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Re: Treatment ideas for adult ataxia
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Re: Treatment ideas for adult ataxia - December 12, 2001 3:17:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Hello,
I might be getting in over my head... but here goes.
It makes sense to me that trunk control must be achieved first, before the legs get addressed, (meaning that ball therapy or horse therapy makes sense to me before walking control can be established), for a couple reasons:
1. The legs come out of the trunk embyologically; the unfoldment of the nervous system happens from the top down.
2. Developmental control starts at the top and moves distally in babies.
Seems logical to me that we would want to replicate natural development of "normal" motor control by helping a patient control trunk balance/coordination first, then get them working up on their pins after.
This is crude reasoning, I admit. But why put the cart in front of the horse? Oops. Mixing up horse ideas.
To Hirsh: the article suggested to me that motor control is devilishly hard to accomplish for so-called normal people, let alone someone with ataxia. Because people who allowed themselves to be subjected to this completely artificial robotic interference, learned to overcome it, when I connect the dots I feel hope for folks with ataxia, etc.. Perhaps the brain really can deepen its inter/intraconnectivity and produce a new level of function that is brought out by lots and lots of novel playful postural stimulii.
Diane
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Re: Treatment ideas for adult ataxia - December 12, 2001 4:54:00 PM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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SJ,
For a PT who's never done hippotherapy, but have a horse, you raise some very good points. If you're truly interested in this subject, I'd once again suggest that you actually read Dr. Haehl's article. Most of your questions (good questions) are answered quite clearly. In answer to your direct and implied questions:
First of all, Hippotherapy and Therapeutic Riding are not the same thing. Hippotherapy is far more passive on the part of the patient, and far more human-resources intensive. There are at least 3 adults per child, and sometimes a 4th actually riding with the child (at least initially). Riding is a different story altogether, and issues of saddles and stirrups must be dealt with in ways that are moot in hippotherapy. Hippotherapy is usually either bareback, or with specially designed saddles.
You have the right idea with respect to how the size of the circle affects trunk and LE adduction reactions, and you are correct in your assumption that certain horses are matched up with riders. Lots of things go into it. Not only temperament of the breed, but size of the horse and gait. Many people might think that a pony is a good choice because they tend to be smaller than horses . . . but their temperament not only tends to be non-condusive to hippotherapy, but their gait tends to be more choppy, not allowing the rider as fluid a frontal plane motion (needed for CPG stimulation).
"If the rider is able to sense body position, riding a horse is more involved than a gymnastic ball." Yes and no. It's certainly more motivating to ride a horse, but hippotherapy and riding are not exactly the same thing.
"There is also an immediate internal feedback loop - if the wrong muscular/balance/righting corrections occur the rider's center of gravity changes and requires a quick correction to maintain the position on top of the horse." That's right. That's specifically one of the values of hippotherapy and PWB-TT
"Not just the pelvis and trunk are key for maintaining balance on a horse, but also head, shoulder and leg positions." Yes, but the primary importance of trunk control, over head control, shoulder, and leg positions is recognized by NDT therapists, and kinesiologists alike. Head control can't occur without a sound base. Even in the first
few months of life where the unskilled pediatric PT focuses upon capital extensors, it's the obliques that actually fire first --- producing a stable base for head control and turning in prone.
"Riding a horse is more complex of a task than a gymnastic ball, if you ask me." Yes,
that's true, but hippotherapy and riding a horse aren't the same thing. Hippotherapy is much more passive on the part of the patient than is riding. Hippotherapy isn't any more difficult than gymnastic ball exercises, but it is different --- and it's FAR more motivating for a child. This is perhaps why better gains in developmental skills are noted when hippotherapy or PWB-TT is incorporated into a PT program. Actually, great gains are often seen even when these developmental skills aren't specifically addressed by the therapist.
"Analyzing a treatment session with anyone on horse would be quite time consuming also - the horse movements and the rider movements would both have to be taken into account." Incorrect. It's actually quite easy. Dr. Haehl was able to do this quite effectively with minimal cost or effort."
"Granted, I have no clue how hippotherapy would improve walking, but maybe it has to do with the fact that it's a whole body movement pattern kind of thing that has to occur to keep oneself on top of the horse. It may have little to do with the therapist focus on the trunk and pelvis." That essentially both completely correct, and completely incorrect. The therapist will begin with central control and then work outward.
