Physiotherapy Theory and Practice, 26(7):447–458, 2010

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ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593980903532234

SINGLE SUBJECT RESEARCH REPORT

Use of trunk stabilization and locomotor training in an

adult with cerebellar ataxia: A single system design
Jane E Freund, PT, MS, DPT, NCS and Deborah M Stetts, PT, DPT, OCS, FAAOMPT
Associate Professor, Department of Physical Therapy Education, Elon University, Elon, North Carolina, USA
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ABSTRACT
The purpose of this study is to describe the effects of trunk stabilization training and locomotor training (LT)
using body-weight support on a treadmill (BWST) and overground walking on balance, gait, self-reported
function, and trunk muscle performance in an adult with severe ataxia secondary to brain injury. There are
no studies on the effectiveness of these combined interventions in persons with ataxia. The subject was a
23-year-old male who had a traumatic brain injury 13 months prior. An A-B-A withdrawal single-system
design was used. Outcome measures were Berg Balance Test (BBT), timed unsupported stance, Functional
Ambulation Category (FAC), 10-meter walk test (10-MWT), Outpatient Physical Therapy Improvement in
Movement Assessment Log (OPTIMAL), transverse abdominis (TrA) thickness, and isometric trunk endurance
For personal use only.

tests. Performance on the BBT, timed unsupported stance, FAC, 10-MWT, and OPTIMAL each improved after
10 weeks of intervention. In additions, TrA symmetry at rest improved as did right side-bridge endurance
time. LT, using BWST and overground walking, and trunk stabilization training may be effective in improving
balance, gait, function, and trunk performance in individuals with severe ataxia. Further research with additional
subjects is indicated.

INTRODUCTION studies or case series with heterogenous populations,

Thirty-two percent of patients with severe traumatic
brain injury (TBI) demonstrate cerebellar ataxia
(CA) during rehabilitation (Walker and Pickett,
2007). Characteristics of individuals with CA include
abnormal timing and trajectory of limb movements,
a wide-based, unsteady gait, increased postural sway,
and impaired balance (Walker and Pickett, 2007).
Despite the high incidence of patients with CA and
the associated severe activity limitations, research
on the rehabilitation of balance and gait is limited.
A systematic review on the effectiveness of physical
therapy for individuals with CA concluded there is
modest evidence that physical therapy may have a
positive effect on gait, trunk control, and/or activity
limitations. The majority of the research was case
Accepted for publication 23 October 2009.
Address correspondence to Jane E Freund, PT, MS, DPT, NCS,
Department of Physical Therapy Education, Elon University, Campus
Box 2085, Elon, NC 27244, USA.
E-mail: jfreund@elon.edu
outcomes, and interventions (Martin, Tan, Bragge,
and Bialocerkowski, 2009).
Rehabilitation traditionally has included compen-
satory strategies such as weighting the trunk or limbs
or the use of gait aids (Martin, Tan, Bragge, and
Bialocerkowski, 2009). However, recent evidence
suggests the use of task-specific training to promote
motor learning in individuals with cerebellar dysfunc-
tion (Cernak, Stevens, Price, and Shumway-Cook,
2008; Vaz et al, 2008). Locomotor training (LT),
using partial body-weight-supported treadmill
walking (BWST) and overground walking, has been
reported as a promising intervention for individuals
with gait impairment secondary to stroke and TBI
(Barbeau and Visintin, 2003; Plummer et al, 2007;
Pohl, Mehrholz, Ritschel, and Ruckriem, 2002;
Scherrer, 2007; Sullivan, Knowlton, and Dobkin,
2002). Locomotor training with BWST is based
on task-specific training principles, allowing for a
progressive increase in postural control demands,
systematic progression of gait speed, and repetitive
training of the gait cycle with appropriate sensory

