- problem solving approach to assessment and treatment of individuals with disturbances of function, movement and postural control due to a lesion of the central nervous system
- for pts of all ages and all degrees of sunctional and physical disability
- it is a continually evolving concept
- it is a problem solving analytical approach
- use of handling to modify a task to make it more efficient, effective and successful for an individual
- uses principles of motor learning to therapy encouraging individual active participation, opportunities to practivce and meaningful goals
- therapy is interactive between individual, task and envt
- uses knowledge that neuroplasticity underlies all skill learning
- is a concept
- want to normalise tone and facilitationg automatic and active movemnt through specific handling
- systems approach to motor control
- interaction of motor procss with cognitive and perceptual processes
- interaction between the envt and state of the person shapes the output
plasticity is the basis for development, learning and recovery
- normalising tone to improve movement through practicing normal movement patterns resulting in an increase in efficiency and less effort in functional tasks
- key aim of intervention is to maximise postural and movement strategies to improve efficiency and optimise the clients ability to automatically interact with their environment
- bases of postural tone is important to more normally
Bobath and cortical plasticity
- cortical reorganisation through selective input optimising the internal representation and control of movement
- selective motor training of a task in an enriche environment helps to promote neuroplastic changes and imprve the functional outcome
- varied repetition important
- need to practice whole movements not just individual mm contraction
- stimulate it or lose it
plasticity (neural and mm)
- motor learningis the permanaent change in persons performance with practice
- neurons that fire together, wire together and promote learning
- short term changes need to be reinforced to promote more significant cellular and molecular modification
- skeletal mm is one of the most plastic tissues in the body
- formfunctioning eg tennis player- non player. form of skeletal mm is influenced by the functional demands put on it. Range of functions of the mm is enabled as the form of the mm responds by adaptation
- learned non use in both sides of the body so need holistic, individual approach to theray
- ability to manipulate and restructure CNS is key to success in the therapy- this is the underlying principle for intervention
Systems approach to motor control
- motor learning, active participation, practise, meaningful goals, plasticity- neural/mm, function, individaul cognitive/ perception/ action systems, task envt, UMNL +ve/-ve features mechanical features
Motor control and learning
- understanding of motor control and motor learning
- the bobath concept involves the whole pt and it is on interactive process
- meaningful goals and task orientated
- therapist knowledge of movement analysis and components of human movement
- want to change and build on propriocptive (internal) and exteroreceptive (external) envts to help the individual more functionally more effectively and efficiently
- treatment is continually adaptive to the changing response of the individual
What are the two areas motor learning are divided into?
What is explicit learning?
- learning factual information involves conscious high level cognition. Too much of this type of learning can interfere with implicit learning after stroke as auditory ijnformation processed correctly
What is implicit learning?
- learning of a motor skill under less cognitive control. Use of integration of sensorimotor information for production of skilled movements
- specific sensory stimulation provides essential information to assist with accurate afferent input to improve individuals opportunities for more efficient movement
- active movement is important as it provides sensory stimulation and this can help to build a more controled movement- may change height of bed and chir
- handling techniques can help with control voer alignment and stability during movements
- ne to maintina posture
- motor aspects- postural tasks related
- sensory aspects- selective attention by the CNS to relevatn stimuli
- cognitive- motivation, judgement, planning and problem solving
- perceptual- spatial and visual
- bimechanical- complementary neural and biomechanical aspects of control
Systems control of posture and movements with bobath
- help client maximise acquisiton of postural control and movement through the manipulation of improved feed-forward and feedback control
- postural responses occur in anticipation of and alongside a movement and result of an unexpected displacement
- maintaining stability requires a very highly tuned complex process of information to have the necessart postural stability in the many varied positions
- when descending infor form spinal cord is disrupted this leads to a problme in organising patterns of activity with a background of postural tone
What are the postural control foundation for movement?
- balance strategies
- patterns of movement
- speed andacuracy
- strength and endurance
Bobath aims to
- regain the most efficient movement for a pt
- postural control is very important
What do you need to think about with postural tone?
- accept BOS and still move
- maintain posture and still move
- automatic changes in tone
- environmental and genetic influences
Selective movement with postural tone
- ability to grade postural tone
- coordinated grading from concentric to eccentric activity
- changes in response to a demand
Bobath patterns of movement belief?
- CNS is wired for better efficiency to use patterns of movement
- they can be modulated by sensory input
What is sensory and proprioceptive input?
- afferent info in important in initiating and modifying movement
- CNS gives attention to this to provide appropriate motor output
What is facilitation?
- is a way of using sensory and proprioceptive controls to make movement easier
- part of the active learning process helps pt overcome inertia, initiate, continue or complete functional tasks
- helps alow sequencing of activities
- helps increase, activate or direct postural control needed
Is facilitation active or passive?
- never passive
Idea of the process of faciliation?
- to be successful it must lead to a change in motor behaviour therefore amount of facilitation is reduced and gradually withdrwan when client can initiate and complete a task
- makes activity posible
- demands a response
- allows the response to happen
What are associated reactions?
