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Bobath approach:

Bobath approach Hetal shah


Origin of approach Old concept Current concept Ndt assumptions Examination Ndt intervention content

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“The Bobath Approach”, the original approach, began in England, 1940’s. NDT is not a method, but an evolving, “living concept” in management. “Give life, not exercise.” Berta Bobath

Origins of Theoretical Approach :

NDT, first known as “The Bobath approach” was originated and developed by Berta Bobath , physiotherapist , and Dr. Karel Bobath in the late 1940s Name Bobath is still used in many countries, NDT is the name commonly used in North America Developed from observations, practical applications and desire to find better solutions for client’s problems Origins of Theoretical Approach


A concept of treatment based on the inhibition of abnormal reflex activity and the relearning of normal movement , through the facilitation and handling OLD CONCEPT


Bobath concept is a problem-solving approach to the assessment and treatment of individuals with disturbances of tone, movement, and function due to a lesion of CNS, The goal of treatment is to optimize function by improving postural control and selective movement through facilitation (IBITA 1995). BOBATH CONCEPT


Developed empirically to explain the observed signs and symptoms of the patients at 1945-1975 CNS developed as a hierarchical structure The complexity of the structure was defined in terms of the size and number of connections(Sherrington, Magnus, Walshe ) ORIGINAL BOBATH CONCEPT 1


Movement was elicited through the stimulation of reflexes in the spinal cord( Bobath , Walshe ) Lesions of the pyramidal tract produced a loss of inhibitory control and therefore contra lateral spastic hemiplegia (Sherrington, Brown, Walshe , Bobath ) AR and Spasticity were one and the same thing and they were involuntary reflex actions( Walshe , Bobath ) ORIGINAL BOBATH CONCEPT 2


To identify and address the specific areas of low tone in the anti-gravity musculature To seek to control the amount and diversity of proprioceptive input To identify the primary goals for function in the individual person, and to understand the nature of how that function is performed efficiently "Normally" GOALS OF BOBATH CONCEPT 1


To facilitate specific motor activity without overflow of irradiation that could elicit associated reactions To minimize compensation and therefore sensory/motor neglect of the affected body parts To identify when and how voluntary controls can be used effectively GOALS OF BOBATH CONCEPT 2


“NO LONGER EMPIRICAL” The CNS is a complex organization consisting of "systems & subsystem“ The CNS can adapt and change it's structural organization The manipulation of afferent input can therefore directly effect a change in the structural organization of the CNS "CURRENTLY" CONCEPT 1


Changes within the structure of the CNS can be organized or disorganized producing adaptive or maladaptive sensory-motor behavior Movement control's dependent upon and intact, integrated neurological and musculoskeletal system Selective movement control of the trunk & the limbs, both concentric and eccentric are interdependent and interactive with a postural control mechanism "CURRENTLY" CONCEPT 2


Rehabilitation is a process of learning to regain motor control and should not be the promotion of the compensation The cellular mechanisms underlying learning are the same mechanisms that take place during : motor development refinement & re-learning of motor control "CURRENTLY" CONCEPT 3


Advanced hands-on approach to the examination and treatment of individuals with disturbances of function, movement and postural control due to a lesion of the central nervous system (CNS ) Used primarily with children who have cerebral palsy (CP) and adults with cerebral vascular accidents (CVA) NDT

NDT evolution :

1 . Decreasing muscle tone through the use of reflex inhibiting postures 2. Incorporation of hierarchical motor sequences into therapy , with one activity following another during facilitation (head control, rolling, sitting, quadruped, kneeling ) 3. Facilitation of automatic movement sequences as opposed to isolated developmental skills 4. Currently, it is recognized the need to direct the treatment towards specific functional situations NDT evolution

NDT Assumptions:

Impaired patterns of postural control and movement coordination are the primary problems in clients with CP These system impairments are changeable and overall function improves when the problem of motor coordination are treated by directly addressing neuromotor and postural control abnormalities in a task specific context Sensorimotor impairments affect the whole individual – the person’s function, place in the family and community, independence and overall quality of life A working knowledge of typical adaptive motor development and how it changes across the life span provides the framework for assessing function and planning intervention. NDT clinicians focus on changing movement strategies as a means to achieve the best energy-efficient performance for the individual within the context of the age appropriate tasks and in anticipation of future functional tasks. NDT Assumptions

