Terry Gorst Northern Devon Healthcare NHS Trust Module II ...

© Terry Gorst, NDHT 1

Does a Bobath approach to improving postural alignment influence balance and gait

in Parkinson’s Disease?; A single case study

Terry Gorst

Northern Devon Healthcare NHS Trust

Module II Basic Bobath Course

February 2015


Abstract

Background/Introduction

Parkinson’s Disease (PD) is a disabling neurodegenerative disease in which postural instability, balance

and gait impairments, and poor postural alignment are common (Smania, 2010). Whilst a definitive cause

of these impairments has yet to be identified, it is suggested that abnormal sensory processing may con-

tribute (Patel, 2014). The Bobath concept is a problem-solving approach to the assessment and treatment

of individuals with disturbances of function, movement and postural control due to a lesion of the central

nervous system (IBITA, 2008). Treatment is an interaction between therapist and patient where facilita-

tion leads to improved function.

Purpose/Aims

The purpose of this study is to investigate whether therapy based on the Bobath concept can improve

postural alignment and postural control in a single patient with Parkinson’s Disease and thereby positively

influence measures of gait and balance. The primary aim of this study assignment is to answer the ques-

tion : Does a Bobath approach to improving postural alignment influence balance and gait in Parkinson’s

Disease? The secondary aim of this study/assignment is to apply the practical and theoretical learnings

from the Basic Bobath Course to a patient with PD.

Methods

The intervention consisted of 8 x 1 hour therapy treatment sessions using a Bobath approach. The inter-

vention was over a six week period and was administered by a qualified physiotherapist who had attend-

ed Module I of the Basic Bobath Course.

Results

Postural alignment improved in sitting and standing using pre-and post intervention photographs. Out-

come measures of 10m walk speed, stride length, Functional Reach test and the Activities Specific Balance

Confidence scale also improved following the intervention in excess of minimal detectable change thresh-

olds.

Conclusions

Postural alignment and thereby postural control may be influenced by a Bobath approach to the rehabili-

tation of patients with Parkinson disease. The abnormal processing of sensory input is thought to contrib-

ute to poor postural alignment and postural instability in PD so an approach which emphasises therapist

facilitation and the summation of afferent input, may be particularly efficacious through informing and

improving the internal representations of posture and movement.


arkinson’s disease (PD) is a progressive and complex neurodegenerative disorder, pri-

marily of motor function, which is ascribed to a loss of dopaminergic neurons in the sub-

stantia nigra in the basal ganglia. It affects 120,000 people in the UK and is the second

most common neurodegenerative condition after Multiple Sclerosis (European Parkin-

son’s Disease Association, 2014).

Whilst PD is most commonly known for the classical resting tremor of arms, hands or legs, the

symptoms and signs of PD encompass a much broader spectrum. The cardinal motor symptoms of

PD can be separated into appendicular and axial symptoms. Appendicular symptoms include rest-

ing tremor, bradykinesia (slowness of movement) and rigidity. Axial symptoms include gait disor-

ders and balance impairments, such as the characteristic stooped posture and postural instability.

This posture is attributed to the contractile elements of the flexors becoming shortened and the

extensors becoming lengthened and weakened (Schenkman, 1989). It is these axial symptoms

that are most difficult to treat, especially when the disease progresses (Colgrove, 2010).

Reduced postural control, or postural instability is a highly disabling disturbance that predisposes

patients with PD to poor balance and unexpected falls (Smania, 2010). In fact, of all neurological

diseases, PD patients are at the highest risk of falling (Hely et al., 2008; Pickering et al., 2007) and

impairments in gait and balance are some of the most disabling symptoms in Parkinson’s disease

(Patel, 2014). With falls and a fear of falling decreasing a person’s mobility and negatively influenc-

ing quality of life (Hartholt et al., 2011) postural instability inevitably has far reaching implications

on social participation.

Despite this, the underlying pathophysiology of balance impairments in PD remains unclear

(Boonstra et al., 2008). Some suggest that one of the factors contributing to decreased balance

control in PD patients is an impaired intersegmental coordination between body segments and

poor trunk control (Maurer et al., 2003). It is also suggested that the mechanisms of postural insta-

bility in PD may involve dysfunction at the level of several neural subsystems. Studies on the path-

ophysiology of postural control in PD suggest multifactorial origins but suggest the role of im-

paired multimodal integration of sensory feedback from vestibular, visual, and proprioceptive sen-

sory systems is significant (Patel, 2014). Sensory information of body states are measured by vi-

sion, the vestibular organ and muscle spindles, and then sent to the Central Nervous System to be

processed. Based on an estimate of body kinematics appropriate control plans are selected, and

then corresponding motor commands are produced as joint torques. (Fig 1). Impaired vestibular

responses, reduced internal representation of their bodies, and impaired proprioception (Wright

et al, 2010) clearly contribute to the impairments in gait, posture and balance in patients with this

disease (Coelho et al, 2010).

P


Fig. 1. Schematic model of long-loop human postural control by the CNS (Kim et al, 2009)

Others have suggested that deficiencies in postural control are possibly related to an abnormal

choice of postural strategies under different surface conditions (Horak et al, 1992). Studies of au-

tomatic leg responses to sudden platform movements have partially clarified that PD postural ab-

normalities may not be related to dysfunction of dopamine systems (Beckley et al, 1993). Thus,

unlike the situation in bradykinesia, dopaminergic medications may produce a limited improve-

ment in postural instability (Visser et al, 2008). In particular, the velocity of postural movements is

not improved by drugs (Shivitz et al, 2008) and early automatic postural responses are only par-

tially corrected while later occurring postural corrections do not improve at all (Bloem et al, 1996).

