Clinical Case Study of an MS patient using the Bobath Concept by alextt


									  Clinical Case Study of an MS
patient using the Bobath Concept

             Karen Saunders
      Manchester Neurotherapy Centre
                 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
• 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 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

               Selective                         Ankle & hip
               movement                          strategies
               of limbs

                     Somatosensory information

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

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.
•   Mobilisation/realignment left foot to access ankle strategy
•   Activate triceps surae(gastroc)to switch on hip and knee from “heel
•   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
•   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
    (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
                     posture   20                   posture
                     PF ROM    15                   ROM
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


      2                                                      22/05/2006
                                                             Mar07 43/56

          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

1.5                                  today 30/56
      1 2 3 4 5 6 7 8 9 1011121314
   Muscle bulk measurements
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
• 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
• 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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