The Role of the Foot in Postural Control, Locomotion and Body-weight Support Training

I just got back home from Helsinki where we had an intensive studies with Julie Vaughan-Graham from Canada. Julie is an Advanced Bobath Instructor in IBITA and also PhD in University of Toronto. She has her own practice in Toronto called Physio-Logic. She has done lots of research about clinical reasoning and she amazed the participants with it while analysing, making hypotheses and treating the patients.

The course was a workshop and also an introduction to the Bobath Concept. The days included theoretical sessions, practical work and patient demo's by the instructor. 

The days were full of theory about the foot as an sensory and motor organ, the locomotion - a whole body activity, how the locomotion and postural control is controlled by neuronal mechanisms and of course how we can use body-weight support training as a tool in therapy. I'd like to share some highlights from the course by Julie Vaughan-Graham.

The Bobath Concept is a living concept and one of the most 
 widely used 
 neuro-rehabilitation approaches worldwide. The Bobath Concept today: "Optimizing movement potential and movement Performance"

The theory begun with the postural control. It is the maintenance of upright posture what makes us a human. It requires multi-sensory integration, body schema and internal models. We need to remember that the gravity provides unique sensory information for the posture. The upright posture is essential for spatial perception, posture and movement.

The neurophysiological organization subserves the integration of 
 posture and locomotion
The corticoreticulospinal system (CRSS) is fully integrated with supraspinal and spinal structures involved in the initiation, processing and execution of locomotion (Takakusaki et al., 2016)

We had a lecture from the foot as a sensory and motor organ. How cleverly it is designed to absorb forces, accommodate uneven terrain and develop propulsive forces. The recruitment of the largest plantar intrinsics is synchronized with postural demands. An efficient foot intrinsic activation is necessary for function of the anterior and posterior tibial musculature.

Lectures included also some new studies and some new aspects about locomotion. There was Lacquiniti et al. research (2012) about the muscle synergies or modules in locomotion. It gives us thoughts about few kinetic chains we use in many functions and locomotion, and how they are modified by feedback and feedforward signals.
Julie also pointed out that is the postural sway just for measuring the stability and "stifness" or is it for more dynamic way to interact with the environment? Postural sway may be viewed as part of a perceptual action strategy that allows an individual to gain essential information about its interaction with the environment (Carpenter et al 2010).

In four days we were doing lots of practical sessions with the foot and locomotion. We also got the possibility to use Body-Weight Support training with two patients who visited the course and the Instructor did two therapy for them. They had different diagnosis. The first two days our Instructor worked with the patient who had incomplete spinal cord injury. He had lots of capacity to get better and even if he had the trauma in C3-5, he had connections all the way to the toes.
The other patient has had an hemorrage few years ago and told that her goal was to walk faster and more smoothy way. At the end of the second sessions they both were facilitated to body-weight support treadmill training. The results were excellent and the patients were more than satisfied with the treatment and practice.

After patients treatments we did the clinical reasoning with the instructor. It started with listing the cues, making movement analysis and then hypotheses for the next treatment. In the pictures you can enjoy us with the cues:).

How would have you been treated them?

Patient with incomplete spinal cord injury and the patient with hemorrage (left side more affected)

In the course we also did some spesific gait facilitation in treadmill which is quite challenging for the therapist. You as a therapist want to show the patient what is the optimal alignment and movement in gait pattern. And what's the best in BWST, you are able to facilitate the patient from the foot. You need to be sure before going to treadmill that your patient has some preparedness to extend the trunk in upward posture, possibility to stand in one leg and hopefully they don't have problems in perception.

There is lots of things you need to consider when using body-weight support. It can be used also as a "safety system" and give support to the patients to stabilize their posture while standing or stepping. BWST can be used to get cardiovascular practice or faster walking or it can be as an aid in balance practice.
But as we all know walking is an all body activity and the benefits or goals for patients can be not just to improve locomotion, but also improve
- postural control for upper limb reach
- modulation of tone
- lower limb strengthening
- cardiovascular endurance
- bone density
- bowel and bladder function or
- psychological benefits.

This updated information is more or less modified from Julies lectures. Me and my colleagues in the course were very happy to have Julie in Finland and hopefully we'll see her soon again!

Kind regards,
TAB