Despite this the most common method of counteracting the symptoms experienced by individuals

with PD is through medication. Schaafsma et al (2003) studied the relationship between levodopa

therapy and falls in individuals with PD and found that levodopa significantly reduced stride time

variability which has been found to increase in people with PD that fall on a frequent basis

(Schaafsma et al., 2003). From this study and others, it is clear that pharmacotherapy has a posi-

tive effect, however, the effects of these medications can wear off over time and have negative

side-effects such as night time or early morning deteriorations, and medication induced dyskine-

sias (Guttman, et al, 2003; Johnson, 2007).

Physiotherapy is perhaps the most commonly referred to profession alongside drug therapy to

treat PD and balance impairments. Most research to date on the efficacy of rehabilitation in PD

has focussed on the treatment of bradykinesia (Smania, et al, 2010) with the evidence for physio-

therapy in the management of balance impairment in PD requiring further good quality evidence

(Deane et al, 2001). The brief review of the literature highlights some similarities between the Bo-

bath approach and the impairments which contribute to balance/gait impairment in PD.


Specifically, the attainment of postural control, postural orientation and postural stability are key con-

siderations in the Bobath concept (Raine et al, 2009) and are clearly suggested as lacking in patients

with PD. Further, with an emphasis on sensorimotor integration, a Bobath approach may also help ad-

dress the abnormal processing of sensory information suggested as a cause of balance, postural and

gait impairment in PD. Ultimately however, rehabilitation of balance, with the aim of improving mobil-

ity and reducing falls, requires an understanding of the multiple mechanisms underlying postural con-

trol (Horak, 2006).

Theoretical assumptions

Postural Control

Postural control is a complex motor skill derived from the interaction of multiple sensorimotor pro-

cesses and is widely regarded as an essential precursor to efficient movement (Massion et al, 2004;

Raine et al, 2009). It forms a central tenet of the Bobath concept and has two main functional compo-

nents: postural orientation and postural stability (Horak, 2006). Postural orientation involves the ac-

tive alignment of body segments with respect to gravity, the supporting surface, the visual environ-

ment and our internal references or body schema (Horak, 2006). Postural stability involves the coordi-

nation of movement to stabilise the centre of body mass during disturbances of stability (Horak,

2006). So in sum, postural control is about alignment and coordination; it allows us to create a pos-

ture, maintain a posture, cope with displacement, control the displacement beyond our base of sup-

port, take up a new base of support and ultimately create a new posture (Eustace, 2014). It provides

choice and efficiency but as Horak (2006) highlights, it requires multiple resources (fig 2).

Fig 2. Diagrammatic representation of resources required for postural stability and orientation. Central graph illustrates the

correlation between age and incidence of falls (Horak, 2006)


Control of Posture.

Body posture usually means the maintenance of an upright posture, with the integration of body and

limbs, and orientation of head and body. The achievement and maintenance of an upright posture re-

quires the interplay between the body’s centre of gravity/line of gravity within its base of support (figs

3-5).

Figs 3 – 5 ; Concept of Centre of gravity ( ); Line of gravity ( ); and base of support ( ) as indicated in case study patient

Where the line of gravity falls within the base of support influences the specific demand upon muscle

activation; manipulation of where the line of gravity falls within the base of support thereby allows the

therapist to influence muscle activation (Eustace, 2014).

Whilst there are clearly a large number of different postures in which the human form can adopt, the

upright sitting and standing postures are the most studied as the ability to gain, maintain and control

this posture is a precursor to many functional tasks. Due to its inherently unstable nature however, an

upright standing posture requires continuous adjustment. Any internal or external pertubation to these

postures, no matter how minor, shifts the centre of gravity within the base of support and as such re-

quires anticipatory postural adjustments (APA’s). Arm movement, head movement and even a deep

breath, require postural adjustments in advance of and in response to these perturbations in order to

stabilise and maintain upright stance (Schepens and Drew, 2004). In response to these destabilizing

actions, the central nervous system initiates APA’s through feedforward activation of appropriate mus-

culature at appropriate corrective torques (Fig 2) with the axial muscles of neck, trunk, hip and lower

limb muscles, activated during the upright standing posture (Santos, 2009). It is also suggested that

APA’s are experience dependent and are therefore learned responses (Massion et al, 2004).


Neurophysiological control of posture

Without the regulation provided by higher brain centres on the activation of spinal motor neurons, the

human sensorimotor system would be limited, for example, to a set of relatively stereotyped move-

ment patterns such as reflexive eye movements, postural shifts, and withdrawal reflex (Cohen, 1998).

Four long descending motor pathways project from cortical and subcortical structures to coordinate

the execution of voluntary and automatic actions and play key roles in postural control. The descend-

ing pathways that project fibres to the spinal cord are organised into two main functional groupings;

ventromedial and dorsolateral. These groupings are based on their termination in the spinal cord with

the ventromedial grouping including the vestibulospinal, medial reticulospinal, and tectospinal tracts.

The dorsolateral groups include the rubrospinal, corticospinal and pontospinal tracts (Kuypens, 1982).

The motor neurons innervating the axial and more proximal musculature are located more ventrome-

dially and are thus integral to the control of posture, balance and APA’s. These ventromedial systems

are suggested to “switch on” to control posture prior to the activity of the dorsolateral systems, which

involve limb movement (Williams, 2014). The medial reticulospinal system is especially important for

providing the excitatory input to axial i.e. neck, shoulder, trunk, hip and back muscles and lower limb

extensors to maintain postural support and thus play a crucial role in postural control through anticipa-

tory postural adjustments (APA’s). The activity of the vestibulospinal system is concerned with postur-

al tone adjustments and plays an important role in anti-gravity function. This is especially active during

weight bearing activities with moribund, hoist-transferred patients often lacking proprioceptive anti-

Fig.2 Feed forward and feedback system for postural control (reproduced from Haas, 2010)


gravity action, becoming overly reliant on visual and vestibular information for vertical orientation

(Williams, 2014).

