CHAPTER 24—Optimizing Motor Behavior Using the Bobath Approach 643
Total Page：16
File Type：pdf, Size：1020Kb
91413 ch 24.qxd 1/12/07 4:16 PM Page 642 LEARNING OBJECTIVES CHAPTER After studying this chapter, the reader will be able to do the 24 following: 1. Identify the major problems that result from stroke according to Bobath and Bobath. 2. Describe the major principles underlying the Neuro- Developmental Treatment (NDT)/Bobath approach to stroke rehabilitation. 3. Discuss the role of muscle tone and postural control in the production of normal movement, and describe how problems in these areas contribute to impaired occupational functioning. 4. Integrate NDT/Bobath concepts and techniques with the occupational functioning model. 5. Develop an OT treatment plan for a patient with acute stroke using NDT/Bobath Optimizing Motor principles and techniques. NVIR NTEXT E ONMENT T CO CONT MEN EXT ON CONTEXT ENVIRONME E IR VIR Sense of self-efficacy NT C NV V T EN ON IR N X andE self-esteemXT ENVI TE E TE T CONT RONMEN XT ON MEN T CO E ENVIRONMENTON N N Behavior Using the C IR CONTEXTTE V EXT ENVIRONMENT CO X N ONT ENVIRONMENT NTEX T E NT C T E E CONTEXT N M TEXT ENVIRONMENT CON CON Satisfaction with TEXT ENT EN M T ENlifeVIR rolesONM ENT ONTEX CONTEX NT C • Self-maintenance T E ME ENVIRONMENT N XT ENVIRONMENT CONTEX Bobath Approach ONTE • Self-advancement T EN C • Self-enhancementONMENT EXT ENVIR CONTEXT CONT EN ENVIRONMENT CONTE NTEXT XT EN CO CONTEXT ENVIRONMENT CON NTEXT Competence in tasks TEXT E COENVIRONMENT N MofEN lifeT CrolesONTEX ENVIRON T ENVI Kathryn Levit MENT CONTE ENVIRON XT ENVI ENVIRONMENT ENVIRONMENTMENT CONTEX ENVIRActivitiesON and habitsT ENVI MENT CONTE ENVIRON XT ENVI CONTEXT CONTEXTMENENVIRONMENTT CONTE ENVIRON XT ENVI Abilities and skills MENT CONTEXT ENVIR MENT CONTEXT ENVIR ENVIRONMENTT CONTEXT ENV MEN DevelopedCONTEXTIR MENT capacitiesCONTEXT ENVIR MENT CONTEXT ENVIR CONTEXT CONTEXT ENVIRONMENTFirst-level CONTEXT CONcapacitiesTEXT ENVIR ENVIRONMENT CONTEX EXT ENVIRO CONT NM NMENT C VIROOrganic ONTE EN X substrate 91413 ch 24.qxd 1/12/07 4:16 PM Page 643 CHAPTER 24—Optimizing Motor Behavior Using the Bobath Approach 643 GlossaryGlossary Abnormal coordination—Patterns of muscle activation, Inhibition—Manual techniques and positions used to timing, and sequencing that deviate from normal, resulting decrease or eliminate the effects of spasticity and abnormal in inefficient, stereotyped movement patterns. coordination. Abnormal tone—Muscle tone that is higher or lower than Key points of control—Hand placements used to influence normal. the quality of posture and movement. Associated reactions—Involuntary and non-functional Loss of postural control—Inability to use automatic changes in limb position and muscle tone associated with dif- patterns of muscle activation to maintain the body within a ficult or stressful activities. stable base of support at rest and during movement. Facilitation—Manual techniques and other processes includ- Placing response—Part of the normal system of postural ing tactile and verbal feedback used to help the patient adjustments to changes in position, characterized by auto- achieve a more normal quality of movement. matically maintaining a position when support is removed. Flaccidity—Muscle tone that is lower than normal. Also Reflex-inhibiting pattern (RIP)—A position that is used to known as hypotonicity. inhibit spasticity by lengthening shortened muscles. Handling—Manual techniques designed to change muscle Spasticity—Muscle tone that is higher than normal and tone and normalize movement. Handling includes inhibition resists passive stretching; also known as hypertonicity. and facilitation. Bobath and B. Bobath developed a treatment ap- History and Principles proach designed to increase normal movement patterns in children with cerebral palsy and Bobath and Bobath began to develop their treatment ap- adults with acquired hemiplegia. Their treatment proach in England in the 1940s. B. Bobath, trained in K.is known as the Bobath approach or Neuro-Developmental Germany as a gymnast and remedial movement specialist, Treatment (NDT). NDT/Bobath treatment focuses on went to England to avoid persecution and found work as eliminating abnormal movements and restoring normal a physical therapist. When treating adults with hemiple- movements. The occupational functioning model usually gia, she noted the abnormal stiffness in their affected describes this type of treatment as preparatory because it is extremities, their asymmetrical body postures, and the directed toward establishing sensorimotor performance non-functional stereotyped patterns of movement in their components that are prerequisites for function while mini- involved side. B. Bobath tried to help her patients regain mizing the impairments that interfere with functional