Diane,
BINGO! You've got it! I'd clarify one statement though:
"Developmental control starts at the top and moves distally in babies." That's not quite true. Central control (lower trunk control of RA and obliques) actually comes online before any kind of head control. This is what is meant when NDT therapists and Kinesiologist talk about the lower trunk being the key point of control for head control. This is why competent therapists, when working with a patient with poor head control in prone, won't stroke capital extensors, but will instead place their hands on the patient's obliques. For a more detailed explanation of this, pick up a copy of Lois Bly's Motor Development in the first Year of Life for about $65 or take one of her courses for at least $800. Once head control is established, however, control pretty much moves from head to toe --- that much is clear.
Drew
[This message has been edited by Andrew M. Ball MS MBA PT (edited December 12, 2001).]
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Re: Treatment ideas for adult ataxia - December 12, 2001 5:50:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Drew, thank you for your clarification. (I immediately jump to wondering if there might be some connection then in so-called orthopedic neck problems and some hitherto overlooked abds. dysfunction/imbalance... But that's a whole other topic..)
Diane
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Re: Treatment ideas for adult ataxia - December 12, 2001 6:20:00 PM
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Andrew M. Ball MS MBA PT
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From: Chapel Hill
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Great question. In short, I think the answer is yes. It's often overlooked by physical therapists and chiropractors alike.
Drew
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Re: Treatment ideas for adult ataxia - December 13, 2001 12:03:00 AM
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Mark Hirsch
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Hi Drew and Diane, good discussion going on. I hope the following post can spark some good discussion on the use of the treadmill with PBWS, associated reactions and mass synnergies, NDT-Bobath.
Drew, I havent read the article and I'm not knowledgeable about Hippotherapy so I can't comment on its efficacy. This was a case study with two subjects right? Have there been studies with more N? My fax in Germany is: 49-211-8116281....please make it out to Prof. Dr. Mark A. Hirsch, Ganglabor, Department of Orthopedics, University of Düsseldorf. Thanks
"Seems logical to me that we would want to replicate natural development of "normal" motor control by helping a patient control trunk balance/coordination first, then get them working up on their pins after"
Diane you said something about the beauty and logic of the hierarchical proximal to distal development and how that relates to physiotherapy practice. What would you do with a , say, 7 year old spastic diplegic CP child who is not ambulatory, has poor trunk control (can crawl and sit, not walk, cannot ambulate with walker), and good head, arm, hand control?
In my opinion our goal in PT should not be to "normalise" movement. Diane, I'm glad you put normal in "". It's a subtle point but I picked up on it. To me normalization is not whats so important. Important is that the patient, in the case of ambulation, can move from point A to point B, as quickly (or slowly, if they want) as possible, without long and short term injury to self or others. Many therapists, especially NDT and Bobath trained therapists, but also therapists without Babath training, will say that patients should not be allowed to practice repetitive stepping or grasping movements if they display associated reactions, mass synnergies or increased tone, spasticity during the practice of the task, at least that has been my experience talking with roughly 100 Bobath therapist -- so I know its just my opinion and I'm sure there are plenty of progressive NDT-Bobath trained therapists among our Rehabedge readers. I would love to see a topic started on "why we need to worry about associated movements in neurological rehabilitation"? To my knowledge no study has looked at if associated movements interfere with motor learning or if they are correlated with long term injury etc. Might associated movements actually HELP motor learning? I don't know. Havent thought long enough about it if pathological movement patterns can be used to teach the CNS system something usefull or how to design a study to test this hypothesis. Do patients who display associated movements during therapy, learn faster or slower -- do they learn more or less, is their quality of movement at the end of therapy different if we allow Associated movements during therapy sessions than if we try to inhibit them when they occur?
I'd also like to know if there is any scientific evidence showing that pathological gait patterns are a long term risk factor for joint pathology or other disease processes. I overhear the argument therapists and physicians(!) make towqard patients: "it's bad for you to walk that way" all the time. I know its not "pretty" to walk with associated reactions and it certainly isn't "normal" to walk with spasticity. If spasticity intereferes with my rehabilitative goal then I need to address the spasticity or the goal or both. Normal is not the only desirable endpoint, in my opinion, although normal or "physiological" gait might be less energy cost efficient to the patient and that would be an important point to consider. But efficiency of movement isn't the only important factor to consider. Maybe it's normal to strive for normality, from the perspective of the therapist. I'd be interested to hear from other therapist how important realization of "normality" is to them.