447
 448 Freund and Stetts
input (Barbeau, 2003; Behrman, Bowden, and Nair,
2006; Behrman et al, 2005). Single-subject cases on
LT in persons with CA provide preliminary evidence
for its inclusion as an intervention to improve gait and
balance (Cernak, Stevens, Price, and Shumway-Cook,
2008; Vaz et al, 2008).
The trunk, although recognized as integral to function
and commonly impaired in patients with neurological
dysfunction, is often overlooked or not systematically
addressed in rehabilitation (Ryerson et al, 2008). Trunk
stability is required for maintaining balance and efficient
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limb control during gait. Muscle strength, muscular
endurance, and sensory-motor control are important
factors in trunk stability (Anderson and Behm, 2005;
Saunders, Rath, and Hodges, 2004). The trunk muscles
(e.g., rectus abdominus (RA), external oblique (EO),
internal oblique (IO), transverse abdominis (TrA),
thoracic and lumbar erector spinae (ES), and multi-
fidus (MD)) act as a corset to provide both a stabiliz-
ing and a mobilizing function during kinetic chain
activities (Hides et al, 2006; Van Dieën, Cholewicki,
and Radebold, 2003). Cholewicki and McGill (1996)
demonstrated that in most persons, sufficient stability of
the lumbar spine is achieved with low levels of abdo-
For personal use only.
minal and paraspinal muscle cocontraction. Hodges and
Richardson (1997) reported that trunk muscle activity,
specifically TrA and oblique abdominal muscles, often
occurs before the activity of lower extremity musculature
and suggest that cocontraction of trunk muscles creates a
stable foundation for movement of the lower extremities.
The TrA was consistently the first trunk muscle active
prior to the hip prime movers in all directions. EMG
studies have also described abdominal muscle activation
patterns during gait. Specifically, the TrA is tonically
active throughout the gait cycle and the IO, EO, MD,
and ES are phasically active during gait (Saunders, Rath,
and Hodges, 2004). Because persons with CA may
demonstrate truncal ataxia and have difficulty regulating
force and speed of trunk muscle contraction, rehabili-
tation aimed at trunk stabilization may improve limb
coordination, gait, and balance.
Trunk stabilization training is a common physical
therapy intervention for patients with musculoskeletal
disorders. The objective is to improve muscular
control needed to stabilize the trunk against internal
and external forces associated with activities of daily
living. Although all of the abdominal muscles contribute
to spinal stability, the focus of rehabilitation programs
has been the deep abdominal muscles, specifically
evaluation and training of the TrA (Richardson,
Hodges, and Hides, 2004; Teyhen et al, 2005; Teyhen
et al, 2007; Tsao and Hodges, 2008). TrA activity,
studied by using EMG and ultrasound imaging, is
delayed (Hodges and Richardson, 1996; Hodges and
Richardson, 1998), reduced (Ferreira, Ferreira, and
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Hodges, 2004), or less tonic (Saunders, Rath, and
Hodges, 2004) in subjects with low back pain compared
to healthy individuals. Recent research reported these
impairments can be altered through specific abdominal
training to improve the coordination of trunk muscles
(Tsao and Hodges, 2008). Despite apparent truncal
instability in persons with CA, the performance of
the TrA and associated interventions has not been
investigated.
Ultrasound imaging (USI) of the abdominal muscles
has been used to evaluate muscle contraction in patients
with low back pain and as visual feedback during
stabilization training. Using USI, a patient can see the
abdominal muscles and contraction of the TrA during
trunk stabilization training (Henry and Westervelt,
2005; Teyhen et al, 2005). The use of real-time
ultrasound imaging for evaluation and feedback is
novel in patients with neurological impairments.
Ultrasound imaging has been used in musculoskeletal
rehabilitation since the 1980’s (Stokes and Young,
1986). Research has established USI as a safe, cost-
effective method for observing and evaluating contrac-
tion of the deep abdominal muscles (Teyhen et al,
2007). USI is a valid and reliable method to quantify
muscle size at rest and during contraction compared to
other well-accepted techniques (i.e., MRI and EMG)
(Hides et al, 2006; Koppenhaver et al, 2009). This
noninvasive technique can be used as an indicator of
muscle activity (Hides et al, 2006; Hodges, Pengel,
Herbert, and Gandevia, 2003; Juul-Kristensen, Bojsen-
Moller, Holst, and Ekdahl, 2000; McMeeken et al,
2004). There are no published studies known to these
authors on the use of ultrasound imaging or trunk
stabilization training in persons with ataxia.
The combination of impaired trunk control, balance
and lower extremity movement suggests a strong
rationale for the use of LT and trunk stabilization
training in persons with ataxia. The purpose of this
research is to describe the effect of trunk stabilization
training and LT on balance, gait, self-reported
function, and trunk muscle performance in an adult
with severe ataxia secondary to TBI.
METHODS
Research design
This study had an A-B-A withdrawal single-system
design (Jewell, 2008) with trunk stabilization exercises
and locomotor training using body-weight support on
a treadmill and overground ambulation during the
intervention period and not during the pre/post inter-
vention periods. The preintervention baseline period
was 6 weeks, the intervention period was 10 weeks,
 Physiotherapy Theory and Practice 449

and the postintervention period was 6 weeks. The TABLE 1 Examination at baseline
intervention period was initially planned as 6 weeks;
however, because of subject functional improvement Finding
and continued interest, it was extended to 10 weeks.
This study was approved by the Alamance Regional Test/Observation Right Left
Medical Center Investigational Review Board and the
Manual muscle test*
subject provided informed signed consent.
Ankle dorsiflexors 4/5 5/5
Ankle 3-/5 3-/5
plantarflexors
Subject Knee extensors 4/5 5/5
Knee flexors 5/5 5/5
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The subject was a healthy, 23-year-old male who Hip abductors 3-/5 3-/5
sustained a severe TBI as a result of a motor vehicle Hip extensors 4/5 4/5
accident 13 months prior to this study. Additional
Finger to nose Mild dysmetria Moderate dysmetria
injuries included fractures of his right upper extremity,
Heel to shin No dysmetria Mild dysmetria
ribs, clavicle, and facial bones. He was unconscious for
2 months after the accident with an initial Glasgow Range of motion** Ankle dorsiflexion 0 Ankle dorsflexion 0
(degrees) Hip extension -10 Hip extension -10
Coma Scale score of 6/15. He participated in physical
therapy in the acute care, inpatient rehabilitation, and Vision Glasses with diplopia reported with quick
home settings for a total of 5 months, followed by head movements***
ongoing, outpatient physical therapy. Cognition Fully oriented, correctly followed multi-
This individual was selected for this study for several step commands
reasons: (1) he had severe truncal and extremity ataxia; Speech Slow, understandable
For personal use only.