- can be present in varying degrees in arm, hand, foot or leg
- pathological and sterotypes abnormal patterns of movement which often became more apparent with effort
- they can be initiated with movement and in some cases in prep of movement
- often are the results of postural fixing when stability is not present eg in trunk. Therefore therapist look for cause rather than change patterns
- they can change andcan be an indicator of improved movement
- eg flicking ur hand along when u walk and not even realise
What are associated movements?
- these are normal coordinated movements in response to stress
- can be inhibited when made aware of them
- often associated with learning a new skill
What are postural sets?
- posisiton or posture of normal symmetry or alignment of key points from which normal person moves
What are the postural set against gravity?
- agonistic acitivty
Postural set with gravity?
- letting go of agonistic activity
Ensure each movement is done to achiefve a motor goal
Where are your central key points?
- xiphod and T8
What are key points of control?
- they are described as areas from which movement may be most effectively controlled
What are the proximal key points?
- shoulder girdles
Where are the distal key points?
- hands and feet
Where is the central key point?
- the area where posture and movement of the trunk can be controlled
- the action of making amends, counterbalancing or making up for
- changes in the CNS can be organised or disorganised affecting the sensorimotor behaviour
- if established they can reienforce altered movements and prevent acquisition of better movements
- at neural level they can affect the recovery of spared neural mechanisms
- minimising compensations and explore neuroplastic changes in response to alteration in task envt etc
- is systematic and flexible as it is different for each pt
- explores full potential for improvement within pts movement control to improve function
Perform assessment for postural control
Assess sensory/ proprioception, alignment
- analyse deviation of movement from the efficaient movement
- mm lenght/rom
- stability/ strength
Asees envt influences, ability to do functional tasks and cognition and perception
- compensation strategies
- fitness/ endurance
remember the picture to analyse tone etc
What is the clinical reasoning process behind bobath?
- the process of assessment, goal setting and intervention needs the therapist to explore al the theory assumptions and their knowledge of the evidence
- analysis of movement and tasks leads the therapist to identifying deviations and hypothesizing what is causeing the impairements then exploring these with respect to pt presentation
- setting short and long term goals
Treatment process of babath
- no standard technique
- focus on acquisition of specific components of a movement sequence in different postures, enviroment and contexts
- integration of components into perfomring a task in different settings to ensure carry over
- alignments of key points and limd
- range and pattern of movement
- postural contol
Treat a pt with reduced mobility, stability and or sensory feedback from foot to ankle
poor dynamic stability of trunk on pelvis
- reduced co activation between hamstrings and quads
Individual comps addressed in diff pstural sets before putting them into STS
- eg imrpove trunk and pelvis activity frees upper limb from fixing
- eg sensory stim of the foot can improve activation of the lower limb so this could be done before addressing activity in the leg
Part and whole of the task practiced in different setting will help with achieving the task
- eg working on ability to stand then move to small amounts of lowering and gain ext at hip
- achieve the appropriate alignment of body segments against gravity prior to and during activity
Lack of literature onBobath
What do we need to move?
- maitain upright against gravity. Needs to be able to vary
- length and strength of mm
- balance strategies
- pattern of movt
- speed and accuracy
- strength and endurance
What is bobath about?
- finding what is missing and fixing it
- need to work out what key point influences movement
What postural sets do you need to look at?
- BOS- shape, size, acceptance
- effects/ line gravity
- postural tone
- everyone is different- make sure you look at the entire person- leg equal weight distribution
- if pt has stroke ensure you have moved arm and supported the shoulder
When do u put a t supine or in standing
- if they are very flexed
- want pt to follow you
- block where you dont want pt to move
What are the basic handling approach for the hand?
- hook your fingers around the pts thumb.
- grasp their thenar eminence
- other hand grasps hyperthenar eminence
- wrist ext will tend to activate triceps and shoulder flexors
What are the basic handling approaches for the foot?
- minimal contact with the plantar surface of fot
- easier to approach pt from lateral side of the leg
- left hand for left foot etc
middle 2-3 fingers fan out over the distal portion of their longitudinal arch
- index- grasp medial side ofankle
- thumb over dorsum
- this allow DF and eversion
- makes it easier to activate quads making the leg more active
- other hand on the knee
Correct a pt with poor posture
see page 89 of manual
What can you use the central key point for?
- encourage changes in thoracic posture
- can also influence pelvic position
- can also use for pts who are holding on- can lean them back
Perform a way to get your pt to do anterior pelvic tilt
- use of thumb
Assist lateral pelvic elevation
- important for reaching laterally
- important for moving up and down in bed
- rocking pt onto opp butt checks
- anterior pelvic tilt must be maintained
Assist with bridging
- needed for bed mobility, toileting, exercise glutes and abs
- mass ext pattern
- posterior pelvic tilt then up to bridge
When do you use sitting to treat your pt?