It’s also worth noting the role of the reticular formation in postural control especially in the context

of PD. The reticular formation comprises a collection of nuclei and tracts running the length of the

brain stem which play a role in motor control (Schepens & Drew, 2004). They also receive afferent

input from the one of the major nuclei of the basal ganglia, the globus pallidus (Felten et al, 2003)

which is known to be impaired in people with PD. The ponto-medullary tract of the reticular for-

mation (PMRF) is thought to play a role in regulating the postural activity required for movement and

movement itself (Schepens et al, 2008). If afferent input into the reticular formation is distorted, it

may influence the ability of the PMRF to coordinate both posture and movement, as is often the clin-

ical case scenario with PD.

In summary, the clinical, theoretical and neurophysiological complexities surrounding postural con-

trol run well beyond the scope of this case study, and in fact, my cerebral capabilities. However, the

brief literature review suggests that a lack of postural control and resultant postural instability in PD

involves changes in both anticipatory (feedforward) and compensatory (feedback) postural reactions

(Kim et al, 2009; Boonstra te al 2008) . Key to postural control is the alignment and orientation of

body segments and the coordinated activity and stability of those segments relative to one another.

The research question of this study is therefore concerned with determining whether a Bobath ap-

proach to improving postural alignment, orientation and stability will influence outcome measures of

balance and gait in a single case with PD. It is initially hypothesized that through the use of facilita-

tive techniques aligned to the Bobath approach, muscle activation patterns can be altered to re-

educate the individuals internal reference system of postural alignment. This it is hoped, will facili-

tate greater movement choices and improved efficiency of movement.

This study is a single case research design which is acknowledged as a scientifically robust and clini-

cally useful method of exploring the effectiveness of an intervention when there is little existing evi-

dence (Graham et al. 2012).


Development of critical cues and hypothesis generation

Verbal Cues

Medical: Mr X is a 79 year old gentleman who has been living with Parkinson’s Disease since 2006. He

considers himself fit and well for his age and reports no other major illness, disease, trauma or surgery

in his past medical history.

Personal/Domestic: Mr X lives alone in a bun-

galow, is a current driver and is independent

with all personal activities of daily living

(PADL) although struggles with putting socks

on. He employs a cleaner to help with keep-

ing the house tidy.

Mobility: Walks without an aid, both indoors

and out. Finds walking greater than 400-500

yards outdoors difficult due to increasing stiff-

ness in the left foot and ankle and occasional-

ly catches/scuff toes when walking. Does not

report freezing or initiation of movement a

problem. He is a little worried about falling

and reports some concerns about his balance.

He does report feeling uncomfortable with the way he walks and reports his walking does not feel

very smooth. He also reports his toes tend to touch the floor before his heels (especially on the left)

when walking. He would like to increase walking distance and improve smoothness of walking.

Social: Enjoys gardening although feels restricted due to difficulties with bending and reaching for-

wards, and walking outside on uneven terrain. He is an active member of Parkinson’s Disease (PDUK)

and attends a weekly “keep moving” PD specific exercise class.


Visual Cues

1. Standing Posture (posterior view)

Centre of mass shifted to left within base of support

Overall, poor alignment head on trunk and trunk on pelvis;

Cervical R side flexion to counterbalance trunk lateral shift to

left

Left lateral shift of trunk over pelvis;

Extended through left trunk with suggestion of extensor

activity;

Side flexed to right through right trunk with suggestion of

lack of extensor activity

Left and right femurs externally rotated

Left and right feet overpronated

L Tibial internal rotation++ secondary to over pronation

2. Standing Posture (anterior view)

Protruding chin

Decreased lower abdominal activity

Increased femoral external rotation through R

Trunk rotated around vertical axis to right

COM forward and to left of BOS

3. Foot Posture

Poor proprioceptive BOS

through feet;

Marked L and R overprona-

tion and hallucis abduction


Visual Cues (cont)

3. Sitting posture (anterior view)

Left lateral shift of trunk over pelvis

Externally rotated femur L and R

Posteriorly rotated pelvis

R side flexion of Cx Spine

Pelvis tilted laterally to left

4. Sitting Posture (posterior view)

Posteriorly tilted pelvis

Mild scoliosis (concave to right)

Poor trunk extensor activity

COM posterior and to left within BOS

5. Sitting posture (lateral view)

Lower Cx flexion and upper Cx extension

Increased thoracic kyphosis

Protracted should girdles bilaterally

Posteriorly tilted pelvis

COM posterior in BOS

Minimal forward translation of tibia over feet during sit—stand

and stand-sit


Handling Cues

Increased activity and fixing through upper fibres of trapezius, sternocleidomastoid;

Poor proprioceptive BOS in sitting;

Decreased weight bearing through Right ischium;

Directional preference in sitting - lateral shift to left; almost impossible to move laterally to right;

Poorly compliant right thorax/rib cage into vertical extension;

Poor femur to pelvis contact— both left and right femurs externally rotated and poorly compliant

into internal rotation;

Poorly compliant through R thorax into left rotation around a vertical axis;

Left and right feet/ankles—able to gain plantargrade and inversion/eversion passively;

Poor selective activation of foot inverters and intrinsic foot musculature;

Poor selective activity of lower abdominals and lower trunk extensors in standing and supine—

improved in sitting;

Minimal selective activity of proximal left hamstrings in quiet standing;

Decreased weight bearing bilaterally through calcaneum;

Increased weight bearing through medial foot and forefoot structures

Medial head of talus easily palpable bilaterally - unable to palpate lateral head of talus

Initial thoughts to hypothesis development;

Feet are giving him nothing; he lacks any kind of proprioceptive BOS in standing;

He has a likely long-standing altered body schema relative to midline orientation especially with respect

to his trunk, pelvis and head alignment. He has a loop of fixation (Eustace, 2014) – he doesn’t know any

different or how to move appropriately/efficiently.