(2) he was extremely motivated with personal goals
to walk better and farther; (3) he had a brief positive
experience with LT as a volunteer in a university
physical therapy course; and (4) he had a very suppor-
tive family to transport him to the research laboratory
three times a week.
At the time of the study the subject was 60 200 and
weighed 225 pounds, lived with his mother and was
unemployed. His primary means of mobility was a self-
propelled, manual wheelchair. However, he reported
walking using a two-wheeled walker with moderate
assistance at home approximately 24.4 meters on a
carpeted surface. He was independent in transfers,
bathing, dressing, and eating, except for activities
requiring fine motor skills such as buttoning, tying
shoe laces, and cutting food. Daily activities included
playing computer games, riding a stationary bike, doing
sit-ups and light, upper-extremity weight training. He
did not drive and was limited in activities outside the
home. His medications included ibuprofen, esompera-
zole, amantadine, methylphenidate, sertroline HCl,
amitriptyline, carbamazine, and zolpidem tartrate
extended-release. See Table 1 for examination findings
at baseline.
Investigators
Two physical therapists provided both the intervention
and testing. Three physical therapy students assisted
with the intervention.
Affect Pleasant, eager to participate
Gait analysis Severe truncal ataxia, Flexed trunk
Bilateral lower extremity ataxia
Variable foot placement (left . right)
Excessive arm support, Difficulty with
walker placement
Short steps, Full foot initial contact
bilaterally
Left knee hyperextension at midstance
Maximum Distance 6 meters with a two-wheeled walker and
Walked one person moderate assistance
*(Kendall, McCreary, Provance, and Rodgers, 2005).
**Hip abduction/flexion, knee flexion/extension and ankle
plantarflexion within normal limits for both lower extremities.
***No change with previous vestibular rehabilitation, currently
treated by neuro-opthamologist.
Outcome measurements
Because there is no ‘‘gold standard’’ outcome measure
related to ataxia, the measures selected were based on
clinical accessibility and the objectives of the interven-
tion. The following clinical measures of balance, gait,
and self-reported function were administered: (1) Berg
Balance Scale; (2) timed unsupported stance; (3)
Functional Ambulation Category (FAC); (4) 10-meter
walk test (10-MWT); and (5) Outpatient Physical
Therapy Improvement in Movement Assessment Log
(OPTIMAL). Trunk muscle performance was measured

Physiotherapy Theory and Practice

 450 Freund and Stetts
by using ultrasound imaging and isometric trunk
endurance tests.
The Berg Balance Scale (BBS) is a 14-item, func-
tional measure of balance with excellent reliability,
validity, and sensitivity to change in older adults and
subjects with stroke (Berg, Wood-Dauphinee, Willimas,
and Gayton, 1989; Berg, Wood-Dauphinee, Williams,
and Maki, 1992; Berg, Wood-Dauphinee, and
Williams, 1995) and excellent preliminary test-retest
reliability for subjects with TBI (Newstead, Hinman, and
Tomberlin, 2005). Timed unsupported stance, an item
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on the BBS, is essential to many functional activities.
The Functional Ambulation Category (FAC) is
clinical gait assessment with six levels of walking
ability based on physical assistance required (Holden
et al, 1984; Holden, Gill, and Magliozzi, 1986). FAC
levels are defined in Table 2. The FAC has excellent
reliability, good concurrent and predictive validity, and
good responsiveness in patients with hemiparesis after
stroke (Merholz et al, 2007). Validity and reliability of
the FAC has not been established in patients with TBI.
The 10-MWT is a measure of gait speed with excellent
test-retest reliability in subjects with TBI (Vanloo et al,
2004). Improvements in gait velocity have been related
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to clinically meaningful changes in function and quality
