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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6044_Библиотеки_им_академика_М_И_Перельмана.pdf
336
33.2.1 Tetrax FB
Tetrax FB works within the principles of Simplexity [ 18 ], which state that a human
body’s balance in space is based on the cooperation and interaction of a multiplicity
and complexity of many subsystems which are under the control of effi cient neurophysiological mechanisms. It consists of four independent mobile force plates, two
for each foot. Each plate contains a strain-gauge force transducer, which is sensitive
to vertical force. Tetrax provides independent output from the four balance plates.
Subjects are requested to stand quietly on the platforms and control CoG displacements using both feet, toes, and heels in a synchronized and coordinated way. “Tetra
CoG” have to be moved along visual presented pathways (e.g., a labyrinth, Fig. 33.3 )
as correctly as possible (Fig. 33.4 ).
The pressure fl uctuations produced by the heels and toes of a subject standing
with different positions of the trunk or the head may be visually balanced through
the feedback presented on the screen.
PATIENT INFORMATION AND TEST SETTINGS
Limits of stability
Age: 30
Ht.: 172 cm
LOS: 75 %
Test Date. 02/16/95
Order #: 6
Pacing Speed: 10 sec
Patient Name:
Data file
Target/prot. Type: SP06
Therapy Mode: Beep, Feedback
Post-Test Comment:
PAT H
Transition
1
2
3
4
5
6
7
8
4.28
4.00
4.04
2.94
3.74
6.72
4.50
3.70
127.68
172.16
157.96
169.83
237.19
347.19
188.06
158.90
N/S
N/S
N/S
N/S
0.58
0.13
0.20
0.41
68.6
70.1
70.8
314.2
124.8
176.6
<230.8>
<–0.8>
<–2.2>
<–5.8>
<1.9><–1.6>
<–14.4>
<–3.2>
<–2.9>
<271.9>
<87.8>
<359.2>
42.7 –2.3
–10.2
–3.4
–0.8
–8.2
–6.4
–4.2
–4.9
66.8
<60.6>
<73.4>
<71.8>
<72.1>
(RF)
(F)
(RB)
(B)
(LB)
(L)
(LF)
Mvt
Time
(sec)
Path
Sway
(% Path Len)
Numeric Summary
Target
Sway
(% Max Area)
(R)
SWAY AREA
Direction
Error
(deg)
Distance
Error
(% LOS)
Patient
Position
(% LOS) (deg)
Fig. 33.2 Example of LoS, a not completely statistical representation
D.C. Alpini et al.
337
No
Target
ST1 Ctr/
Ant
Align
Ctr
Ctr/
RLat
Ctr/
3L
Ctr/
Post
Ctr/
LPost
Ctr/
LLat
Ctr/
LAnt
Ctr/
LLat
Ctr/
Ant/
Post
LPost/
RPost
LAnt/
LPost
RLat
RAnt/
RPost
Ctr/
RPost
LAnt/
RPost
LAnt/
RAnt
Circle
R
Circle
L
ST23
Ctr/
3Ant
Ctr/
3R
Ctr/
RAnt
LLat/
RLat
Rant/
LPost
Ctrl/
3Post
Ant/
Post
ST3
ST4ST2
ST5 ST13 ST21
ST22ST14ST6
ST7 ST15
ST16
ST24ST8
ST9
ST17
ST25
ST18
Standard Targets
ST10
ST11
ST12 ST20
ST19
Fig. 33.3 Standard targets available for treatment
33 Visual Feedback Postural Control Re-education
338
33.2.2 Delos
It is based on an electronic rocking board, with “a degree of freedom” and visual
tracking of the micro-rolling of the point of support. Its exclusive rocking movement, combined with the subcortical visual tracking in real time, creates conditions
of instability capable of activating high-frequency proprioceptive fl ows both in
standing (Fig. 33.5 ) and sitting position (Fig. 33.6 ).