Now, I allow patients to practice walking on the treadmill even if the movement pattern is a-physiological or they display mass synergies or associated movements (as many of my stroke patients will do initially during the first training sessions).
Anyway, getting back to gaittraining in CP, I put these children on the treadmill with partial body weight support and don't wait for self-initiated standing trunk control prior to gait training. We have custom harnesses which are made for extremely small patients (very expensive but its crucial that harness fits snugly and does not chaff skin or irritate pressure sores). We have a ramp leading up to the actual treadmill (Woodway, by the way), and a special handlebar for children. Very little is done in the way of facilitating movement while the child walks on the treadmill. There are different techniques which can be used, ranging from placing the foot very carefully and ensuring heel to toe movement during stance, facilitating the hip, quads etc, to just pushing the heel forward in swing phase and not worrying so much about "physiological" gait movement patterns...but there are no standardized protocols on what works better and what works less in terms of patient handling while on the treadmill. Perhaps its important that in stance, the patients foot contacts the ground and the patient puts weight on the foot. Of course these children still receive the standard training, where we concentrate more on quality of movement but thats secondary on the treadmill where quality is also considered on a patient to patient basis but repetition and intensity of therapy are more important...patients practice roughly 1000 steps in 30 minutes of treadmill training and roughly 50-100 steps during level-ground therapy.
To those who say that walking on a treadmill is not physiologically equivalent to walking on the level ground, I say that several studies have confirmed that EMG traces taken during level walking and during treadmill walking are virtually identical. Another point of contention is spasticity. Will it increase as a result of training? Several studies have shown, using EMG, that the amplitude of the EMG signal decreases during training and this is meant to infer less pathological tone during gait training on the treadmill...but it has not conclusively been shown if spasticity is reduced following treadmill training. I think it is, but I can't explain how this would occur just yet. My hunch is that initially the tone will increase (cautious PT's might stop therapy at this point thinking -- oh my gosh this therapy is increasing the tone and spasticity!). After 2-6 weeks of training tone will "normalize". At least this is what appears to be happening in studies with patients after stroke who are given treadmill training with PBWS. It is also possible to combine treadmill training with EMG stimulation (Hesse does this in Berlin). There are also treadmills on the market with "smart" motors. One developed in Zürich by Dietz group (called the Locomat) features braces attached to a frame which provides support for the hips during walking. The brace is worn on each leg and features smart motors at the joints (knee, ankle, hip) so that when a patient initiates movement at that joint, the motor at that joint produces less torque for that particular step. So far there have been a few case reports documenting its efficacy but nothing serious yet in terms of hard science. There are other gait machines as well, for example the gait-trainer by Hesses group in Berlin. I think its an excellent gait-training tool and it now has a foot adaption for use with children. Studies using the gait trainer have also shown very impressive improvements in Functional Ambulation Category (FAC) scores when compared to a Bobath approach to gait training....very intriguing work.
Another point is that we use 1-3 "therapists" with the treadmill. With some of my TBI patients you need 1 therapist per leg-foot and its hard work (but worth it)taking just 5-6 steps. But without a treadmill the patient would be have to be mobilized exclusively in bed because working on gait on a level surface with these patients is next-to-impossible. With the Hesse gait-trainer only one therapist is needed because here we have a smart motor which assists leg movement, harness and a gadget to help patients with poor trunk control maintain trunk control during gait training. Works well with TBI patients, but I prefer the treadmill because there is more the patient has to do to self-initiate movement. Some critics say, treadmills will make PT's obsolete. Not so! I put the term in "" because a therapist does not necessarily have to be a PT during treadmill training but, like I said, we could have 2 PT's work the treadmill 8 hours a day if we could afford it. Actually we almost have that right now. Some times, patients are so functional they can train on their own. Liability is a problem in Germany. But compared to the USA this is heaven here. Yes, we worry about patient safety but we are not paranoid about it and people are not a sue-happy here as they are in the States.
We also have a lift-system under the Woodway treadmill which makes it more comfortable for therapists to work with patients. The whole thing weighs roughly 1000 kg. Being 5-6 feet off the ground is not threatening for patients. This has never been a problem.