of life (Schmidt et al, 2007).
The OPTIMAL is a self-report questionnaire of
difficulty and confidence in the performance of 21
movements related to functional activities. The subject
rates each movement on a scale of 1 through 5 for
TABLE 2 Functional ambulation category (Holden et al, 1984;
Mehrholz et al, 2007)
Categories
0 (Nonfunctional ambulator) indicates a patient who is not
able to walk at all or needs the help of 2 therapists.
1 (Ambulatory, dependent on physical assistance [level II])
indicates a patient who requires continuous manual contact
to support body weight as well as to maintain balance or to
assist coordination.
2 (Ambulatory, dependent on physical assistance [level I])
indicates a patient who requires intermittent or continuous
light touch to assist balance or coordination.
3 (Ambulatory, dependent on supervision) indicates a patient
who can ambulate on level surface without manual contact of
another person but requires standby guarding of one person
either for safety or for verbal cueing.
4 (Ambulatory, independent, level surface only) indicates a
patient who can ambulate independently on level surface but
requires supervision to negotiate (eg, stairs, inclines, nonlevel
surfaces).
5 (Ambulatory, independent) indicates a patient who can walk
everywhere independently, including stairs.
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difficulty and confidence with a possible total score of
5 to 105. A lower score represents less difficulty or
greater confidence in performance. The OPTIMAL
has demonstrated strong psychometric properties
in adult physical therapy outpatients (Guccione et al,
2005).
USI is a useful clinical procedure for evaluation and
rehabilitation of the abdominal muscles (Teyhen et al,
2007). For this report TrA muscle structure and
performance were measured by using USI, a reliable
and valid measure of TrA muscle geometry (MRI) and
activation (EMG) compared to other well-accepted
techniques (Hides et al, 2006; Hodges, Pengel,
Herbert, and Gandevia, 2003; Koppenhaver et al,
2009; McMeeken et al, 2004). Images were taken to
compare the left and right TrA at rest and changes
in TrA muscle thickness during contraction. The
authors previously reported ICC (3,1) intraimage
and interimage reliability for USI TrA thickness were
0.97–0.99 and 0.77–0.92, respectively (Stetts, Freund,
Allison, and Carpenter, 2009).
Isometric trunk endurance tests for trunk extension,
flexion, and side-bridge (left and right) were used to
evaluate muscle performance based on McGill’s theory
that maintaining sufficient spine stability for tasks
of daily living is not compromised by insufficient
strength, but insufficient endurance (McGill, 2007).
The trunk extensor, trunk flexor, and side bridge
endurance tests have good reliability in healthy sub-
jects (Evans, Refshauge, and Adams, 2007; Latimer,
Maher, Refshauge, and Colaco, 1999; McGill et al,
2003) but have not been studied in patients with
neurologic impairment. McGill et al (2003) estab-
lished normative trunk endurance times in young,
healthy individuals. Maximum isometric trunk
endurance for each test is the time the subject is able
to maintain the specific test position. The isometric
trunk endurance test positions as described by McGill
(2007) are:
(1) Trunk Flexor Endurance (Figure 1a): Subject is in
a sit-up position with feet held by the examiner
and a trunk angle of 55 degrees is measured while
the subject is supported on a wedge. The wedge is
then removed and the subject must maintain this
position.
(2) Trunk Extensor Endurance (Sorenson Test)
(Figure 1b): Subject is prone with ASIS’s at end
of table, with arms at sides and ankles held by the
examiner. Subject maintains horizontal position
against gravity.
(3) Side-Bridge (Figure 1c): Subject is side-lying, hips
and knees extended, with his trunk off the table,
supporting himself on his lower elbow and foot.
It is performed on each side.