He has good potential to improve as somatosensation is subjectively reported intact

Where is he gaining his stability?

What are his stability limits – this will help me identify which muscle groups are habitually active/

inactive – poor activation of appropriate musculature indicates very poor stability limit. Need to then in-

fluence those activation patterns of those muscle groups.

I am seeking to influence alignment by changing his patterns of activation


Hypothesis—Improving active posturing of feet and providing a more proprioceptive BOS will improve

core stability and intersegmental coordination between lower limbs pelvis, trunk and head. It is hypothe-

sized that this postural improvement will facilitate improved automatic postural adjustments (APA’s) and

measures of balance and gait.

Outcome Measures

Balance

The Functional Reach Test (forwards) (Duncan, et al. (1990) is a measure of balance that mirrors the

everyday activity of reaching for objects beyond arm’s length. It measures the maximum distance the

participant can reach forward beyond arm’s length (to the limits of stability) without moving their feet,

using a ruler fixed at shoulder height. It has demonstrated excellent test-retest reliability (ICC = 0.84)

(Steffen & Seney, 2008). Age related normative data for PD = 33.54cm (Lim et al, 2005) and a reach of

less than 25.4 cm is suggestive of an increased risk in falls in PD (Behrman et al, 2002). Minimal detecta-

ble change (MDC) = 9cm (Lim et al 2005). In line with the established protocol three trials of reaching

forwards were performed and the mean determined.

Foot ground contact will be assessed using a Tekscan pressure mat (Matscan, Biosense Medical, Essex

UK). It is a portable, feasible and reliable objective measure of providing plantar pressures in standing .

10 m timed walk (Bohannon, 1997) The 10m timed walk is a performance measure used to assess walk-

ing speed in metres per second over a short distance. It was also used to assess stride length and ca-

dence over the 10m distance. Three trials were completed with the average used as the final measure.

Both self-selected walking speed (normal pace) or fastest walking speed were assessed. In PD, the 10m

walk has demonstrated excellent test-retest reliability for comfortable gait speed (ICC = 0.96) and maxi-

mum gait speed (ICC= 0.97) (Steffen & Seney, 2008) and excellent correlation with dependence in activi-

ties of daily living and community ambulation in neurological populations (r = 0.76) (Tyson & Connell,

2009) across both speeds. Minimal Detectable change (MDC) in PD (comfortable gait speed = 0.18 m/s;

Fastest gait speed = 0.25 m/s) (Steffen & Seney, 2008).

Activities Specific Balance Confidence Scale (Hobart et al 2006) is a 16-item self-report measure in which

patients rate their balance confidence for performing activities. This stem is used to lead into each activi-

ty considered: "How confident are you that you will not lose your balance or become unsteady when

you..." Items are rated on a rating scale that ranges from 0 - 100 with a score of zero representing no

confidence and a score of 100 represents complete confidence. The overall score is calculated by adding

item scores and then dividing by the total number of items. It has excellent test-retest reliability in a PD

population (ICC = 0.94) with an MDC = 13 (Steffen & Seney, 2008); Normative data in PD = 73.6% (19.3);

score less than 69% considered increased risk of falls in 12 month period (Mak & Pang, 2008)


Treatment sessions

In total, 8 x 1 hour one to one treatment sessions were completed over a six week period. In addition, the

patient attended a weekly “keep moving” class specifically for people with PD. Mr X had been attending

the class for approximately 1 year before the start of the one-to-one sessions.

Treatment Strategy 1 - Improving postural alignment of feet and lower limbs

I worked systematically, with the first 2-3 sessions spent solely (no pun intended!) working on the feet

and lower limbs. My approach involved mobilising the very tight structures across mid, fore and rear-foot,

(Fig 6-7), facilitating the activation of the local stabilizers and intrinsic musculature of the foot (Fig 8-9),

maximising heel contact in weight bearing (fig 10), mobilising and facilitating activation of medial arch sta-

bilisers and foot inverters in weight bearing (11-15)

Fig 6. Mobilising tight medial structures into in-

version around the left fore and mid foot

Fig 8. Lengthening of left fifth toe abductor (heel

is about to go to ground and the foot into dorsi-

flexion!!) as I move the force distally

Fig 7. (about to) apply posterior glide to talocriral

joint to facilitate dorsiflexion - patient encour-

aged to initiate active dorsiflexion in conjunction

with mobilisation

Fig 9. Facilitating activation of abductor digiti

minimi


Following the first session the patient was given a home exercise programme (HEP) which was designed

to address the poor postural alignment of his feet, lack of intrinsic muscular activity and poor heel con-

tact. Adequate heel contact with the ground is a major point of stability for ankle movement and there-

fore dorsiflexion and plantarflexion (Raine et al, 2009), whilst flexor digitorum brevis, the interosseous

muscles, abductor hallucis and tibalis posterior are especially important in supporting the medial longitu-

dinal arch and controlling pronation during static stance (Headlee et al, 2008). It is also suggested that the

antigravity systems of the vestibulospinal system (responsible for activation of axial muscles as discussed

earlier) are switched on by mid-foot contact (Eustace, 2014).

The patients HEP included spending time stood with increased heel contact using a towel (fig10) and car-

rying out short foot exercises (fig 11) and toe curling exercises in sitting.

Fig. 10—Encouraging heel contact during static stance

Fig 13. Facilitating postural activation of medial arch stabi-

lisers and inverters during forward translation of tibia in

standing

Fig 12. Facilitating postural activation of medial arch stabi-

lisers and inverters during weight bearing (my right hand

is realigning medial head of gastrocs by laterally rotating

it around the tibia—ie so it is more medially aligned!!)