Right, Drew, I agree with you that children are EXTREMELY motivated to walk on the treadmill. I have one patient ( a little boy with cs) who wakes up every morning and the first thing he says when he sees me is "when can I go on the treadmill today?". Perhaps motivation (an optimal level of CNS arousal) is the key to motor learning and that is why the treadmill "works" so well with children.
There are numerous studies using this approach to neurological rehabilitation and most of them come from CP, stroke and SCI populations. I would be happy to post them here if anyone is interested. I wonder if, someday, in the case of children with CP, this appraoch will be seen as superior to the approach of "facilitating" movement patterns and focusing on hierarchy.
Diane:
are you suggesting that before we work on gait in children with developmental disabilities, we should be working on head and trunk control? i.e. follow a developmental sequence of crawl, sit, stand walk (I may have left out a few). In other words, is it ok, in your opinion, to skip stand -- and go directly from sit to walk in therapy of CP children?
Following a set hierarchical structure sounds like a very NDT-Bobath oriented approach to neurological rehabilitation. Not sure if the hierarchical model is still state-of-the-art thinking about how the CNS is organized and how it learns from experience through neurological rehabilitation.
Sorry to be so long winded. I hope my post generates discussion. Mark Hirsch
[This message has been edited by Mark Hirsch (edited December 13, 2001).]
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Re: Treatment ideas for adult ataxia - December 13, 2001 3:11:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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Hirsh,
Furthering your points, you may want to take a look at Dr. Visintin's work comparing PWB-TT to gait training in parallel bars. She shows that traditional therapy can (when subjects were matched), actually CREATE the dorsal foot drag gait abnormality.
PT's should be embarrassed by this. We should have known better. That's simple motor learning theory:
Teach in the functional environment with which the movement will be used. If you teach stability in the parallel bars, that's what the foot will try to seek during gait! If you teach mobility from the beginning, even before the patient can stand well (as is possible with PWB-TT) it's MOBILITY that's taught. The between group differences are staggering.
To paraphrase the words of the great philosopher Kevin Smith (Writer Director of Clerks, Mallrats, Chasing Amy and Jay and Silent Bob Strike Back), through his character Randall:
"If you're going to teach standing, teach standing. If you're going to teach walking, teach walking . . . but don't pine for one and sleep with the other!"
Drew
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Re: Treatment ideas for adult ataxia - December 13, 2001 4:53:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Hello,
Hirsch, Sounds like you are doing awesome things with treadmills.
When I referred to "normal" I was thinking about "efficient", like a cost/benefit ratio of energy expended to movement achieved. My naive idea was that energy efficiency might be a treatment goal... Yup, I'm in over my head.
I have no opinion on what to do with children of the sort you mentioned... mostly I treat non(or only slightly)-neurologically impaired ortho/injured folks who seek me out in my cash practice... so really, I'm out of my league here trying to discuss your business with you. Just got intrigued by the anti-ball stance you took...but now I can see how if there's access to a treadmill kids might have more of a ball than just sitting on one, and probably get a lot more input/involvement at the cortex/cognitive/emotional level. Cause they're walking, and it's exciting.
To Drew. Thanks for the tip re: abdominals and necks. Didn't know about the reflex connection. Have seen so many people who are tight through the abdominals on one side only and have chronic neck pain. They usually sleep only one one side all night (because they don't like being breathed on by their spouse or some reason like that...) so I had chalked it up to mechanical/postural tension... This early control sequence is another layer to think about. Probably all patients are neuro patients to some degree or other.
Diane
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Re: Treatment ideas for adult ataxia - December 13, 2001 5:08:00 AM
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Mark Hirsch
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From: USA
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Hi Diane,
we're all in the same league as far as I'm concerned (helping people), perhaps just playing for different ball clubs (different philosophies)...
I have a broblem with the ball, because 1) therapy on it has not been validated scientifically to transfer to walking (in the case of adult ataxia) and 2) ball therapy can be very therapist driven therapy -- versus patient initiated therapy. I think the CNS reacts differently to the tow approaches unless its patient driven or patient initiated I think its pretty worthless to teach balance and or gait, no matter what you use as a teaching aid. As soon as the therapist puts their hands on the patient the CNS learns to execute the task with the afferent feedback from the patients and therapists hands (wherever they are touching)...structural and chemical plasticity occurs within milliseconds in the CNS...the CNS reorganizes and this reorganization reflects architectural changes within, for example, the motor cortex. The next time the task is required, and the CNS is missing the afferent feedback from the therapists hands (wherever they were touching/stabilizing/facilitating/inhibiting)...can the CNS execute the skill without the therapist there? Its similar with the ball, although when a patient balances on a ball they are making corrections to their own movements and these corrections are not necessarily dependent on the therapist. So thats good if you want patients to learn to execute sitting on a ball. If you are working with a ball and the purpose is to teach the patients CNS something about balancing independently or walking, crouching, jumping, sliding or skipping -- my hypothesis is that it wont carry over.