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For personal use only.
FIGURE 1 Isometric trunk endurance test positions. (a) Trunk
extension; (b) Trunk flexion; (c) Trunk right side bridge.
Measurement procedures
All outcomes, except USI, trunk endurance tests, and
OPTIMAL, were measured during a 6-week preinter-
vention period (PRE-I) at weeks 1, 3, and 6 to
Physiotherapy Theory and Practice 451
demonstrate stability of the measures despite ongoing
outpatient physical therapy. Those outcomes were
measured again after 6 weeks of intervention (I-6),
after 10 weeks of intervention (I-10), and 6 weeks
postintervention (POST-I) for a total of six measure-
ment sessions. Ultrasound images were taken PRE-I
(week 1), I-6, I-10, and POST-I. Trunk endurance
tests were only completed PRE-I (weeks 1,3,6) and I-6
due to time constraints. The OPTIMAL difficulty
and confidence questionnaires were completed by the
subject PRE-I (week 1), I-6, and POST-I. Because of
an oversight, only the OPTIMAL difficulty question-
naire was completed at I-10.
The same testers, not blinded to the intervention,
measured all outcomes in the following order for each
testing session: USI, 10-MWT, the BBS (including
timed unsupported stance) and trunk endurance tests.
Exceptions to standardized test procedures were:
(1) Once the subject was able to walk 10 meters on
a cement floor, the 10-MWT was timed with the
subject walking at self-selected speed using a two-
wheeledwalker with assistance as needed.
(2) Timed unsupported stance was reported as a
separate measure because the subject was unable
to stand unsupported for at least 30 seconds as
required by the BBS. His maximal unsupported
stance time of three trials was recorded.
(3) The side-bridge trunk endurance test was performed
with knees flexed due to inability to maintain the
position with knees extended.
Ultrasound imaging procedures
During the first test session the subject was instructed
in the anatomy and USI of the abdominal muscles and
the proper performance of the abdominal drawing-in
maneuver (ADIM) (Teyhen et al, 2005). The ADIM,
a foundational exercise in trunk stabilization programs,
is a gentle voluntary contraction of the lower abdom-
inal wall designed to preferentially activate the TrA
and performed by pulling the belly up and in toward
the spine without moving the pelvis, rib cage, or spine
(Teyhen et al, 2007).
He was positioned on a plinth in supine hook-lying
with the head in midline, arms across the chest and a
bolster under the knees. The subject was taught to
perform the ADIM at the end of exhalation and then,
hold the contraction while continuing to breathe
normally and maintaining a neutral posture of the
lumbar spine. Prior to testing on each side, the ADIM
was practiced three times using USI for feedback. The
researchers provided verbal and tactile feedback to
minimize substitution patterns and facilitate proper
Physiotherapy Theory and Practice
 452 Freund and Stetts
performance. Ultrasound images of the lateral
abdominal muscles were obtained at rest (relaxed
state at the end of exhalation) and during the ADIM
(contracted state) (Figures 2 a, b). Three images were
obtained in each state for each side, one side at a time.
A 3-minute rest was provided between practice and
testing, as well as between sides, to minimize potential
effects of fatigue. Ultrasound images were taken using
the Aquila system (Biosound Esaote, Indianaoplis, IN)
with a 5-MhZ curvilinear array transducer. The
transducer was placed in a transverse plane halfway
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between the ASIS and the lower rib cage along the
anterior axillary line (Figure 3). The location of the
transducer was further standardized by positioning
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FIGURE 2 A. Ultrasound image of the muscles of the left lateral
abdominal wall at rest showing transverse abdominis (TrA), inter-
nal oblique (IO), and external oblique (EO) muscles. (White line
at top of image used to standardize image position on screen.)
B. Ultrasound image of the muscles of the left lateral abdominal
wall during the drawing-in maneuver, showing the TrA contracted.
FIGURE 3 Placement of the ultrasound transducer head in a
transverse plane halfway between the ASIS and the lower rib
cage along the anterior axillary line.
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the hyperechoic interface between the TrA and the
thoracolumbar fascia on the far left side of the image
(Figure 2a). One researcher positioned the transducer
to optimize the quality of the image and the second
researcher captured the image at the end of the
subject’s exhalation at rest and during the ADIM.
Stored images were measured using Image J, version
1.38, Oct 2006, provided by NIH. A single researcher
measured the thickness of the TrA for all images, as
previously described (Teyhen et al, 2007). The mean
thickness of the TrA at rest and during contraction was
computed by using three images of each state.
Intervention
The intervention consisted of 28 sessions, two or three
times a week for 10 weeks; 18 ninety-minute sessions
for the first 6 weeks and 10 sixty-minute sessions for
the next 4 weeks. The subject attended all scheduled
training sessions. During the first 6 weeks each
intervention session was split equally between pro-
gressive trunk stabilization and LT. Trunk stabilization
training was initiated by using USI as feedback while
performing the ADIM. Once the subject demonstrated
proper performance of the ADIM, trunk stabilization
exercises were performed in supine, sidelying, quad-
ruped, sitting, standing, and during functional activ-
ities. Exercises were selected on the basis of previously
reported dynamic stabilization programs (Hicks, Fritz,
Delitto, and McGill, 2005; Richardson, Hodges, and
Hides, 2004) Except for functional activities (i.e., sit to
stand, sitting rocker board, and wall squats), progres-
sion was based on his ability to complete 10 repetitions
of each exercise with a 10-second hold while main-
taining a normal breathing pattern and neutral lumbar
spine. Four to five exercises were completed during
each session as shown in Table 3. Performance of the
ADIM was encouraged prior to all exercises and
during LT. Supervised trunk stabilization exercises
(other than performing the ADIM in gait) were
discontinued after week 6 and continued as a home
exercise program. Adherence to the home exercise
program was not documented, although the patient
verbally reported consistent practice at home.
LT included walking on the treadmill (Trackmaster
TMX55 treadmill, Full Vision Inc., Newton, KS) with
partial body weight supported on a LiteGait system
(model LGI-250 L, Mobility Research,Tempe, AZ)
and overground ambulation (Figure 4). Vital signs,
monitored at the beginning of each training session
and after each bout of treadmill walking, were within
normal exercise response parameters (ACSM, 2006).
During BWST the subject initially required the
assistance of three trainers, one assisting each foot
 Physiotherapy Theory and Practice 453