Fig 11. Short Foot Exercise—Sorry forgot to take picture!!

http://www.biomechanics.completesportscare.com.au/wp-content/uploads/2014/04/Doming-exercise.emf_.png


Fig 14-15 Realignment of medial head of gastrocs (more medially) during knee bend and heel off. Incorporating knee bend

was also intended tended to separate gastrocs from soleus. Initial stability limit analysis highlighted Mr X had a small stability

limit suggesting poor activation of soleus, proximal hamstrings as well as trunk extensors, scapula retractors and cervical ex-

tensors.

Why so much focus on the foot?

There is an increasing body of evidence to indicate that the foot and ankle complex plays an important

role during balance and functional tests as it involves multiple segments and joint mechanisms which

strongly influence the interaction between the lower limb and the ground (Ridola & Palma, 2001). From

a biomechanical viewpoint, the foot is typically considered a “functional unit” with two important aims:

to support the body weight (static foot) and to serve as a lever to propel the body forward (dynamic

foot) (Wright et al, 2012). However, support of the body weight in the erect posture involves not only

the counterbalancing of the gravitational load, but also equilibrium maintenance, which is dynamic in

nature. The foot and ankle complex is therefore suggested to play a key role not only in propulsion (gait)

but also balance maintenance and postural correction (Wright et al, 2012). Impairment to this functional

unit may critically impair these functional tasks, as has been repeatedly demonstrated in studies of older

adults (Spink et al, 2012; Menz et al, 2005)

There is also more evidence demonstrating the importance of the foot as a sensory organ (Henning,

2009). Foot–support interactions and appropriate sensory signals are an integral part of the rhythm-

generating networks (Duysens et al 2000) as a variety of sensory receptors are activated by limb loading.

These may include Golgi tendon organs, muscle spindles, cutaneous receptors, and various load mecha-

noreceptors in the foot arch.


Treatment Strategy 2- Improving postural alignment and activation of trunk

Whilst I continued to work on Mr X’s feet in each session, the emphasis in sessions 4-8 was on educating

and facilitating postural trunk activity, gaining truncal verticality (especially through the right) and greater

truncal symmetry. Initial visual clues (Fig 16 left) illustrated a signifi-

cant asymmetry in postural alignment in the medial-lateral plane

between the pelvis, trunk and head, and I felt this was driven initial-

ly by poor foot posture, especially in the left foot. This significantly

overpronated left foot resulted in several compensatory postural

deviations; left pelvis to drop, resulting in left lateral shift of the

trunk relative to pelvis, extension through the left thorax, and right

side flexion through the right thorax, topped off with right cervical

flexion to maintain level eyes.

My treatment approach focussed initially in supine building contact

between the thorax and bed using it as a point of reference seg-

mentally (fig 17). This is suggested as a good position to treat ky-

phosed patients (Eustace, 2014). From here I worked to mobilise a

poorly compliant thorax which was very fixed through the right. We

then progressed into sitting which was the position in which Mr X

was best able to select pelvic movement (figs 18-21). I also worked

on facilitating selective pelvic movement by deweighting Mr X’s

head (fig 22-23) as I felt overactivity in upper trapezius and SCM

meant his fixed head and neck tended to lead any forward translation of his thorax. Finally, I also worked

Mr X’s in right side lying in an attempt to increase activation through his right trunk. Right side lying, re-

quires the ipsilateral trunk to provide

a stable base for contralateral upper

limb movement (fig 24-25)(Eustace,

2014).

Fig 17—Looking at compliance of thorax. Us-

ing a chair to biomechanically tilt the pelvis

posteriorly and extend the spine vertically

Fig 16. Standing posture


Fig 19. Facilitation of selective AP pelvic movement with thera-

pist providing proprioceptive input to pelvis in order to make

patient more aware of pelvis without moving trunk. My knees

are preventing patient femoral external rotation. This allows

the femurs to provide a more proprioceptive BOS, intetract

with the pelvis thereby facilitating selective pelvic movement

and significantly improved lower abdominal recruitment—

check out the abs!!

Fig 18. Facilitation of extensor activity of paravertebral mus-

cles to extend lower trunk. Patients hands on table posi-

tioned in front to prevent forward flexion of the trunk.

Fig 21. Self practice of AP pelvic tilt. Strapping used

around femurs to maintain good femur-pelvic contact and

prevent excessive external rotation

Fig 20. Using a table in front to prevent forward flexion of

trunk whilst providing sensory input through the hands

utilising the theoretical principle of contractual hand ori-

entating response (CHOR). The CHOR is defined as a fric-

tional contact of the hand to a surface that allows for the

hand to begin its functional role in the development of

midline orientation, balance and limb loading (Raine et al

2009)


Fig 22– 23. Overactivity in upper fibres of trapezius, cervical extensors and sternocleidomastoid meant Mr X had limited

flexibility through cervical movement, tended to fix through his head and neck which meant pelvic and truncal move-

ment was difficult to disassociate from the head and often led by the head. Working on deweighting the head facilitated

improved selective movement of the pelvis, recruitment of lower abdominals, lower paravertebrals and improved trun-

cal verticality.

Figs 24-25. Improving ipsilateral trunk

activity through contralateral upper

limb activation in side lying. This re-

quired Mr x to provide a stable base

through his right side in order to acti-

vate the left upper limb


Fig 26 . Mobilisation and realignment of head and

neck relative to thorax in supine building contact

between the thorax and bed using it as a point of

reference.

Figs 27 . Facilitation of head and neck movements in

to cervical rotation and retraction with soft tissue

work to overactive cervical muscles.

