terry gorst northern devon healthcare nhs trust module ii
TRANSCRIPT
© 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
© Terry Gorst, NDHT 2
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.
© Terry Gorst, NDHT 3
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
© Terry Gorst, NDHT 4
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.
© Terry Gorst, NDHT 5
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)
© Terry Gorst, NDHT 6
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).
© Terry Gorst, NDHT 7
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)
© Terry Gorst, NDHT 8
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).
© Terry Gorst, NDHT 9
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.
© Terry Gorst, NDHT 10
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
© Terry Gorst, NDHT 11
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
© Terry Gorst, NDHT 12
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
© Terry Gorst, NDHT 13
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)
© Terry Gorst, NDHT 14
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
© Terry Gorst, NDHT 15
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!!
© Terry Gorst, NDHT 16
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.
© Terry Gorst, NDHT 17
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
© Terry Gorst, NDHT 18
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)
© Terry Gorst, NDHT 19
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
© Terry Gorst, NDHT 20
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
© Terry Gorst, NDHT 21
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!!
© Terry Gorst, NDHT 22
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.
© Terry Gorst, NDHT 23
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
© Terry Gorst, NDHT 24
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
© Terry Gorst, NDHT 25
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).
——————————————————————————-
© Terry Gorst, NDHT 26
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