TABLE 3 Summary of trunk stabilization training progression

Intervention
Exercises
week

1 ADIM with USI feedback, SSE with unilateral hip

flexion, clam shell, sit to stand, quadruped
unilateral leg raise
2 ADIM without USI feedback, SSE with unilateral
heel slide, clam shell, sit to stand, side bridge with
knees flexed, rocker board weight shift in sitting
3 SSE with unilateral hip/knee extension, sidelying
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hip abduction with eccentric focus, sit to stand,

side bridge with knees flexed, rocker board weight
shift in sitting, wall-supported standing,
quadraped unilateral leg raise
4 SSE with unilateral hip/knee extension on ½ foam
roll, sit to stand, side bridge with knees extended,
wall-supported standing, wall supported mini-squats
5 SSE with unilateral hip/knee extension on ½ foam
roll, sit to stand, side bridge with knees extended,
wall supported mini-squats, bridging with
bilateral/unilateral leg support
6 SSE with bilateral hip flexion and unilateral hip/
knee extension on ½ foam roll, sit to stand, wall
supported mini-squats with weight shift, bridging
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with bilateral/unilateral leg support

ADIM5abdominal drawing-in maneuver; SSE5supine
stabilization exercises.

for placement and stepping and one assisting with

trunk control, although the amount of assistance
gradually decreased over time. His left foot required
more assistance than the right to help with foot
placement and to prevent ankle inversion with
stepping. He was also given verbal cues to encourage
upright posture and reciprocal arm swing. As upright
posture and stepping ability improved, the subject was
progressed by removing his hand support, decreasing
the percent of body weight supported and physical
assistance provided, and increasing treadmill speed
and walking time. After week 2 he no longer required
trunk control assist and by week 8 assistance with
each foot was minimal. LT progression is displayed in
Table 4. During the BWST he progressed from walking
0.6 mph holding on to the treadmill with 40% body
weight supported to walking 2.0 mph without hand
support with 20% body weight supported.
Each session after BWST, the subject practiced
walking overground with one-person assistance as
needed (moderate to contact guard), using a two-
wheeled walker and eventually lofstrand crutches. Verbal
cues were provided to decrease his upper extremity
weight bearing and increase his upright posture. The
overground walking distance per session was progressively
increased, determined by subject fatigue, from 6.6 meters
to 39 meters using the wheeled walker on a cement
FIGURE 4 Body-weight supported treadmill training system.
floor. During intervention week 8 as his trunk posture
and stability, foot placement and reciprocal arm swing
improved on the treadmill, he progressed to using
lofstrand crutches with minimal assistance for over-
ground walking training. The subject was encouraged to
continue to trunk stabilization exercises and overground
ambulation at home during the postintervention period.
During the preintervention period and first 6 weeks
of intervention the subject also received outpatient
physical therapy one to two times a week for a total of
16 sessions, which did not include treadmill walking or
trunk stabilization exercises. Interventions included in
his outpatient physical therapy sessions were gait
training with a rolling walker, standing with weight
shifting, reaching and stepping to targets, transfers, sit
to stand, and stair training. Physical therapy sessions
were generally not on the same days as the research
intervention. At week 6 of the research he was
discharged from outpatient physical therapy due to
lack of progress toward his established therapy goals:
(1) walking 75 ft with minimum assistance and least

Physiotherapy Theory and Practice

 454 Freund and Stetts

TABLE 4 Locomotor intervention progression

Treadmill % Treadmill Mean treadmill Treadmill bouts Mean distance

Intervention week body-weight speed range training time with or/without walked
support* (mph) (min)/session hand support overgound/session (m)

1 40 0.6–.8 9 11/0 6.6

2 40 0.6–1.0 13 7/2 7.6
3 35 0.7–1.0 15 6/4 7.0
4 30 0.7 15 2/9 16
5 30 0.7–.9 13 3/7 10.4
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6 30 0.9 13 0/11 11
7 30 1.0–2.0 13 0/11 13.1
8 30 1.6–2.0 12 0/10 19.2
9 30 2.0–2.2 15 0/10 28.3
10 20 2.0 11 0/5 39.6
*Body weight support is approximate.

restrictive device; and (2) sit to stand with minimal use score of 1. Ten MWT gait speeds at I-6, I-10, and
of upper extremities and supervision. POST-I were 0.03, 0.04, and 0.04 m/s, respectively, and
the FAC score was 2. The OPTIMAL scores improved
14% for Difficulty and 42% for Confidence from Pre-I
RESULTS to POST-I.
For personal use only.

TrA mean thickness measurements are reported in

Balance, gait, and self-reported functional measure-
ments were generally stable during the PRE-I period
and improved after 6 and 10 weeks of intervention
(Table 5). Using the two standard deviation band
method of analysis (Portney and Watkins, 2009), I-6,
I-10, and POST-I Berg Balance Scale scores were all
greater than two standard deviations above the pre-
intervention mean indicating a significant change.
Timed unsupported stance and FAC scores could not
be analyzed using the two standard deviation band
method as all preintervention scores were equal; there-
fore, there was no standard deviation. Timed unsup-
ported stance improved from PRE-I to I-6 and I-10, but
declined at POST-I to the time achieved at I-6. At
PRE-I the subject was unable to complete the 10-MWT,
walking a maximum distance of 6 meters with a FAC
Table 6. Using the two standard deviation band method
of analysis (Portney and Watkins, 2009), resting values
for both the left and right TrA increased at I-6, I-10,
and POST-I compared to PRE-I. Resting right TrA
mean thickness was greater than resting left TrA mean
thickness at PRE-I, and POST-I and not different at
I-6 and I-10. Mean TrA thickness values during per-
formance of the ADIM (contracted) were bilaterally
greater than resting values at all measurement points.
Mean TrA thickness contracted did not increase on
either side from PRE-I across all measurement points.
Trunk endurance times are shown in Table 7. All trunk
endurance test times increased (17%–142%) from
PRE-I to I-6. Using the two standard deviation band
method of analysis, only the right-side bridge time,
which increased 142%, was greater than two standard

TABLE 5 Gait, balance, and self-reported functional outcome measures

Outcome measures PRE-I Week 1 PRE-I Week 3 PRE-I Week 6 I-6 I-10 POST-I

10 Meter Walk Test (m/sec) Unable Unable Unable .04 .03 .04
Functional Ambulation Category 2 2 2 3 3 3
Berg Balance Scale 5/56 5/56 6/56* 11/56** 12/56** 8/56**
Timed Unsupported Stance (sec) 3 3 3 18 26 18
OPTIMAL—Difficulty 42 NC NC 38 39 36
OPTIMAL—Confidence 48 NC NC 35 NC 28
PRE-I5Pre-Intervention; I-65Intervention week 6; I-105Intervention week 10; POST-I56 weeks Post-Intervention; NC5not
completed.
*PRE-I weeks 1,3,6 mean (sd)55.33 (.58); **Scores.plus 2 standard deviations from PRE-I mean.

Copyright & Informa Healthcare USA, Inc.