Results

Outcomes; Foot Posture

Pressure distribution of feet in static standing was determined using a Tekscan Pressure Mat. Com-

parison between pre and post treatment images shows clear changes in foot/ground contact espe-

cially the left foot. Pressure distribution in the post treatment feet also show improved distribution

bilaterally through the calcaneus as indicated by the Kilopascal (kPa) pressure scale. These images

suggest improved active posturing through both feet with improved static postural alignment, par-

ticularly the left. Whilst the underlying over pronation of the left foot especially was long standing,

by being able to actively move out of this abnormal foot posture into a more posturally aligned one

suggests improvements in selective activity. This can only enhance the role of the feet as providing a

proprioceptive base of support enabling greater selectivity when moving within and out of, this base

of support.

Pre treatment foot pressure during quiet standing Post treatment foot pressure during quiet standing


Results

Outcomes; Sitting postural alignment (anterior and posterior view)

Comparison between pre (on the left) and post (on the right) treatment images show clear changes

in sitting postural alignment, with improved activation of posterior and anterior muscle groups.

These have resulted in several key changes: improved equality of weight bearing through the ischia;

improved femoral align-

ment with pelvis; increased

anterior pelvic tilt with im-

proved lower trunk exten-

sor activity and improved

lower abdominal activa-

tion. There is also im-

proved verticality through

the right trunk and subse-

quent alignment of both

scapula and . The head re-

mains slightly side flexed to

the right and there still is

clear increased activity

through the neck muscula-

ture. Mr X also looks more

miserable in the post treatment shot—we must’ve worked hard that day!!


Results

Outcomes; Standing postural alignment (anterior and posterior view)

Comparisons between pre and post treatment images show clear changes in the standing postural

alignment of Mr X. There is improved foot posture, a more dynamic relationship between the ground

and his feet, and hopefully with it, an improved proprioceptive base of support. He just looks ready

and able to move in the post treat-

ment image compared with the pre

where he looks like he could quite

easily topple over. Standing looks

less effortful and more relaxed as

there is greater activity throughout

the anti-gravity musculature of his

trunk with improved verticality

through the right thorax. It is sug-

gested that improved heel and mid

foot contact with the ground switch-

es on the anti-gravity muscles of the

ipsilateral vestibulospinal system. He

is not needing to cortically

drive his postural muscles; his APA’s are fired up

and raring to go!!

He has an improved alignment be-

tween the lower limbs and the pel-

vis, the pelvis and the trunk, and the

head and trunk. He is less forward

flexed with more weight taken

through the calcaneus. The upper

limbs and shoulder girdles are better

aligned look, freeing his upper limbs

for further freedom and choice of

movement. He does however still

use those neck muscles to help him

find stability.


Results

Outcomes; Measures of balance and gait

Mr X showed an increase in his functional reach test score

of 15cm from 9 cm to 24cm. This difference is above the

9cm Minimal detectable change (MDC) which is a statistical

estimate of the smallest amount of change that can be de

tected by a measure that corresponds to a noticeable

change in ability. He still however scores below the norma

tive distant for PD (33.5cm) and just below the 25.4cm

reach which is considered the cut off point for falls, suggesting an increased risk of falls (Lim et al, 2005)

Results from the 10m walk test show increases in fastest walking speed and normal walking speed across

the treatment sessions. Fastest walking speed increased from 1.13 meters/second (m/s) to 1.37 m/s. Nor-

mal paced walking speed also increased, from 0.90 m/s to 1.17 m/s. Mr X’s post intervention normal

walking speed was in fact quicker than his pre intervention fastest walking speed. The number of steps

taken to walk over a distance of 10m also decreased over pre-and post interventions across both normal

pace and fastest pace conditions demonstrating improved stride length. Increase in walking speed over

the fast speed condition however was just (0.1m/s!!) below the MDC of 0.25 m/s suggesting the change

may not be entirely due to a noticeable improvement in performance. Normal paced walking speed did

however increase beyond the 0.18m/s MDC for normal paced walking. Mr X’s walking speed also falls

within the parameters of what is considered safe for community ambulation (Salbach et al, 2014).

The Activities Specific Balance Confidence Scale (ABC) increased from

54.4% prior to intervention to 78.1 % post intervention suggesting an

improvement in self-reported balance confidence. Prior to the

intervention, Mr X was scoring below the cut off point identified for falls

risk (69%) and below the score considered normal in the PD population

(73%) - see page 13 for detail. Post intervention he is scoring above both

those cut off points.

Functional Reach test

Test Pre (cm) Post (cm)

1 8 23

2 10 25

3 9 24

Mean 9 24

10m walk

fast pace (m/s) normal pace (m/s) steps (normal pace) steps (fast pace

Pre Post Pre Post Pre Post Pre Post

1.1 1.4 0.8 1.2 19 17 13 10

1.2 1.3 0.9 1.1 18 17 14 10

1.1 1.4 1 1.2 19 18 13 11

1.13 1.37 0.90 1.17 18.7 17.3 13.3 10.3

ABC Score

Pre (%) Post (%)

n/a n/a

n/a n/a

54.4 78.1

54.4 78.1


Conclusion

Firstly, wow! Secondly, apologies for going over on the word count; I just couldn’t stop writing!

Thirdly, this single case study supports the initial hypothesis that improving postural alignment in a pa-

tient with PD will improve measures of balance and gait. Specifically, I hypothesised that improved active

posturing of the feet would provide a more proprioceptive BOS, thereby influencing core stability and

intersegmental coordination between lower limbs pelvis, trunk and head. Through this improved align-

ment, anti-gravity musculature appears more switched on and potentially his automatic postural adjust-

ments (APA’s) more responsive. His walking speed increased, as did his stability limits. His stride length

increased under test conditions , but perhaps most significantly, his overall confidence in his balance in-

creased.