The rolling surfaces with variable radius permit the proposal of different levels
of instability and the selective activation of the postural strategies. The postural
reader measures the subject’s levels of stability in static and dynamic, monopodalic, bipodalic, and seated conditions. It records and visualizes in real time the
movements on the frontal and sagittal planes in relation to the vertical axis. The
system may use also a wireless electronic rocking board with “3 degrees of freedom” with visualization in real time of the movements on the x -, y -, and z -axis.
Tridimensional view of the trials represents the completion of DEB2 proposal,
widening the number of biomechanical and postural situations to be managed.
The rolling surfaces with variable radius permit the proposal of increasing levels
of instability.
Fig. 33.4 Tetrax FB
equipment
D.C. Alpini et al.
339
Figs. 33.5 and 33.6 Delos
DEB 2 equipment comprising
the electronic rocking board
and the two accelerometers
on the head and the trunk
33 Visual Feedback Postural Control Re-education
340
Conclusions
VFB provides a ready source of information about postural instability for both
the patient and the therapist. The purpose of VFB is to detect and make available
to the patient objective information about physiological function or movement
that is not ordinarily perceived by the patient (e.g., Balance Master).
In the case of postural instability caused by whiplash injuries, visual and auditory (beep) signals have been used to give the patient information about head and
trunk orientation (e.g., Delos) and about symmetry of weight bearing through the
lower extremities (e.g., Tetrax). The assumption is that the patient can use visual
or auditory cues better than he or she could use somatosensory or vestibular
inputs.
For the therapist the VFB facilitates the design of custom treatments, and for
the patient it enhances motivation through real-time visual feedback, links perception to movement, internalizes the appropriate alignment or movement pattern, improves volitional control, and builds confi dence to perform activities of
daily living.
Recently it has been proposed the use of Nintendo Wii, a popular virtual reality (VR) video gaming system, both as physiotherapist-assisted [ 19 ] and home-
based [ 20 ] exercises.
Nintendo Wii Balance Board is cost-effective and user-friendly [ 21 ] and has
been proposed as an alternative to other popular frequently used systems in
elderly patients [ 22 ], but it is limited in its customizability to accommodate dif-
ferent functional levels, thus in our experience, professional equipments have to
be preferred for WAD rehabilitation.
References
1. Horstmann GA, Dietz V (1990) A basic control mechanism: the stabilization of the center of
gravity. Electroenceph Clin Neurophysiol 76:165–176
2. Shumway-Cook A, McCollum G (1991) Assessment and treatment of balance defi cits in the
neurologic patients. In: Montgomery P, Connelly B (eds) Motor control. Theoretical framework
and practical application, & physical therapy. Chattanooga Corp, Chattanooga, pp 123–138
3. Di Fabio RP, Andersen JH (1993) Effect of sway-referenced visual and somatosensory inputs
on human head movement and postural patterns during stance. J Vest Res 3:409–417
Figs. 33.5
and 33.6 (continued)
D.C. Alpini et al.
341
4. Hamann KF, Krausen C (1990) Clinical application of posturography. Body tracking and biofeedback training. In: Brandt T, Paulus W, Bles W (eds) Disorders of posture and gait. Thieme,
Stuttgart, pp 295–298
5. Lee DN, Lishrnan JR (1975) Visual proprioceptive control of stance. J Hum Mov Stud 1:87;
Moore S, Wollacott MH (1993) The use of biofeedback devices to improve postural stability.