 Physiotherapy Theory and Practice 455

TABLE 6 Transverse abdominis (TrA), mean thickness (cm), and standard deviation (sd) at rest and contracted and comparison of
left and right TrA mean thickness at rest

PRE-I I-6 I-10 POST-I

Left TrA Resting 0.54 (.04) 0.79* (.05) 0.70* (.08) 0.65* (.02)
Right TrA Resting 0.64 (.04) 0.80* (.09) 0.76* (.03) 0.73* (.03)
Difference Between Sides Resting 0.10** 0.01 0.06 0.08**
Left TrA Contracted 0.89 (.23) 0.93 (.16) 1.12 (.02) 1.06 (.08)
Right TrA Contracted 1.17 (.23) 1.05 (.07) 1.23 (.11) 1.24 (.08)
PRE-I5Pre-intervention; I-65Intervention week 6; I-105Intervention week 10; POST-I56 weeks post-intervention.
Physiother Theory Pract Downloaded from informahealthcare.com by Florida International University on 12/28/14

*Value is .plus 2 standard deviations from the PRE-measurement.

**Value is .2 sd, using the greater sd of left or right TrA mean for that measurement session.

TABLE 7 Trunk endurance times (sec) with normative values balance after 10 weeks of intervention. Although his
and percent change primary means of independent mobility continued to be
self- propelled manual wheelchair, he was able to walk
PRE I Mean (sd) Norms I-6 % Change longer distances with less assistance using a wheeled
Trunk Extension 33.2 (8.49) 161 40 20.48 walker in his home, achieving his personal goals.
Trunk Flexion 50.3 (4.73) 136 59 17.30
Right-side bridge 33.1 (17.04) 95 80* 141.69
Balance and gait
Left-side bridge 45.7 (18.77) 99 74 61.93
For personal use only.

PRE-I Mean (sd)5mean and standard deviation of 3 pre-invention
measurements, Norms5mean normative values established by
McGill (2007), I-65intervention week 6, % change5change from
mean PRE-I to I-6.
*.2 sd from the PRE-I mean.
deviations above the preintervention mean reflecting a
significant change (Portney and Watkins, 2009). Quali-
tatively, gait improved with decreased trunk flexion,
improved foot placement bilaterally, and decreased upper-
extremity support. In addition, at I-6 and maintained
through POST-I, the subject reported the following
functional gains: (1) an increase in maximal walking
distance at home from 24.4 meters to 65.5 meters on
carpet; (2) improved transfer ability; (3) an increased
feeling of independence; (4) ability to pull his pants
up in standing for the first time; (5) independently
completing a full shower using a shower chair; and
(6) achieving a personal exercise goal of performing
a standard push-up.
DISCUSSION
This research examined the effect of LT and trunk
stabilization training on balance, gait, self-reported
function, and trunk muscle performance in a subject
with severe ataxia secondary to TBI. Despite being
13 months postinjury, the subject improved in all
observational and self-reported measures of gait and
The subject’s specific improvements on the BBS:
(1) coming to a stand independently using his hands;
(2) sitting down with controlled descent using his
hands; and (3) transferring with verbal cues may be
associated with self-reported functional improvements
in transfers and dressing. BBS has been shown to have
moderate to strong correlation with the Functional
Independence Measure in patients with TBI (Feld,
Rabadi, Blau, and Jordan, 2001). The subject’s FAC
improved from 1 to 2 enabling his mother, who was
considerably smaller and had a history of back pain, to
provide the assistance needed for safe ambulation at
home. Prior to intervention, the subject could only
ambulate at home when a family friend was available
to provide the needed support. Changes in FAC scores
have been correlated with changes in the Rivermead
Mobility Index (RMI), walking velocity and step
length, differing significantly for each of the FAC
categories in subjects with stroke (Mehrholz et al,
2007). The FAC has also demonstrated moderate
correlation with Functional Independence Measure
scores in subjects with stroke (Cunha et al, 2002) but
has not been studied in subjects with TBI. A minimal
detectable difference (MDD) for the FAC has not
been reported.
Initially, the subject was unable to complete the
10-MWT on a cement floor despite his reported ability
to walk 24.4 meters on a carpeted surface at home.
At I-6 he completed the 10-MWT at 0.04 m/s and
reported a maximum walking distance of 65.5 meters
at home. In retrospect, maximum distance walked