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Movement is linked to sensory processing Intervention strategies involve the individual’s active initiation and participation, often combined with therapist’s manual guidance and direct handling NDT intervention utilizes movement analyzes to identify missing or atypical elements that link functional limitation to system impairments Ongoing evaluation occurs throughout every treatment session The aim of NDT is to optimize function


NDT Focus : to identify constrains that limit the client’s ability to perform functional activities. Components: Present and anticipated functional skills or limitation of skills Posture and movement components and compensatory strategies Anatomical and physiological status of those systems that contribute to functional limitations Examination

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Functional Skills Gross and fine motor control, communication, and control of behavior and emotions Functional abilities and limitations Potential to change function Clusters of function and activity limitations Relationship between participation and activity level Assistive devices, splinting and orthothics

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Observation of posture, movement and compensatory strategies Spontaneous posture and movement Typical and atypical posture and movement Compensatory movement strategies Alignment, weight bearing, balance, coordination, muscle and postural tone, and movement components

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Individual systems related to function Neuromuscular system Musculoskeletal system Sensory, perceptual, cognitive systems Regulatory system (arousal, attention, emotional and behavioral responses) Limbic system (emotions, fear, pain) Respiratory, cardiovascular system Integumentary system (skin)

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Measurement Tools Norm-referenced tests WeeFIM , AIMS(abnormal involuntary movement scale) The School Functional Assessment)Criterion-referenced tests (COPM) canadian occupation performance measure. Non-standardized tests (compare the performance at the beginning and at the end of the session)


The therapist observes, describes and formulates hypothesis, linking treatment planning with outcomes. Client’s internal and external resources Functional limitations and participation restrictions The relationship between posture and movement components Hypotheses regarding impact of impairments on daily life function Potential to change Intervention plan developed Evaluation

NDT Intervention :

NDT Focus: what differentiates NDT intervention from other approaches is the precise therapeutic handling, including facilitation and inhibition, used to provide sensoriomotor cues that facilitates change in function ( Howle , 2004). “Handling is graded input provided by the therapist’s hands at key points of control on the child’s body…. and results in active control or movement” (Kramer, 1993, p. 78) NDT Intervention

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Sequence of Intervention Preparatory activities for passive movement or body alignment Selection of the key points for therapeutic handling according to the child’s postural tone Facilitation of active or automatic movement patterns by applying graded and varied therapeutic input

key points:

The key points (proximal or distal) are the places of physical contact between the therapist’s parts of the body or therapy equipment and client’s body. (Boehme, 1988) Proximal key points: Located closer to the source of the problem, usually at the head, trunk, or large joints Used to influence posture and movement in all three planes ( sagittal , frontal, and transverse), especially during difficult moments key points

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Distal key points: Located away from the source of the problem, usually at the upper and lower extremities level Used to allow the client to engage in activities with minimal control of the therapist

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“Facilitation is the process of intervention which uses the improved muscle tone in goal-directed activity. Facilitation techniques involve stimulation of the muscle activity to produce a desired motor response. It is related with the functional goal that needs to be achieved.” (Boehme, 1988, p. 3) Modifies postural control Guides the child’s posture or movement during the activity Techniques: tapping and intermittent compression to provide proprioceptive and tactile stim ulation

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“ Inhibition is the process of intervention that reduces dysfunctional muscle tone.” (Boehme, 1988, p. 3) Reduces the intensity of spasticity Reduces the effect of fluctuating muscle tone Improves the range and variety of movements Not used with hypotonicity Techniques: traction and light joint compression It is used in combination with facilitation

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Weight bearing and weight shifting promote: Postural alignment Child’s movements Proximal stability Adaptive equipment and orthothic devices Allows more independent movement Decreases the possibility of deformities and contractures Can be used by parents and other professionals to reinforce the therapy

Role of Play in NDT Intervention with Children :

Motivates and engages the child Provides appropriate stimuli for development of normal movement patterns Fulfills therapeutic goals Facilitates the handling techniques Facilitates the use of the gained movements in other activities Allows observation of child’s spontaneous and automatic postures and movements Role of Play in NDT Intervention with Children

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