Phys Ther Pract 2(2):1–19
6. Nashner L (1994) Evaluation of postural stability, movement, and control. In: Hasson SM (ed)
Clinical exercise physiology. Mosby, St Louis, p 57
7. Neurocom International Inc. (1989) Balance master operator’s manual. Neurocom, Portland
8. Daleiden S (1990) Weight shifting as a treatment for balance defi cits. A literature review.
Physiother Can 48:81–87
9. Alpini D, Cesarani A, Pugnetti L, Cardini R, Hahn A, Sambataro G (2000) Project to prevent
mobility related accidents in elderly and disabled. Proceedings of the 3rd international conference on disability, virtual reality and ass. Tech., Alghero, Italy, pp 249–254
10. Himmelfarb R, Kohen-Raz R, Rapaport J, Bloom A (1992) The application of posturography
in the assessment of vertiginous disorders caused by head and neck injuries. Proceedings of he
international meeting on whiplash injuries. University of Wales, Wales
11. Kohen-Raz R, Gentaz R (1993) Posturographic characteristics of patients with lower back
pain. Cahiers de Posturologie, Paris
12. Kohen-Raz R (1986) Learning disabilities and postural control. Freund Publishing House, Tel
Aviv
13. Kohen-Raz R, Roth V (1998) Posturographic characteristics of Whiplash patients. Proceedings
of the XII regular meeting of the Barany Society, Wuerzburg, Germany. In: Claus CF, ClausToni H, Hoffenberth B (eds) Equilibrium research, Clinical equilibriometry and modern treatment. Elsevier, Amsterdam, 2000
14. Roth V, Perlson Y (1997) The contribution of an interactive balance recording system (IBS) to
the diagnosis, treatment and follow up of Foot and Ankle Injuries. Proceedings of the international congress on foot and ankle injuries, Jerusalem, January 1997
15. Turner D (1998) Evaluation of the tetrax interactive balance system and equitest using normal
subjects. MSc thesis, University of Southampton
16. Lee KG, Chun MH, Kang SH, Kim BR (2008) The evaluation of effect after biofeedback training using interactive balance system in sub-acute stroke patients. Asan Medical Center Korea,
XVII. European stroke conference Nice, France. Poster Session: Recovery and rehabilitation,
May 2008
17. Sjostrom H, Allum JH, Carpenter MG, Adkin AL, Honegger F, Ettlin T (2003) Trunk sway
measures of postural stability during clinical balance tests in patients with chronic whiplash
injury symptoms. Spine 28(15):1725–1734
18. Berthoz A (2012) Simplexity. Yale University Press, London
19. Levac DE, Miller PA (2013) Integrating virtual reality video games into practice: clinicians’
experiences. Physiother Theory Pract;29(7):504–512
20. Prosperini L, Fortuna D, Giannì C, Leonardi L, Marchetti MR, Pozzilli C (2013) Home-based
balance training using the wii balance board: a randomized, crossover pilot study in multiple
sclerosis. Neurorehabil Neural Repair 27(6):516–525
21. Sparrer I, Duong Dinh TA, Ilgner J, Westhofen M (2013) Vestibular rehabilitation using the
Nintendo® Wii Balance Board – a user-friendly alternative for central nervous compensation.
Acta Otolaryngol 133(3):239–245
22. Taylor MJ, Shawis T, Impson R, Ewins K, McCormick D, Griffi n M (2012) Nintendo Wii as a
training tool in falls prevention rehabilitation: case studies. J Am Geriatr Soc 60(9):1781–1783
33 Visual Feedback Postural Control Re-education
343
D.C. Alpini et al. (eds.), Whiplash Injuries,
DOI 10.1007/978-88-470-5486-8_34, © Springer-Verlag Italia 2014
34.1 Introduction
The meaning of ataxia is failure of coordination. Ataxic patients are not able to
defi ne the width, velocity, and rhythms of muscle contractions and cannot coordinate more muscle groups which are synchronously activated. The ataxia can be
determined by (1) injury of the proprioceptive afferences, (2) labyrinthic injury, and
(3) injury of cerebellum or its connections which are reciprocally connected to the
cerebral cortex (neocerebellum), the spinal cord (paleocerebellum), and the vestibular system (archeocerebellum).
Post-whiplash ataxia is not frequent and it attains to polytrauma patients. The
walking ataxia – often generically considered as walking balance disease – can also
be generated by an injury of the pyramidal paths causing a heavy recruitment defi cit
of the lower limb proximal areas. We use the word “ataxia” with the meaning of
coordination and motor control alteration due to the inability of the antagonistic
muscle couples to synergistically operate. It can occur as postural instability of one
or more body segments or as dyssynergia when holding a posture during the execution of a complex motion [ 1 , 2 ]. Ataxia can be often found in whiplash- type injuries
and sometimes in the acute phase shows reversibility, probably because it is supported by a simple neuro-apraxia of the corresponding nervous paths. In cases in
which the ataxia is present with instability, it is usually supported by injuries of the
direct or indirect proprioceptive paths or the cerebellospinal paths fl owing to the
cervical spinal cord. From the functional point of view, ataxia can be defi ned as a
specifi c diffi culty in controlling the center of gravity of the whole body or of single
articulated segments. In fact, it magically disappears when the patient is immersed
into water [ 3 ].