Physiotherapy Theory and Practice

 456 Freund and Stetts
would have been a better measure to detect change in
his functional ambulation.
Cernak, Stevens, Price, and Shumway-Cook (2008)
demonstrated improved ambulation (maximum assis-
tance to supervision) in a 13-year-old girl with severe
cerebellar ataxia after 5 months (1 month in clinic;
4 months at home) of LT with BWST. Similarly, the
subject in our study demonstrated improved gait
(moderate assistance to contact guard) after 10 weeks of
LTand trunk stabilization training. In contrast to Cernak,
Stevens, Price, and Shumway-Cook (2008) whose
Physiother Theory Pract Downloaded from informahealthcare.com by Florida International University on 12/28/14
subject used a treadmill with a body-weight support
system in the home, our subject’s locomotor training at
home was limited to overground walking. After 6 weeks
without LT with BWST (POST-I), his BBS and Timed
Unsupported Stance declined. Decreased outcomes
POST-I highlight the need for continued regular
practice to maintain reacquired functional abilities.
Self-reported function OPTIMAL
The subject’s total scores for OPTIMAL difficulty and
confidence scales both improved (lower scores) from
For personal use only.
PRE-I to all other measurement sessions (Table 5).
Related to the subject’s personal goals of walking better
and farther, his confidence in walking short distances
improved from a 5 (not confident in my ability to
perform) at PRE- I to a 3 (very confident) at POST-I. It
is of interest that his OPTIMAL difficulty score for
walking short distance did not change, remaining 4
(able to do with much difficulty) throughout testing.
The OPTIMAL, a self-report measure, did not reflect a
change in his short distance walking difficulty, despite
the decreased level of assistance required. Perhaps the
ordinal scale used on the OPTIMAL was not sensitive
enough to detect change between 5 (much difficulty)
and 4 (moderate difficulty). Optimal responses for long-
distance walking improved for difficulty and confidence
from baseline to I-6 and for difficulty at I-10, but both
returned to baseline at POST-I. Improvement in
Optimal difficulty score for long-distance walking may
have been more meaningful to the subject than short-
distance improvements. Initially, he was unable to walk
long distances, but could at I-10, although with much
difficulty. Additional self-report items, difficulty bend-
ing and confidence in stair climbing, each improved by
two points. Stair climbing was particularly important to
the subject because his sister’s house had stairs to enter.
Trunk muscle performance
This study is the first to demonstrate the feasibility of
using USI and trunk endurance tests to evaluate and
Copyright & Informa Healthcare USA, Inc.
train trunk muscle performance in a subject with CA
and may be appropriate for a similar patient popula-
tion. However, patients with cognitive or visual deficits
may have difficulty isolating a voluntary TrA contrac-
tion or using USI for feedback. Patients with shoulder
pain or instability may be unable to perform the side-
bridge endurance test.
This subject’s increase in TrA mean thickness at rest
from PRE-I on each side across measurement sessions
may represent an increase in muscle size related to
training and functional use. TrA contracted values were
greater than resting values indicative of contraction but
did not change across sessions. The lack of change
inTrA contracted values across sessions may be due to
the greater standard deviation for contraction measure-
ments. Increased variability of TrA measurements with
contraction may be the result of voluntary effort or
measurement error. Alternatively, a true lack of change
with contraction may indicate persistent motor control
deficits. The duration, dosage, and type of exercise may
not have been an adequate intervention to produce
a significant change in TrA contraction.
TrA symmetry at rest and during contraction has
been established in a population of healthy, elite, male
cricket players, mean age of 21.3 years (Hides et al,
2006). TrA mean thickness at rest in this subject was
asymmetrical (left , right) at PRE-I, symmetrical at
I-6 and I-10 after stabilization training and again
asymmetrical POST-I. POST-I asymmetry may be due
to the lack of supervised trunk stabilization training
after I-6. The significance of TrA resting asymmetry
and its relationship to the subject’s left-sided ataxia are
unknown.
Current research in subjects with low back pain
demonstrated that training of repeated, isolated,
voluntary TrA contractions using USI feedback
performed over 4 weeks resulted in more sustained
EMG activity during self-paced walking and earlier
onset of TrA EMG during arm movements. The
retention of these motor control changes at 6-month
follow-up demonstrates that this training approach
leads to motor learning of automatic postural control
strategies (Tsao and Hodges, 2008). Training
procedures were similar to those used in this single-
subject design. Future studies are needed to investigate
these findings in subjects with CA.
The subject’s trunk endurance was impaired on all
tests with trunk extension 21%, trunk flexion 37%,
right-side bridge 43%, and left-side bridge 46% of
the normative values (McGill et al, 2003). Trunk
endurance impairments are reasonable considering the
subject seldom sat or stood unsupported prior to the
onset of the intervention. Although right-side bridge
endurance was the only trunk measure exceeding two
standard deviations from baseline at I-6, combined

improvement in all trunk performance measures may
have contributed to his performance of a standard
push-up. In addition, improvement in right-side bridge
endurance may have provided increased trunk stability
during the right stance phase of gait allowing improved
left foot placement. Although improved after inter-
vention, all trunk endurance times remained below the
norms, and he continued to have difficulty with trunk
control in gait.
Physiother Theory Pract Downloaded from informahealthcare.com by Florida International University on 12/28/14
One-year follow-up
After the completion of this report, the subject
increased overground walking practice at home and
returned to outpatient physical therapy 5 months later.
He continued LT with a focus on trunk stabilization
during gait and functional activities two to three times
a week (66 visits) and increased his walking practice
at home and in the community. At one-year follow up
his 6-minute walk test distance was 157 meters
independently with a rollator; BBS score was 26/56;
unsupported stance time was greater than 2 minutes;
10-MWT gait speed using a rollator on a cement floor
For personal use only.
was 0.45 m/s (limited community ambulation) (Perry,
Garrett, Gronley, and Mulroy 1995); and his FAC
was 4. His primary mode of ambulation changed from
using a wheelchair to walking with a rollator with
supervision.
CONCLUSION
This study suggests that a combined intervention of
LT and trunk stabilization exercises may be effective in
improving gait and balance in a subject with severe
ataxia secondary to TBI. The relative contributions
of LT, trunk stabilization training, and outpatient
physical therapy to the outcomes cannot be deter-
mined. However, it should be noted, the subject made
no improvement in the outcome measures during the
6-week preintervention period when he received only
outpatient physical therapy, which did not include
locomotor training using BWST or trunk stabilization
exercises. The optimal intensity, duration, and inter-
vention for patients with ataxia needs further study.
ACKNOWLEDGMENT
Grant funding was provided by Elon University.
Declaration of Interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
Physiotherapy Theory and Practice 457
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