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This page intentionally left blank Bobath Concept Theory and Clinical Practice in Neurological Rehabilitation Dedication This book is dedicated to all of our patients and students from whom we have learnt and through whom we have developed. This book is dedicated to the memory of Pam Mulholland, MCSP, Bobath Tutor, our colleague and friend. Bobath Concept Theory and Clinical Practice in Neurological Rehabilitation Edited by Sue Raine Linzi Meadows Mary Lynch-Ellerington A John Wiley & Sons, Ltd., Publication This edition fi rst published 2009 © 2009 by Blackwell Publishing Ltd Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publish- ing programme has been merged with Wiley’s global Scientifi c, Technical, and Medical business to form Wiley-Blackwell. Registered offi ce John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom Editorial offi ces 9600 Garsington Road, Oxford, OX4 2DQ, United Kingdom 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offi ces, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www. wiley.com/wiley-blackwell. The right of the author to be identifi ed as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or oth- erwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authorita- tive information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging-in-Publication Data The Bobath Concept: Theory and clinical practice in neurological rehabilitation / edited by Sue Raine, Linzi Meadows, Mary Lynch-Ellerington. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-7041-3 (pbk. : alk. paper) 1. Movement disorders—Patients—Rehabilitation. 2. Bobath, Berta. 3. Bobath, Karel. 4. Motor learning. I. Raine, Sue. II. Meadows, Linzi. III. Lynch-Ellerington, Mary. [DNLM: 1. Bobath, Berta. 2. Bobath, Karel. 3. Central Nervous System Diseases— rehabilitation. 4. Physical Therapy Modalities. 5. Rehabilitation—methods. WL 300 B663 2009] RC376.5.B63 2009 616.8’3—dc22 2008053126 A catalogue record for this book is available from the British Library. Set in 10/12 pt Palatino by Macmillan Publishing Solutions, Chennai, India Printed in Singapore 1 2009 Contents Foreword viii Preface xii Contributors xiv Acknowledgements xv 1. The Bobath Concept: Developments and Current Theoretical Underpinning 1 Sue Raine Introduction 1 The founders and development of the Bobath Concept 1 Current theory underpinning the Bobath Concept 3 Systems approach to motor control 4 Clinical application of the theory underpinning the Bobath Concept 11 Summary 16 References 17 2. An Understanding of Functional Movement as a Basis for Clinical Reasoning 23 Linzi Meadows and Jenny Williams Introduction 23 Normal movement versus effi cient movement 24 Compensatory strategies 25 Motor control and motor learning 26 Requirements of effi cient movement 31 Summary 37 References 39 3. Assessment and Clinical Reasoning in the Bobath Concept 43 Paul Johnson Introduction 43 Models of clinical reasoning and the Bobath Concept 45 Key characteristics of assessment using the Bobath Concept 47 v Contents Basis for clinical reasoning 52 Illustrating clinical reasoning using the Bobath Concept 53 Summary 57 References 61 4. Practice Evaluation 64 Helen Lindfi eld and Debbie Strang Introduction 64 Evaluation in the context of the International Classifi cation of Function, Disability and Health 65 Factors infl uencing measurement selection 66 Measurement properties 68 Measures 70 Summary 78 References 79 5. Moving Between Sitting and Standing 83 Lynne Fletcher, Catherine Cornall and Sue Armstrong Introduction 83 Clinical considerations from the literature 84 Phases of sit to stand 86 Movements from standing to sitting 89 Effects of ageing 92 Sit to walk 93 Clinical aspects 93 Movement in functional contexts 95 Clinical example 98 References 114 6. The Control of Locomotion 117 Ann Holland and Mary Lynch-Ellerington Introduction 117 Key aspects of bipedalism 117 The gait cycle 122 Use of body weight support treadmill training in the Bobath Concept 127 Assistive devices 129 Outcome measures 147 Summary 149 References 149 7. Recovery of Upper Limb Function 154 Janice Champion, Christine Barber and Mary Lynch-Ellerington Introduction 154 The importance of postural control in upper limb function 155 vi Contents The shoulder complex 157 Functional reach 162 The hand 170 Early treatment and management of the hand 170 Assessment of the hand 171 Contactual hand-orientating response 173 Selective