be- functional use of their hemiplegic side. She assumed that havior. This chapter introduces the NDT/Bobath approach the abnormal patterns of muscle tone and motor control to the treatment of adults with hemiplegia. A complete were the major impairments interfering with normal mo- description of the treatment approach and its techniques tor control of the trunk, arm, and leg. Through trial and can be found in Bobath (1990) and Davies (1985). Eggers error, B. Bobath developed techniques for decreasing (1984) provides information on using the approach to im- abnormal reflex activity and muscle tone and for increas- prove occupational functioning. Current theoretical foun- ing control of normal patterns of movement on the hemi- dations and principles of clinical practice are described in plegic side of the body. These techniques were based on Howle (2002). her knowledge of normal kinesiology, not the develop- mental sequence. B. Bobath discovered that she could help her patients INTRODUCTION with hemiplegia move more freely and function with less compensation by decreasing the abnormal tone in their affected side. She also found that, when spasticity de- NDT is one of the classic neurophysiological treatment creased, her patients could acquire improved control of approaches that were developed to address the impair- posture and movement on their affected side and could ments associated with damage to the central nervous sys- use these new patterns for function. Based on these clin- tem. This section briefly reviews the history of the NDT ical findings, B. Bobath developed a new model for treat- approach and provides an overview of principles of treat- ing adults with hemiplegia. Her approach involved the ment and methods for integrating this treatment into oc- use of manual techniques to eliminate abnormal tone cupational therapy for individuals with stroke and brain and dysfunctional movement and to retrain normal pat- injury. terns of coordination in the affected trunk, arm, and leg. 91413 ch 24.qxd 1/12/07 4:16 PM Page 644 644 SECTION FIVE—Treatment of Occupational Function Since her goal was to restore normal movement and function on the affected side, she specifically rejected DEFINITIONde•fin•i•tion 24-1 compensatory approaches that neglected the potential for function in the hemiplegic side and other neurophys- NDT Philosophy iological approaches that encouraged abnormal move- The NDTA website (www.ndta.org) contains the following ment and reflex activity. statement about Neuro-Developmental Treatment: As B. Bobath developed the treatment techniques, neu- “The Neuro-Developmental Treatment (NDT)/Bobath rologist K. Bobath reviewed research in neurology and approach was developed by Berta and Karel Bobath as a neurophysiology to develop a scientific basis for his wife’s ‘living concept.’ The approach is intended to grow and de- treatment. B. Bobath’s claims that her treatment could velop over time as new information is gained from clinical change spasticity and restore normal movement responses experience and scientific research. NDT is used for the treatment and management of individuals with movement were controversial, and K. Bobath used research findings dysfunction resulting from central nervous system (CNS) to support her discoveries. Since the clinical techniques pathophysiology. The individual’s strengths and impair- developed first, K. Bobath presented his scientific ration- ments are identified through an in-depth analytical ale in hypothetical terms, describing it as an explanation process and addressed in relation to functional abilities for, not the basis of, intervention. and limitations. NDT is an interactive process which Bobath and Bobath called their treatment approach a includes individuals, caregivers and members of the living concept because they expected it to change and de- interdisciplinary team in assessment, treatment planning velop over time. They made many changes to the treat- and application. ment over the years to make it more active and functional. The overall goal of treatment and management is to They also made an effort to update their theory by adding enhance the individual’s capacity to function, minimize new scientific explanations for certain aspects of their impairments, and prevent disabilities. To achieve this goal, the therapist addresses the quality of movement treatment. Although controversial when first introduced, utilizing principles of movement science. Intervention many of the assumptions of Bobath and Bobath are now involves direct handling including facilitation, and inhibi- an accepted part of stroke rehabilitation, and the ap- tion to optimize function. The application of NDT con- proach is widely used throughout the world (Rast, 1999). tributes to the individual’s increased independence and The theoretical