THE BOBATH APPROACH AKA - Neurodevelopmental Treatment (NDT) --- Focuses on abnormal movements and restoring normal movements

HISTORY England, 1940 Berta (physiotherapist) treatment Dr. Karel Bobath (neurologist) scientific explanation BERTA BOBATH ---discovered that she help her patients with hemiplegia move more freely and function with less compensation by decreasing the abnormal tone in their affected side. ---Her approach involved use of manual techniques --- to eliminate abnormal tone and dysfunctional movement --- to retrain normal of coordination in the affected trunk, arm, and leg ---- Rejected approaches that neglected the potential for function in the hemiplegic side NDT ---First used on a stroke and then on pediatric patients ---Has evolved over more than 50 years ----Widely used throughout the world BASIC PREMISES 1. Sensations of movements are learned, not movement per se.

2. Basic postural and movement patterns are learned first which are later on elaborated to become functional skills. 3. Skilled activity takes place against a background of normal postural reactions. DEFINITION OF TERMS 1. Engram ---pre-programmed of muscular activity as it is represented in the CNS 2. Placing Response --- Normal adaptation of muscles to passive movement --- Characterized by automatically maintaining a position when support is removed 3. Associated Reactions --- Involuntary and nonfunctional changes in limb position and muscle tone associated with difficult or stressful activities 4. Key Points of Control ---- Points on the trunk and limbs that are used to influence the quality of movement PROXIMAL Shoulder Pelvis Spine / Trunk DISTAL Hand Foot

5. Handling --- Manual designed to change muscle tone and normalize movement

--- Includes inhibition and facilitation STRONG AND FIRM HAND PRESSURE is used to: ---lengthen spastic muscles --- stop abnormal patterns of Coordination LIGHT PRESSURE is used to: --- guide the Px in normal movement patterns --- teach the feeling of normal movement --- elicit an active response from the patient 6. Reflex-Inhibiting Pattern --- positions that spasticity by passively elongating spastic muscles --- Active movement inhibits and facilitates RIPs For flexor spasticity of trunk and arm - neck & spine extension - shoulder ER - elbow extension - forearm supination - wrist extension - thumb abduction for extensor and flexor spasticity leg - hip extension, abduction, & ER - knee extension - ankle DF and big toe abduction (for extensor spasticity) MOVEMENT CONTROL PROBLEMS AFTER STROKE

- movement - Loss of normal responses - Loss of postural control - Loss of selective movement control - Abnormal tone PRINCIPLES OF TREATMENT --- Avoid movements that produce abnormal responses in the involved side. --- Develop normal patterns of posture and movement. --- Incorporate hemiplegic side into all treatment activities. --- Treatment change in the quality of movement and functional performance of the involved side --- Never exercise retrain! --- Start and finish a session with something positive. --- Use slow, controlled movements; fast movements can increase spasticity --- The patient must find the treatment useful, purposeful, and meaningful. --- After spasticity has been inhibited, follow with a purposeful movement put it to use! --- Encourage the patient to look at his or her arm. --- Tell a patient when a movement has been done correctly so that the patient can feel it. --- If spasticity starts, ---The patient often has to relearn movements, even on his good side.

REMEMBER! Bobath is against: a. heavy resistance exercises b. irradiation c. use of associated reaction and mass synergy ASSESSMENT 1. Determine presence and distribution of abnormal tone/patterns. 2. Identify deficits in normal motor responses. 3. Analyze the patients ability to perform functional movement patterns.

INHIBITION TECHNIQUES Designed to --- Decrease abnormal tone --- Restore normal alignment --- Stop unwanted movements --- Decrease abnormal STAGES OF STROKE RECOVERY 1. Stage of Flaccidity 2. Stage of Spasticity 3. Stage of Relative Recovery *TREATMENT GOALS IN VARIOUS STAGES OF STROKE

TREATMENT METHODS a. modify sensory inputs through: - handling - positioning - reflex inhibiting posture - use of key points of control b. facilitate automatic reactions c. integrate normal movement patterns into the developing nervous system FACILITATION TECHNIQUES Designed to: --- Provide sensation of (N) movement ---- Provide system relearning normal movements FACILITATION TECHNIQUES --- Stimulate muscles --- Allow movement with some constraints --- Incorporate involved side into functional tasks and occupation

1. STAGE OF FLACCIDITY SOME CHARACTERISTICS --- severe loss of postural control in the trunk ---- flaccid paralysis of the UE and LE --- poor sitting balance --- requires assistance in bed mob. & transfers GOALS --- to prevent development of spasticity and associated reactions ---to increase functional use of hemiplegic side 2. STAGE OF SPASTICITY SOME CHARACTERISTICS --- Spastic posturing appears when pt uses excessive effort; not evident when relaxed First muscles affected: --- scapular elevators --- flexors of the elbows and fingers --- ankle plantarflexors --- extensors of the knee 3

GOALS --- to inhibit abnormal posturing --- to facilitate normal patterns of movement --- to break down the total patterns by developing control of intermediate joints 3. STAGE OF RELATIVE RECOVERY SOME CHARACTERISTICS --- good control of weightbearing on the hemiplegic leg --- minimal flexor posturing of the arm --- slow and quality of movement GOALS --- to improve the quality of gait --- to improve use of the affected hand In Bobath: --- Always incorporate the hemiplegic side in all treatment activities. --- PT should be on the hemiplegic side or directly in front of the patient. In Bobath: --- Pt is always an active and motivated participant during treatment --- Always inject communication whenever possible.