strength training of the intrinsic muscles of the hand 173 Summary 177 References 178 8. Exploring Partnerships in the Rehabilitation Setting: The 24-Hour Approach of the Bobath Concept 182 Clare Fraser Partnerships in the rehabilitation environment 182 The early days 184 Overcoming sensory deprivation and stimulating body schema 190 Scheduling the day – opportunities for practice 191 Return to work 194 Summary 202 References 204 Index 208 vii Foreword As a physician and neurorehabilitationist whose primary professional concern has been with adult patients, it may seem strange that I feel so deeply indebted to Karel and Berta Bobath, who devoted much of their lives to the rehabilitation of children with neurological problems, especially cerebral palsy. And yet, it is true. I believe that the benefi cent infl uence of the Bobaths on our approach to neurological rehabil- itation has been incomparable, and all of us who are involved in the care of people struggling to overcome the impact of neurological damage owe them a debt of grat- itude. Things that we now take for granted were regarded as heretical or eccentric when the Bobaths started out on their careers so many years ago and developed an approached which combined science, and a deeply humane concern for the plight of individuals, with neurological damage with something we might call ‘clinical nous‘. The results are plain to see for all those who have long enough memories. When I began my career as a doctor in the 1970s, stroke patients were not welcomed on medical wards and rehabilitation services were poorly developed. The nihilism of Hughlings Jackson, the father of British neurology – encapsulated in his observa- tion that ‘You can’t treat a hole in the brain’ – summarised the prevailing attitude. The physiotherapy these patients received was often misguided, having an ortho- paedic bias, as Sue Raine notes in her contribution: massage, heat, passive and active movement techniques such as the use of pulleys, suspension and weights. The results were dreadful: stroke patients routinely ended up with severe fl exion of the upper limbs (with the fi ngers curled over so tightly that hygiene was almost impossible), extension of the lower limbs and foot drop, so that walking was a perilous business – requiring circumduction at the hip – and not infrequently, the chronic misery of severe shoulder pain. Inappropriate splints and walking aids added to the demoralisation of the patient. As a junior doctor, I assumed that this wretched state of affairs was an inevitable consequence of stroke. It was not until the Bobath revolution started to gain a foot- hold in the UK that I began to see that things might be otherwise. At the heart of the revolution was, as the title of this book indicates, a concept. And at the heart of this concept was an understanding that if you are going to promote recovery and independence, then you must (to use Geoffrey Kidd’s phrase) ‘talk to the nervous system in a language it understands’. At any rate, it meant an approach that was viii Foreword remote from the ‘orthopaedic’ strategy that had preceded the Bobath approach. This seems common sense now, but for many years this central notion met with incomprehension or scepticism, particularly among non-physiotherapists – includ- ing, I have to admit, myself. Precisely, how one talks to the nervous system in a language it understands is described in practical detail in this superb book, which is a distillation of the expertise of leading neurophysiotherapists who have been central to the applica- tion and the development of the Bobath Concept in the UK. In a series of wonder- fully lucid chapters, the authors combine a profound knowledge of the underlying neurophysiology of normal and abnormal movements with the insights that come from many years of practical experience. The key to the Bobath approach is under- standing where the patient is ‘at’. This ranges from assessing the impairment and consequent motor behaviour to determining the patient’s expectations, fears, hopes and beliefs. One of the most important aspects of the Bobath Concept is acknowledging the crucial role, in the case of upper motor lesions, of loss of inhibitory control and con- sequent spasticity. The possibility of infl uencing increased tone through afferent input led to the notion of ‘refl ex inhibiting postures’ and less static ‘refl ex inhibiting patterns’.

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