Clinical Case Study of an MS patient using the Bobath Concept Karen Saunders Manchester Neurotherapy Centre 06/03/08 Miss A • Age 67 • Retired 3 years ago – lives alone • 5 years ago (2002) – gradual onset weakness in left leg whilst working • Only diagnosed with primary progressive MS following admission with # R ankle in October 2005 • Neuro-rehab unit for 12 weeks • On admission no sitting balance, hoisted but independent transfers by discharge on 07/12/05 • Supported by MS nurse on discharge • Living independently with social support • Started on 5mg diazepam for spasm as I/P Initial Assessment – 08/05/06 Bobath Concept - Key Components • Postural Alignment • Patterns of movement • Speed/effort/efficiency • Functional range of movement • Goal orientation • Working hypothesis GOALS Goals identified by Miss A • Walk in/out bungalow independently & safely to her car • To be able to drive her car again • To maintain her functional independence Treatment Plan • Explore potential for Miss A to recruit anti-gravity muscle activity in her legs to…build core stability and allow some change of UL pattern to ....increase her postural control during functional tasks • (Investigate what she should do to ascertain whether she can go back to driving) Outcome Measures • Visual Analog Scale – Confidence • Goniometry – ankle joints • Video • Berg Balance Scale • Functional Goal Achievement • Muscle bulk measurements Treatment – Working Hypothesis • To explore the possibility of improving her orientation to her feet and hips by (and for) activation of selective muscle activity • To explore the possibility of changing pattern of movement from sit to stand to strengthen legs • To explore the potential for improving core stability and balance so that ULs are not used so heavily for gait and so are less fatiguable and become more available for other functional tasks Postural Control • The act of achieving, maintaining or restoring a state of balance during any posture or activity (Pollock et al, 2000) • Bobath Concept uses the Systems Model of motor control (Nicholai Bernstein) to make links between clinical observation and the performance of movement – How is posture and selective movement produced ?? • Consideration is given to - • COG – vertical position of COM from ground • Anticipatory Postural Adjustments (aPas and paPas) • Ventromedial systems – creation of posture Postural Alignment 3-d orientation of body parts around midline whilst moving. Visual Head & neck organisation alignment Alignment of Core stability vertebral column & thorax and pelvic stability/mobility Selective Ankle & hip movement strategies of limbs Somatosensory information ANKLE STRATEGY Restores COM to a position of stability through body movement primarily centred about the ankle/mid tarsal joints Used most commonly when the perturbation to equilibrium is small and the support surface is firm HIP STRATEGY Controls motion of the COM by producing large and rapid motion at the hip joints with antiphase rotations of the ankles Used to restore equilibrium in response to large rapid perturbations when the support surface is compliant or smaller than the feet e.g. standing on a beam or a mobile support Head forward posture is often associated with medial rotation and forward position of the shoulders leading over time to decreased ROM in shoulders and reduced vital capacity. Somewhere something went terribly wrong! Head Orientation • The HEAD alignment and postural control is dependent on vision, balance and the underlying stability/mobility of the trunk • Lack of CORE STABILITY leads to frequent over perturbation of the head and vestibular stimulation i.e. micro whiplash type effect • Developing core stability allows weight transfer with a more stable, controlled head and so less stimulation of the vestibular system leading to protective fixation. Treatment • Mobilisation/realignment left foot to access ankle strategy • Activate triceps surae(gastroc)to switch on hip and knee from “heel down” • TS is both a major propulsive muscle in locomotion and a major stabilising aspect of postural control • Work on left hip stability to gain active left quads and proximal hamstrings • Activate left hip extension through sit to stand and stop standing using light touch of hands for balance (Jeka, J. 1997) • Work to keep COG up • Common strategy of increased static behaviour of soleus in postural instability (Singer et al 2001) Facilitation of extension during gait Facilitation of change of pattern in arms from flexion fixation to stable reference points using elbow crutch on right helps weight transfer. Note improved vertical orientation and reduced push through right foot to clear floor with left. Treatment Outcome Measures Visual Analogue Scale - 4 / 10 on 08/05/06 Confidence 8 / 10 on 09/11/06 Goniometry and ankle 08/05/06 activity 18/12/06 Video – sit to stand – 6 secs 08/05/06 control & time >3 secs 01/03/07 Berg balance scale – 27/56 on 22/05/06 Improved in 10/14 items 43/56 on 20/03/07 Functional Goals Achieved being able to walk outdoors to car Ankle ROM and activity- Initial 08/05/06 and 18/12/06 35 40 30 35 30 25 25 20 posture 20 posture 15 PF ROM 15 ROM 10 10 5 5 0 0 left right left right ankle ankle ankle ankle Improved sit to stand > 3 secs in March 2007 - Without frame Berg Balance Scale – overall score improved by 16 points 4 3 2 22/05/2006 02/11/2006 Mar07 43/56 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Main improvements in standing activities such as forward reach, picking up objects from the floor and tandem stance Berg Balance 4 3.5 3 2.5 Aug-07 2 Dec-07 1.5 today 30/56 1 0.5 0 1 2 3 4 5 6 7 8 9 1011121314 Muscle bulk measurements Calves 1. Upper - Feb 07 R 35.5 L 32.5 Sept 07 R 34.5 L 31.5 Feb 08 R 36 L 33 2. Lower - Feb 07 R 32 L 30 Sept 07 R 32 L 28.5 Feb 08 R 33.5 L 30 Quadriceps • Sept 07 R 40 L 37 • Feb 08 R 41 L 38 Assessment at Wrightington Mobility Centre • Comprehensive assessment – by 2 professionals – OT and Instructor • Vision check • Driving rig as simulator – reaction times • Advised on hand controls • Practise with dual control car with adaptations • Report can be sent to GP/Consultant – acts as advice only • DVLA / CSP guidance References • Pollack,A.S. et al (2000) What is balance? Clinical Rehabilitation 14 (4), 402-406 • Hunter,M.C. & Hoffman,M.A. (2001)Postural control :visual and cognitive manipulations. Gait and Posture. 13, 41-48 • Palmieri,R.M. et al (2002) Centre-of-pressure parameters used in the assessment of postural control.Journal of Sports Rehabilitation. (11) 51-66 • Singer,B. et al (2001) Reflex and non-reflex elements of hypertonia in triceps surae muscles following acquired brain injury : implications for rehabilitation.Disability and Rehabilitation.23 (17)749-757 • Jeka,J.(1997) Light touch contact as a balance aid.77 (5)476-487 • Vellas, B. et al (1992) In Shumway-Cook, A. & Woollacott,M.H.(2001). Motor control – Theory and practical applications. 2E.
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