Pressure, Posture, and Limitations -A Neuro Rehab Case

Case example

This case explores mental health, neuro, MSK and breathing physio from a less traditional lens. (I'm not a neuro physio). Details have been protected to support confidentiality. If for the purposes of learning you'd like to explore and understand more please contact me for productive clinical discussion/shared learning.

M — acquired brain injury following self-harm.
Complicating factors included unilateral vocal cord hemi-palsy and antipsychotic medication.

Primary presentation:

• Recurrent backward falls
  
• Increased instability during conversation or higher postural demand
  
  

In standing, particularly when dual-tasking:

• Bilateral upper limb extension
  
• Finger extension and abduction
  
• Thoracic flexion
  
• Posterior pelvic tilt
  
• Slight crouch at knees
  
• Bilateral genu valgus (R > L) with tibial external rotation (R > L)
  
  

During dynamic balance assessment:

• Apparent bilateral freezing of feet
  
• Difficulty releasing a ball from both upper limbs
  
  

Problem list

• Extra Pyramidal Side Effects (EPSE)¹ from meds → presents with bilateral 'parkinsonian' features
  
  
  • Reduced ankle strategy bilaterally²
    
    
• Reduced sensorimotor control secondary to ABI
  
  
• Ataxic presentation
  
  
• Reduced trunk pressure control, ?influenced by vocal chord hemipalsy
  
  
  • Vocalisation appeared to increase power/stability in throwing exercise + ?reduce posterior displacement of centre of mass¹
    
    

Clinical reasoning

There were multiple drivers of instability here — neurological injury, medication side effects, and altered balance strategies.

What stood out was the potential role of pressure regulation, particularly given the vocal chord involvement.
If vocalisation could alter centre-of-mass displacement, could it meaningfully support postural control³?

Treatment approach

• Medication titration (medical team)
  
  
• Balance Ax used to assess static and dynamic balance changes
  
  
• Treatment focus on:
  
  
• Increasing available hip strategy
  
  
• Backward stepping responses
  
  
• Proprioceptive balance exercises paired with vocalisation³:
  
  
• “S” (?pressure generated below vocal cords)
  
  
• “Z” (?pressure generated above vocal cords)
  
  

(SLT colleagues — please correct or clarify. In practice, I trial both and observe whether either improves power, control, or stability.)

Outcome

Despite targeted intervention:

• No meaningful change observed. Would a longer cycle of physio or more frequent sessions have influenced this? (we are always constrained by the environments we operate in.)
  
  

Outcome measures:

• Dynamic Gait Index (I know this is now a little outdated more recently colleagues use - Functional Gait Assessment (FGA)) 
  
  
• Berg Balance Scale
  

References:

1. D'Souza, R..S., Aslam, S. P., Hooten, W. M. (2025). Extrapyramidal Side Effects. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Available from: https://www.ncbi.nlm.nih.gov/books/NBK534115/
2. Hong, S., & Park, S. (2025). Biomechanical optimization and reinforcement learning provide insight into transition from ankle to hip strategy in human postural control. Scientific reports, 15(1), 13640. https://doi.org/10.1038/s41598-025-97637-5
3. Massery, M., Hagins, M., Stafford, R., Moerchen, V., & Hodges, P. W. (2013). Effect of airway control by glottal structures on postural stability. Journal of Applied Physiology, 115(4), 483-490.
   (Not neuro-population specific, but clinically relevant)