M. Forni
Rehabilitation Unit, IRCCS “Don Carlo Gnocchi” Foundation,
Marina di Massa (MS) , Italy
e-mail:
mforni@dongnocchi.it
3 4
Neurorehabilitation of Ataxia
M. Forni
344
34.1.1 Treatment Outlines
If considered on the plane of a system which can be infl uenced by therapeutic
exercise, that is, on the interface between environment and spinal segmentary systems (receptor level and muscle effector level), ataxia can be defi ned as the inability
to couple suitably coactivation and reciprocal activation, the latter the pathologically prevalent characteristic. From the spinal cord point of view, in fact, hypotonia
could be considered as the cause of the ataxia. In fact, if we consider ataxia as
increase of the stretching refl ex threshold due to decreasing of the fusi basal discharge, we can formulate the hypothesis that the motion desynchronization is supported by a decreasing of the tonic “brake,” due to perceptive distortions connected
to the proprioceptor- altered operation. Further, we could consider ataxia as the
extreme pole of a continuous path with variable prevalence grades between coactivation and reciprocal activation, in which the opposite is spasticity. In fact, correct
motion requires a rigidity entity which is able to withstand stimuli or a fl exibility
that is the ability to follow stimuli. Ataxia can be considered as an excessive fl exibility. The posturogram of a normal person is known to often show variability in the
center of gravity displacement, which is the expression of physiological fl exibility.
The motion pre-patterns, that is, the anticipatory muscle activation of an intentional
motion being carried out, are one of the physiological examples of the control of
this CNS variability. The therapeutic approach to ataxia cannot be separated from
such considerations [
4 ]. The most important problem in the spontaneous adaptation
to the symptom in the atactic patient is normally that the spontaneous reaction
increases the symptom.
The “body’s intelligence” reacts against the instability by increasing the rigidity,
that is, the cocontraction, which is the real mechanism altered by the pathology.
This condition activates the paradoxical happening so that the instability increases
with the increasing of attempts aimed to limit it. Some preliminary therapeutical
results can be obtained simply by disconnecting this vicious circle by means of
relaxation techniques (which could be claimed as not suitable with regard to muscle
tone assessment), also of the psychomotor type. Taking into consideration that often
the whole spontaneous attempt of stopping the symptom accentuates it, the proposal
of “balance exercises” for the ataxic patient seems to be not justifi able. In fact, these
exercises are based on quick changes of the center of gravity, as imposed by the
rehabilitator, and are also based on the idea that after some stress of this type, an
adaptation should occur. It is my opinion that this adaptation – based on the idea that
the repetition is one of the mechanisms starting the process of learning – makes the
ataxia problem not solvable from the rehabilitation point of view.
An exercise plan for the ataxic patient should be based on a functional assessment, recognizing the motion-specifi c characteristics as well as the necessary
changes needed to modify it. For example, we can examine whether the ataxic
motion is sensitive to inertial changes applied to the end of the considered segment
(weights), or to intentional changes (automatic-voluntary dissociation), or even
whether it uses any, and if so which, privileged afferent channels. Furthermore, the
description of the altered motion should include the planes on which the alteration
M. Forni
345
is mainly evident as well as the articular angles and motion velocity at which the
motion is mainly compromised. Furthermore, we should examine whether the
motion is dynamically or statically altered.
The most interesting classifi cation from the rehabilitation point of view is still P.
Gasco’s one [ 5 ], relevant to rehabilitation of motion in patients suffering from mul-
tiple sclerosis in its different expressions (Table 34.1 ).
