Name used in
many
countries..
Based on
Hierarchial
BOBATH/
model
NEURO DEVELOPMENT
Na Nort .
TECHNIQUE
in rica.
me
Am ed o
Ba tem
e
sys del
u se
s
mo
h
d
n
GARIMA WADHWA
PART 1
ASSISSTANT PROFESSOR
ISIC - IRS MATA DI
CONTENTS
PRACTIC
AL
ASSUMPT EVALUATI TECHNIQ
ABOUT APPLICAT
IONS ON UE
ION FOR
STROKE
ABOUT
• Dr. Karel Bobath (Neurologist) and his wife Mrs. Berta Ottillie Busse Bobath
(Physiotherapist) developed their treatment concept for cerebral palsy children and
adult hemiplegia.
• The contemporary “bobath concept” is a problem solving approach to the assessment
and treatment of individuals with disturbances of function, movement and postural
control due to lesion of CNS
ASSUMPTIONS
ASSUMPTION 1 ..
Individuals with motor control problems associated with CNS
pathology such as CP or adult hemiplegia, presents with
predictable primary and secondary impairments that limits the
function, for instance: abnormal muscle tone, disordered
control : due to abnormal strong primitive reflex activity and
inability to demonstrate mature motor response.
ASSUMPTION 2 .. MODEL OF
MOTOR CONTROL
OLDER CONCEPT
• It states that the nervous system is organized hierarchal with
spinal cord being the lowest level, brainstem is intermediate
level and Cerebral cortex is the highest level.
• Many system or subsystem works cooperatively for
integration of movement into function. There is a dynamic
interplay between perception, cognition and action system.
ASSUMPTION 3..
• Bobath Believed that the primitive movements, spasticity and pathological limb
synergy (movement) are too hard too get rid of once patient’s learn how to use
them.
• Thus, the first goal of treatment is to inhibit spasticity and pathological limb
movement .
• Treatment then progresses to stimulation of automatic reactions such as righting
reactions, equilibrium reactions and once, if these automatic reactions were
present, Bobath assumed that normal voluntary movements would naturally
emerge.
ASSUMPTION 4..ROLE OF
SENSATION
OLDER CONCEPT
• Bobath placed strong emphysis on proprioceptive feedback for learning.
Proprioception is important when learning is taking place.
NEWER CONCEPT
• The older concept of sensory feedback being primarily proprioceptive has been
revised to include other sensory modalities such as vision.
ASSUMPTION 5.. POSTURAL
CONTROL
Postural control is essential for limb movement. Postural control produces an axial
adjustment that precedes limb movement.
Ex. If you plan to move the arm forward while reaching for an object, axial
contraction occurs prior to forward sway while reaching for an object and these
postural reactions are task specific.
ASSUMPTION 6.. PLASTICITY
OF BRAIN
• Plasticity of structure is ability to show modifications.
• The capacity of nervous system to change is demonstrated in children
during the development of neural circuits , in adult brain during
learning of new skill, establishment of new memories and by
responding to injury throughout life.
ASSUMPTION 6 CONTD..
Mechanism
Collateral
sprouting
•3-5 Days of injury
•Collateral axon from nearby neurons
begin to bypass the damaged area to
reconnect broken synapse.
•Regenerative sprouting is
unsuccessful because of scarring.
Collateral Sproting
EVALUATION OF ADULT
HEMIPLEGIA
SHORT ASSESSMENT
FOR ADULT HEMIPLEGIA
• Patient’s Name, Age, Address, Profession, date of examination, date of
onset, surgical and medical history, Diagnosis by doctor.
• General Impression of patient: co-operation, emotional release,
depression, aggression, instability (Mark on any of these if present in
patient)
• Stay of health : past medical history like - hypertension, respiratory
insufficiency etc
• What can patient do ?
• What can patient not do?
ASSESSMENT CONT.
• Assistance required: tripod, walking stick, brace .
• How is patient’s balance: Sitting, standing, walking
• Can patient use his/ her affected side: arm, hand, leg, foot? Has they
got associated reactions?
• Can patient speak? Understand language? Read or write?
• Sensory state: Deep sensation (proprioception), tactile sensation,
pressure, light touch, sterognosis
• Joint range of individual joint
• Tonus: spasticity / flaccidity : arm or leg
• Muscle power : Assessing muscle power: weakness, contractions, co-
contractions.
• Assessment of postural reactions?