"When I referred to "normal" I was thinking about "efficient", like a cost/benefit ratio of energy expended to movement achieved. My naive idea was that energy efficiency might be a treatment goal"
Efficiency is good. But sometimes its naive to think we can make the system efficient again. But its a laudable goal.
Mark
[This message has been edited by Mark Hirsch (edited December 13, 2001).]
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Re: Treatment ideas for adult ataxia - December 14, 2001 12:09:00 AM
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Mark Hirsch
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From: USA
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Hey Bobcat,
In most situations there would be no justification for treadmill therapy (in your patients? or in general?).
I can just as easily say that in most situations in neurological rehabilitation there is little justification for traditional physiotherapy approaches such as Bobath, NDT or PNF. Since studies comparing the efficacy of these techniques to each other (in over 300 patients) have not shown one approach to be superior to another, each approach is equally (in)effective. Treadmill training has been shown to be superior to traditional physiotherapy techniqes for improvement of gait. Hope this will get some discussion going.
I understand there is a cost factor and you're right about that. And thats a big minus! Perhaps, in the not to distant future, rehab worthy treadmills will become cheaper and more accessible to PT's.
Nevertheless, if we look at the bulk of the literature which shows the benefits of treadmill therapy with PBWS in over 145 patients with CP, stroke and Parkinson's disease and we want to restore gait kinematics and functional EMG patterns as quickly as possible, we cant help but consider it negligent not to give patients access to this modality if such a device exists in a clinic.
Can you give us some examples when treadmill therapy would not be appropriate?
[This message has been edited by Mark Hirsch (edited December 14, 2001).]
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Re: Treatment ideas for adult ataxia - December 14, 2001 10:21:00 AM
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Andrew M. Ball MS MBA PT
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From: Chapel Hill
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Good point Hirch,
There is a HUGE misconception among rank-and-file PT's (of which Bobcat's intellect stands superior to --- so I'm not lumping him into that group) that PWB-TT is not appropriate for people who can walk. This is NOT TRUE. It's the most effective weapon in our arsenal for improving efficiency and quality of gait. Studies by Hesse and Schindall show this quite clearly. Even athletes have shown improvements in running veloctiy and NCV to muscles (for PWB-TT effectiveness for athletes, see the Z-lift webpage).
The ONLY patient group that PWB-TT is not more effective that traditional therapy alone in improving velocity and quality of gait is complete SCI. The ONLY patient group.
I way "than traditional therapy alone," because it MUST be considered that PWBTT is NOT a treatment technique. It is a treatment environment by which the therapist can make much more effective use of NDT or PNF skills. Like hippotherapy, however, the patient is afforded a safe environment to practice supra-optimal speeds and movement patterns without fear or falling . . . and with MUCH greater density per treatment session than NDT or PNF based sessions alone.
Bobcat's point about cost is well taken, but the fact is that for kids with CP, for example, the cost of a system is about the same as a stander or W/C which the school is required to purchase for the child if it's needed for the child to access thier education program. If the same child could be progressed to classroom ambulation, the argument could be made that the W/C is not educationally relevant, not to mention the savings in labor costs of paying a PT for 10 years of service provision versus a year or less.
Food for thought.
Drew
By the way, anyone else going to CSM????
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Re: Treatment ideas for adult ataxia - December 14, 2001 3:43:00 PM
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Mark Hirsch
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From: USA
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Bobcat, I meant for patients who need gait training.
