a soft ball in their hands. Have them take a big lunge forward making sure their knee comes just over the ankle. Once in this position, get them to hold this position and bring the ball around to the same side as the front leg. Get them to pause, return to the centre and push back up into standing. Back, shoulder and balance problems Progressions Encourage a deeper lunge, bigger rotation and bigger step forward where appropriate 36

37 PUSH STEPS This exercise focuses on coordination for upper and lower limbs as well as power generation. Have your patient start standing with feet wide apart. Get them to step forward and stomp. At the same time have them push forwards with both hands. The movement needs to be powerful and coordinated at both the leg and hands. After a short pause have them step back in one move behind them and at the same time retract the hands to the chest and back out to push as the foot stomps down behind them. Place a chair nearby if you are concerned about balance. Modify to any injury as appropriate. Progressions. Alternate legs, repeat single leg, increase power. 37

38 PARTNER BALL PASS This exercise focuses on axial rotation and vestibular balance. This is a partner exercise. Have both partners back to back with one holding the ball with two hands. They will need to be closely matched physically. Have the one with the ball turn to the left and pass the ball to their partner without letting go of either hand until the transfer. After the partner has collected the ball the first person then swings to the other side to collect the ball from their partner, again with both hands. Modify for back and balance concerns Progressions You can use a medicine ball, reduce the base of support and increase the speed of the exercise 38

39 HURDLE CLICKS This exercise focuses on dual tasking and big stepping. Line the hurdles up in a row, about a foot or so apart. Give your patient a clicker and get them to start with it on 0. When they are ready you can get them to step over the hurdles with alternating steps moving forwards so that they don t touch the hurdles. At the same time, have them click once with the clicker in the right hand and then transfer the clicker to the other hand and repeat the process. You are aiming to see how many clicks they achieve while they continue to step (without knocking over the hurdles). Monitor for poor balance and falls. Progressions Patients can walk forwards, backwards and sideways over the hurdles. The further you space the hurdles apart the harder the stepping will become. Challenge the group by having each patient compete to see who can achieve the most clicks during the exercise. 39

40 TRAVELLING LUNGE STEP This exercise works on upper and lower limb coordination, axial rotation and lower limb strengthening. Have your patient start with nice wide legs and open hands. Get them to take a big step forward while maintaining their balance. At the same time you want them to do a power swing with their arms. Think spiderman hands but make sure they don t go above 90 degrees. Get them to step forward again so that their feet are level and their hands come down by their sides. They can repeat on the same or alternate leg. Modify for knee and balance concerns Progressions Have them lunge deeper, step bigger, be more powerful, repeat on the same leg more times. 40

41 FLOOR KNEEL This exercise is for lower limb strengthening and planning. Have your patients face a sturdy chair and place a foam block on the floor for their knees. Get them to slowly lower themselves down into a kneeling position. From there they can stand back up again using alternating leg each time. Advise them that they can use the chair to help themselves get up. Modify for knee and back injury. If you have balance concerns you may only wish to work on half squats Progressions Repeat on the same leg, take away the use of the chair. 41

42 TWINKLE TOES This exercise is for cardio training and coordination. This can be done as a singular or partner exercise. Have your client face a step. Get them to gently tap on the step with one foot and then lower the same foot back down to the floor. Have them alternate feet doing this. Modify for balance and injury concerns Progressions Have them jump the taps so that they have a period of flight when they are changing legs. 42