TEST FOR SPECIFIC MOVEMENT
I. Test for quality of movement pattern : it has 3 grades: grade 1:
easiest, grade 3 : most difficult
II. Test for balance and other automatic protective reactions : Not
graded
TREATMENT TECHNIQUES
SUMMARY OF NDT TECHNIQUES AND CLINICAL
USE
Technique Clinical use
Handling Hands are used to support and assist movement
(active or passive) from one position to another.
Active assisted movement is always encouraged
Positioning Used to provide alignment, comfort, support,
prevent deformity, promote optimal independent
function
Use of adaptive equipment Promote alignment, postural support, enhance
function, offers mobility
SUMMARY OF NDT TECHNIQUES AND CLINICAL
USE
Technique Clinical use
Key points of control To guide the person movement.
Proximal key points: trunk shoulder pelvis
Note: use of proximal key Distal Key Points: hands and feet
points facilitates movements
of the limbs while distal key
points facilitates movement of
trunck
Use of sensory input Proprioceptive input: weight bearing,
approximation, stretching and traction or tapping.
Exteroceptive input: manual guidance,
therapeutic use of hands.
Movement stimulates vestibular system
Vision and verbal inputs are used for motor
learning.
Motor learning strategies Active movement is encouraged through practice,
repetition, feedback and use of functional activities.
APPLICATION ON STROKE
PATIENTS
Process of recovery
• Positioning
• Bed mobility exercises
• Treatment in supine lying, sidelying
Initial flaccid stage
The techniques employed depends on the stage of recovery the
patient has reached . The recovery of the individual may be arrested
at one of these stage
INITIAL FLACCID STAGE
• The initial flaccid stage is found soon after the onset of hemiplegia
and lasts
from a few days to several weeks and may be longer.
• The patient's position in bed is as follows: the neck usually shows
slight
lateral flexion towards the affected side, the shoulder and arm are
retracted and
the elbow still extended at this stage. The forearm is prsmated. * The
leg is
usually extended and laterally rotated, the ankle plantiflexed and
often slightly
supinated.
Positioning- Supine
Arm and head
• Position in bed: patient lying on his back.
• To prevent shoulder retraction: place outstretched arm alongside the body on
a pillow somewhat higher than the trunk. Place outstretched hand on pillow
or, better if possible, supinated against the outside of the pillow.
Pelvis and leg
• The flexor tendency is dangerous for rehabilitation. If the flexor pattern is
allowed to become established and contractures develop, this type of patient
will not have enough extensor tonus to enable him to get up, to· stand, or to
walk.
• Therefore, the therapist must prevent flexor contractures of the hip and knee,
pressure sores of the lower leg, and supination of the foot .
• Position in bed: lying on back. A pillow or sandbag is placed under the pelvis
on the affected side in order .to lift the pelvis (to avoid pelvic retraction). The
pillow must be long enough to give support to the lateral side of the thigh.
Exercises in supine lying
Elevation of arm
Bridging
Exercises for lower limb
Rolling
Turning should commence with the upper part of the body and, in
order to do this, the patient must first learn to lift the affected arm
with the good arm, and to clasp his hands (i.e. with fingers
interlocked). He should then lift his clasped hands, with elbows
extended, to the horizontal and, if possible, above his head. From
there, he should move his arms first to one side and then to the other
Turning over to the sound side should also be started with his arms
and trunk, his hands clasped. He will then need only minimal help, if
any, to turn his pelvis and move the affected leg to the sound side.
Sitting to the side of bed
Turning to the sound side to sit up.
Therapist moves the affected leg over the edge of the bed with her
other hand. The patient should keep his hands clasped together (Fig.
6.4a.)
Weight bearing on affected arm
while sitting to side of bed
Weightbearing on the extended arm is
part of the process of gaining balance
and makes the patient feel sufficiently
safe to bear weight on the affected
side without fear of falling over.
Standing from sitting and transfer
to chair
With the patient sitting on the bed, the therapist will stand in
front of him and let him place his sound arm around her waist
to hold on to her.
She will then take the affected arm and, with one hand under
his arm. Then she will bring the
arm forward and against her waist just like the sound arm She
will fix his arm against her body with her forearm, so that both
her hands will be free to help the patient to stand up. Before he
stands up, she will help him to move forward from the hips.
With the affected foot is on the floor, it tends to pull up, the
therapist can, at first, place her foot lightly upon it. 'When the
patient is standing up, the nurse can help him by placing her
hand, i.e. the one that is by the patient's sound side, on his back
and pushing the lumbar spine forward, so that the hips
straighten and enable him to stand upright.
STAGE OF SPASTICITY
CONT.. PART 2