Therefore we propose a descriptive assessment protocol to be associated, when
possible, with instrumental evaluations [ 1 , 5 ]:
1. Assessment of ataxia “migration” in different body areas, with reference to pos-
ture; in fact, often the oscillation of one segment is complementary to and com-
pensates the adjacent segment oscillation and does not represent the injury site
from the topological point of view. The patient is evaluated in different postures
taking into consideration the syndrome’s acuteness: for example, in the erect
position (possibly also the monopodalic position), both with extended and fl exed
knees, in a quadruped position, in crouched position, sitting down to exactly
examine the planes at which the motion is more compromised, and the postural
conditions in which the instability is evidenced in each body area. In the most
diffi cult cases, the patient can also be evaluated in a supine position thanks to
suitable supports, able to allow the cingulum to move with one or more degrees
of freedom.
2. Evaluation of synergies most stressed by the ataxia in the same body area [
6 ].
Various modes of execution of the same action are evaluated (e.g., reaching to a
point in the space with one limb end or with the head or tracking of a trajectory
Table 34.1 Correlations between lesions and symptoms
Lesion topography
Functions Postural reactions
First-order lesion
associations
Second-order
lesion
associations
Efferent motor
paths
Pyramidal Inhibited
Posterior cord
afferent paths
Kinesthetic and
proprioceptive
(deep sensory)
Uncompleted,
delayed
With synergically
reduced reactions
Cerebrocerebellar
paths
Neocerebellar Sequentially
altered
With
dissociated
reactions
Spinocerebellar
paths
Paleocerebellar Increased intensity With reactions
uninhibited in
direction and
intensity
Vestibulocerebellar
paths
Archeo-cerebellar Dynamically
displaced with
distal prevalence
Vestibulospinal
paths
Vestibular Statistically
distorted with
proximal
prevalence
34 Neurorehabilitation of Ataxia
346
with one limb or the eyes, grasping of objects, reaching possible positions).
In this phase, the performance success or the execution correctness is not evaluated, but the chosen “strategy,” above all on the basis of the degrees of freedom
or constraints imposed on the various segments implied or possible to be implied
in the motion.
3. Evaluation of the maximal voluntary cocontraction effects on the symptoms: the
patient is asked to try to actively stop the tremor or the postural instability by
stiffening as much as possible the involved segment and the adjacent segments.
Under the same other conditions, we note cases in which this operation is successful and cases in which this operation causes instability or increasing
incoordination.
4. Evaluation of differences in the symptoms with respect to the voluntariness or
automatism of the motion; for example, in exercises with multiple conditions in
which an upper limb is laid on a moving plane and executes automatic support
functions, while the other limb executes an intentional job referred to a target
imposed by the examiner, then the operation of the examined limbs is inverted.
We note instability conditions which tend to occur more intentionally, than automatically, and vice versa (considering the required cautions due to the kinesiologic differences between the two tasks).
5. Evaluation of differences in the symptoms [
7 ] subsequent to segmentary motions
which are freely chosen by the patient, or segmentary motions imposed by the
examiner, but without perceptive guide, or motions with perceptive guide, such
as reaching a target or executing a trajectory following paths imposed by the
examiner.
6. Evaluation of the effect of suppression, increase, or distortion of one or more
perceptive channels (acoustic, visual, or proprioceptive) on the posture or
motion. The above six factors allow a functional assessment of the ataxia which
is more suitable than the traditional one used to plan therapy. In this way, the
therapeutic approach can be oriented to correction of the most specifi c aspects
which determine the incoordination or balance defi ciency.
Naturally, this approach should be widened and validated, if possible, with
instrumental analysis able to control both the assessment correctness and the
effi ciency of the therapeutic approach.
34.1.2 Treatment
Research evidence of activity-dependent central nervous system (CNS) plasticity
and the requisite motor learning principles can be used to construct an effi cacious
motor recovery intervention. Brain plasticity after trauma refers to the regeneration
of brain neuronal structures and/or reorganization of the function of neurons. Not
only can CNS structure and function change in response to injury, but also the
changes may be modifi ed by “activity.” For gait training or upper limb functional
training for stroke survivors, the “activity” is motor behavior, including coordination and strengthening exercise and functional training that comprise motor
M. Forni