[QUOTE]Originally posted by Bobcat:
Like if you can already walk but you have trouble getting up and down from a chair because your muscles are poorly coordinated, or you can already walk, but your lower leg is ataxic or dysmetric. Or if you had truncal ataxia.[/QUOTE]
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Re: Treatment ideas for adult ataxia - December 16, 2001 10:20:00 PM
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Mark Hirsch
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From: USA
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Hi Bobcat,
I dont mean that is works for EVERY patient. I have not looked at how many patients we wanted to use it for and it did not produce an effect so I can't tell you the stats here. But...I have not experienced the problem you described in your previous post, Bobcat. We use 2 state-of-the-art treadmill systems in a 240 bed neurtological rehabilitation facility with pediatric, geriatric and adult neurological patients -- we have the Woodway and Hesse Gait Trainer, so perhaps my experiences with PBWS are biased.
We have a large neuro-geriatric ward here (roughly 90 beds) and have many comorbid patients, so I have seen the effect of this technique in many patients. Many of these patients are post-stroke and post TEP. We routinely put them on the treadmill with PBWS and or the Hesse Gaittrainer, which also unloads the system but provides even more assistance during gait training, especially if patients are not allowed to ambulate using full body weight post-hip replacement. Of course they are also treated using conventional therapeutic modalities, but they all receive 3-6 30 minute sessions on the treadmill 6 days a week (5 minutes to put on the harness, 10 minutes therapy, 3-5 minutes rest, 10 minutes therapy). We have therapy on saturdays as well -- the PT's dont like it but our patients are thankful. The treadmill and gait trainer basically run nonstop from 8:45 AM to 5:30 PM M-F and from 9-12 on Saturday.
I have not seen any studies confirming the usefullness of this approach. Many of our patients are not permitted to load the affected hip more than 20kg, making conventional gait training difficult...when we conduct therapy on the treadmill we begin working on stride length, cadence, gait velocity. Very often we will combine rhythmic auditory stimulation with treadmill training with PBWS -- we can assure that not more than 20kg are carried by the affected hip -- actually we have a system that unloads both legs equally. This way we can begin retraining their hemiparetic side earlier than can be done with conventional techniques, patients spend less time immobilized, in bed, wheelchair, on a mat, or walking with a walker and we are not putting more than 20kg on the affected hip during therapy, which often is the same leg that was affected during the stroke. Patients also probably have less fear of falling (my opinion) while in PBWS. [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
[This message has been edited by Mark Hirsch (edited December 17, 2001).]
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Re: Treatment ideas for adult ataxia - December 17, 2001 3:00:00 PM
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Mark Hirsch
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From: USA
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Hi Bobcat,
the system is built so tough that one could suspend a 300lbs. person in mid air. As to incontinence, this is not a big problem. We have patients who have a catheter and it is not a problem with the harness. Also, the harness does not restrict upper bodz movement and it does not restrict trunk movements...it is not meant to do that. Patients should have enough trunkal tone to sit at the bedside unassisted for roughly 10 seconds before we put them into the harness and let them walk with PBWS.
Ive never had anyone try it with the ball...sounds like an interesting idea. Mark
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Re: Treatment ideas for adult ataxia - February 19, 2002 5:44:00 PM
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Jacob Barr
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Wow! I got in on this one rather late, but it seems that a great gag gift for Hirsh would be a "therapy ball". Hirsh, you made a statement in one post about "therapy on a ball improves motor control ON THE BALL" Well, it would seem that improved motor control of this kind would translate to other activites. If not, it would be like saying that a patient who repeatedly lifted a ten pound dumbbell would only be proficient in lifting a ten pound dumbbell and nothing more. I would hope that you agree that the ability for the patient to lift the ten pound dumbbell would translate to other lifting activities.
I realize that evidence based practice is critical to P.T., but sometimes therapists perform treatments that are not 100% proven beneficial. Just as you ask for studies that show that therapy on a ball works, I would ask for any studies that show that therapy on a ball does not work. I think the main problem is lack of studies period.
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Re: Treatment ideas for adult ataxia - February 20, 2002 1:28:00 AM
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Mark Hirsch
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From: USA
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Hi Jacob,
It's never to late to breathe fresh air into a post. I think I made the point that ball exercises are not evidence based practice for adults with ataxia and I challenged the use of a spherical object to improve anything and the transfer of learning on the ball to other environments. I am skeptical about putting a person with ataxia on a ball when there is not much evidence (other than anecdotal) to show that when a person sits on the ball and the therapist manipulates the environment, the persons postural control improves and that translates to improved postural control in, say, standing and walking. It's interesting to see what an effect challenging conventional ideas can have in physical therapy.
Mark
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