Analysis of postural alignment is a key feature of the assessment process in the Bobath concept as Bo-

bath therapists analyse posture and movement through the alignment of key body points in relation to

each other and in relation to the base of support (Raine et al, 2009). This study has shown that using a

Bobath approach to improving postural alignment can have a positive influence on outcome measures of

balance and gait speed. It may also improve postural alignment in the postural sets of sitting and stand-

ing in patients with PD. A hands on, facilitative approach which provides afferent input to PD patients

regarding their postural alignment enhances the theoretical stance in the literature in which postural

instability in PD, may be due to abnormal processing of sensory information (Patel, 2014; Wright et al

2010; Coelho, 2010). By providing a therapeutic approach which is based on the summation of afferent

input and bringing the sensory cortices to threshold, the PD patients ability to adopt self-corrective strat-

egies to maintaining postural alignment may be enhanced. It also suggests that patients with PD can

learn new motor sequences despite basal ganglia damage. This is of course, a very simplistic view point

and a topic minefield way beyond the scope of this discussion and in fact my cerebral capabilities.

Critical cues developed during assessment identified significant abnormal foot posture as a key cause un-

derlying the overall poor postural alignment of Mr X. By focussing initially on addressing this impairment

my initial hypothesis suggested that improving the active posturing of his feet would provide a more pro-

prioceptive BOS, which in turn would improve core stability and intersegmental coordination between

lower limbs, pelvis, trunk and head. This further supports the literature in which the importance of foot

and ankle function in balance and gait is emphasised.

Whilst I would happily take the credit for my new found “magic Bobath hands” it should be made clear

that there are several limitations to this study. Firstly, whilst Mr X attends a weekly “keep moving” PD

class, he has never had any formal physiotherapy to address his postural impairments. Focussed input

over a six week period may have improved his postural alignment over the short term but it is not


possible to draw conclusions from this study on the longer term efficacy of this particular approach.

Secondly, the inclusion of outcome measures which may more sensitively measure postural instability

would allow the firmer drawing of conclusions around the Bobath approach. Thirdly, this was a single

case study so applying learnings to the wider PD population is not possible.

On a personal note, this has been great. It has especially heightened my observation skills and really

made me think about the importance of afferent input, postural alignment and postural control and

the significance of my handling. The notion of hypothesis development through identifying critical cues

is one that is already increasingly part of my clinical practice and will hopefully continue to be.

On a very final note, many thanks to my patient, for his patience with my fumbling “magic hands” and

great humour throughout. I owe you Graham (Sorry, Mr X).

——————————————————————————-


References

Behrman, A. L., Light, K. E., et al. (2002). "Is the functional reach test useful for identifying falls risk among individ-

uals with Parkinson's disease?" Archives of Physical Medicine and Rehabilitation 83(4): 538-542

Beckley DJ, Bloem BR, Remler MP. Impaired scaling of long latency postural reflexes in patients with Parkinson’s

disease. Electroencephalogr Clin Neurophysiol. 1993;89:22-28.

Bloem BR, Beckley DJ, van Dijk JG, Zwinderman AH, Remler MP, Roos RA. Influence of dopaminergic medication

on automatic postural responses and balance impairment in Parkinson’s disease. Mov Disord. 1996;11:509-521

Bohannon, R. W. (1997). "Comfortable and maximum walking speed of adults aged 20-79 years: reference values

and determinants." Age Ageing 26(1): 15-19

Boonstra, T.A., van der Kooij, H., Munneke, M. and Bloem, B.R. Gait disorders and balance disturbances in Parkin-

son's disease: clinical update and pathophysiology. Curr Opin Neurol, 2008. 24(4): p. 461-471.

Cohen, H., 1998. Neuroscience for Rehabilitation. JB Lippincott, Philadelphia

Coelho M, Marti MJ, Tolosa E, et al. Late-stage Parkinson’s disease: the Barcelona and Lisbon cohort. J Neurol

2010; 257: 1524–32.

Colgrove YS, Sharma N, Kluding P, Potter D, Imming K, et al. (2012) Effect of Yoga on Motor Function in People

with Parkinson’s Disease: A Randomized, Controlled Pilot Study. J Yoga Phys Ther 2:112.

Deane KHO, Jones D, Playford ED, Ben-Shlomo Y, Clarke CE. Physiotherapy versus placebo or no intervention in

Parkinson’s disease. Cochrane Database Syst Rev. 2001;(3):CD002817

Duncan PW, Studenski S, Chandler J et al. Functional reach: predictive validity in a sample of elderly male veter-

ans. J Gerontol. 1992;47(3):M93-8.

European Parkinson’s Disease Association, accessed 19th December 2014. available at http://

www.parkinsonsawareness.eu.com/campaign-literature/prevalence-of-parkinsons-disease/

Eustace C. Movement Analysis. BBTA Basic Bobath Course, Barnstaple, UK. 2014

Graham, J.E., Karmarkar, A.M. & Ottenbacher, K.J., 2012. Small sample research designs for evidence-based reha-

bilitation: issues and methods. Archives of physical medicine and rehabilitation, 93(8 Suppl), pp.S111–6.

Guttman, M., Kish, S. J., & Furukawa, Y. (2003). Current concepts in the diagnosis and management of Parkinson's

disease. Cmaj, 168(3), 293-301.

Haas, B. (2010) Motor Control – Chapter 4 pp-47-70 in Human Movement, Everett, T. & Kell C. (eds) Churchill Liv-

ingstone ISBN: 978-0-7020-3134-2

Hartholt, K et al . Societal consequences of falls in the older population: injuries, healthcare costs, and long-term

reduced quality of life. J Trauma, 2011. 71(3): p. 748- 53.

Headlee DL, Leonard JL, Hart JM, Ingersoll CD, & Hertel, J. (2008). Fatigue of the plantar intrinsic foot muscles

increases navicular drop. Journal of Electromyography and Kinesiology, 18, 420-425.

Hobart, J. C., Riazi, A., et al. Measuring the impact of MS on walking ability: the 12-Item MS Walking Scale (MSWS

-12)." Neurology 2003. 60: 31-36.

Horak F. 2006. Mechanistic and physiological aspects. Postural orientation and equilibrium: what do we need to

know about neural control of balance to prevent falls? Age and Ageing 35-S2:ii7-ii11.

Horak FB, Nutt JG, Nashner LM. Postural inflexibility in Parkinsonian subjects. J Neurol Sci. 1992;111:46-58.

Hely, M.A., Reid, W.G., Adena, M.A., Halliday, G.M. and Morris, J.G. The Sydney multicentre study of Parkinson's

disease: the inevitability of dementia at 20 years. Mov Disord, 2008. 23(6): p. 837-44.


Henning, M and Sterzing, T. Sensitivity Mapping of the Human Foot: Thresholds at 30 Skin Locations. Foot Ankle

Int 2009 30: 986-991

Johnson, A. M., et al. (2009). Plantar cutaneous sensory stimulation improves single-limb support time, and EMG

activation patterns among individuals with Parkinson's disease. Parkinsonism Relat Disord.

Kim S, Horak F, Carlson-Kuhta P and Park S. Disease Postural Feedback Scaling Deficits in Parkinson's J Neurophys-

iol 2009 ;102:2910-2920,

Kuypens, H. A new look at the organisation of the motor system. Progress in Brain Research 57:381-403

Lim, L. I., van Wegen, E. E., et al. (2005). "Measuring gait and gait-related activities in Parkinson's patients own

home environment: a reliability, responsiveness and feasibility study." Parkinsonism Relat Disord 11(1): 19-24.

Menz, H, Morris, M., Lord, S. Foot and ankle characteristics associated with impaired balance and functional ability

in older people. J Gerontol A Biol Sci Med 2005; 60A:1547-52

Massion J et al Why and how are posture and movement coordinatedProgress in Brain Research, Vol. 143; 13-27

Maurer, C., Mergner, T. and Peterka, R.J. Abnormal resonance behavior of the postural control loop in Parkinson's

disease. Exp Brain Res, 2004. 157(3): p. 369-76.

Mak, M. K. and Pang, M. Y. (2009). "Balance confidence and functional mobility are independently associated with

falls in people with Parkinson's disease." J Neurol 256(5): 742-749.

Patel N, Jankovic J, Hallett M Sensory aspects of movement disorders. Lancet Neurol 2014; 13: 100–12

Pickering, Ret al. A meta-analysis of six prospective studies of falling in Parkinson's disease. Mov Disord, 2007. 22

(13): p. 1892-900.

Raine S, Meadows L, Lynch-Ellerington M. 2009. Bobath concept. Theory and clinical practice in neurological reha-

bilitation. United Kingdom: Wiley-Blackwell.

Reichert WH, Doolittle J, McDowell FH. Vestibular dysfunction in Parkinson disease. Neurology 1982; 32: 1133–38.

Ridola C, Palma A. Functional anatomy and imaging of the foot. Ital J Anat Embryol 106: 85–98, 2001

Santos M, Kanekar N, Aruin A. 2009. The role of anticipatory postural adjustments in compensatory control of pos-

ture: 1. Electromyographic analysis. Journal of Electromyography and Kinesiology 20:3 388-397.

Smania N et al . Effect of Balance Training on Postural Instability in Patients With Idiopathic Parkinson's Disease-

Neurorehabil Neural Repair 2010 24: 826

Shivitz N, Koop MM, Fahimi J, Heit G, Bronte-Stewart HM. Bilateral subthalamic nucleus deep brain stimulation

improves certain aspects of postural control in Parkinson’s disease, whereas medication does not. Mov Disord.

2006;21:1088-1097

Schaafsma, J. D., Giladi, N., Balash, Y., Bartels, A. L., Gurevich, T., & Hausdorff, J. M. (2003). Gait dynamics in Park-

inson's disease: relationship to Parkinsonian features, falls and response to levodopa. J Neurol Sci, 212(1-2), 47-53.

Schepens B, Stapley P & Drew T Neurons in the Pontomedullary Reticular Formation Signal Posture and Move-

ment Both as an Integrated Behavior and Independently J Neurophysiol 100:2235-2253, 2008

Schenkman M, Butler RB (1989) A model for multisystem evaluation treatment of individuals with parkinson's dis-

ease. Phys Ther 69: 932-943

Spink, M. J., Fotoohabadi, M., Wee, E., et al. Foot and ankle strength, range of motion, posture, and deformity are

associated with balance and functional ability in older adults. Arch Phys Med Rehabil 2011; 92(1): 68–75.


Steffen, T. and Seney, M. (2008). "Test-retest reliability and minimal detectable change on balance and am-

bulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people

with parkinsonism." Physical Therapy 88(6): 733-746.

Tyson S and Connell L. The psychometric properties and clinical utility of measures of walking and mobility in

neurological conditions: a systematic review. Clinical rehabilitation. 2009;23:1018-33

Visser JE, Allum JH, Carpenter MG, et al. Effect of subthalamic nucleus deep brain stimulation on axial motor

control and protective arm responses in Parkinson’s disease. Neuroscience. 2008;157:798-812.

Williams J. Neurophysiology. BBTA Basic Bobath Course, Barnstaple, Devon, UK. 2014

Wright WG, Gurfi nkel VS, King LA, Nutt JG, Cordo PJ, Horak FB. Axial kinesthesia is impaired in Parkinson’s

disease: effects of levodopa. Exp Neurol 2010; 225: 202–09.

Wright W, Ivanenko Y, Gurfinkel V. 2012. Foot anatomy specialization for postural sensation and control.

Journal of Neurophysiology 107:5 1513-1521.

Terry Gorst Northern Devon Healthcare NHS Trust Module II ...

Documents

Transcript of Terry Gorst Northern Devon Healthcare NHS Trust Module II ...