- work on trunk control, scap mobility and control and ability to transfer weight laterally
what are the advantages of using sitting to treat ur pt?
- relatively stable position except for severe pts
- easy access to trunk and shoulder girdle
- elimiated the need to control legs at the same time as trunk
- less postural tone nedded than in standing- good for pts who have difficullty with postural tone
Disadvanage of treating your pt in sitting?
- not always appropriate if you need to work on control hip movement
Why use perched sitting to treat pts
- posture is harder to maintain than sitting but easier than standing
- increase mm demand
- balance tested
- hips more extended- like standing
what are the advantages of treating your pt in perched sititng?
- easy to move to stand to progress the treatment
- can start to work on sit to stand from this posture and lower the bed to increase the challange
- some weight bearing through legs is demanded by this position
Why would you treat your pt with arm supported?
- this posture is often used whe it appears that theweight of thepts arms are preventing them form extending their spine correctly.
- sometimes with the arms taken away the pt is more able to recruit appropriate postural activity
- the therapist can work with them to gain ability to selectively tilt the elvis, transfer weight laterally, and extend the thorax
- the challenge to the pt can be increased by lowering the arms slowly, asking them to slide the arms back and forwards and back on the support surface, and finally asking them to lift the arms off the support surface and lower to the thighs
What is the disadvantage of sitting with arm support?
- the therapist only has access to the posterior aspect of the pt
Why would you put your patient in a forward leaning sitting position?
- the head is supported
What are the advantages of forward lean sitting?
- for pts are unable to extend their supine without extending their neck also, this is a good position to be working on their ability to separate these movements
- well supported posture, pts, usually not anxious about balance
What are the disadvantages of forward leaning sitting?
- poses some challanges for therapists to access the pt-can really only work from behind
Why would you put a pt in crook lying?
- flat back and knees up
- good early position for pts to work on hip extension in
- little postural challange so unlikely to increase tone (note pillows flexing thorax a little and hip/knees flexed- to minimise extensor tone). Great for bridging
- good position to work on the shoulder, and ability to rotate trunk against gravity
Why would you put a pt in prone standing?
- can be used to work on isolated knee control (ie maintaining appropriate extension of the leg without having to worry about maintaining spinal posture)
- the arms may be supported up on the support surface, or be hanging as shown- depending on the characteristics of the pt
- this position gives good access for the therapist to work on aspects of pelvis control (eg anterior/pelvic tilt, lateral weight transference), and knee control.
- usually, the therapist would sit on the inth behind the t.
- the therapist may ensure knee ext of the pt weaker side by circling one of their legs aroung the pts weaker leg
- this support can be reduced as the pts learns to take control. the degree of inclination of the trunk is reduced to increase the challenge of the movements
Stand with arms supported- why would you stand like this to treat ur pt?
- stand with arm support
- progression of prone stand
- used when the weight of the pts arm appears to be making it hard for them to maintain appropriate ext
- this posture can also be used to wrok on leg contol, as the pt is well supported
- the pt should be encouraged not to hold on with arms (to try to avoid them using upper limbs for postural control), but to gently rest on the support
- the central key point is also supported in this posture and the pressure of the support table can be used as sensory feedback to guide correct postural alignment
- to progress, add arm movement, or gradually remove the level of support and ask the pt to take control of the movement
What are the disadvantage of stand with arm support?
- the therapist again can only work behind the pt or to one side
What are the considerations for choice of postural sets?
- mm tone- you dont want to choose a postural set work from that increases abnormal mm tone- either increases it or decreases it
- functional goals- eg if the goal is normal trunk contol in walking, you probably wouldnt choose crook lying
- the functional level that the pt is at. If the pt is very low level, you would be careful about choosing postural sets that require standing
- you want to choose a postural set that provides some level of challenge to the pt without stressing their system too much
See notes for sample cases
- problem solving
- understanding of tone, patterns of movement and postural control for functional task
- active participation required by pt
- therapy- comb between individual, task and enironment
What are the objectives of bobath?
- analyse postural influences in normals in different postural sets
- demonstrate knowledge of key points of control
- demonstrate facilitatory techniques within postural sets
- highlight the importance of providing the correct afferent info to assist with functional gains
- use nackground of normal movement to assist with problem solving and optimizing postural control and movement strategies to maximise clinets ability to interact in the environment
- have knowledge on compensatory strategies can influence efficiency of movement
Key requirements for efficiency of movement
- balance strategies
- patterns of movement
- speed and accuracy
- strength and endurance
See notes for moer on postural sets
How can you determine movement problems through the key points?
- to determine which key point to use to influence movement the person needs to be able to respond to
- eg person must have good postural tone in the trunk to be able to facilitate movement from the hand. If this was not present then trauma to the arm would occur
What are postural sets?
- position or posture of normal symmetry or alignment of key points from which a normal person moves
What are postural sets affected by?
- BOS- size/shape/ acceptance
- effect of gravity
- line of gravity
- postural tone
- tonal influences
- limb patterns
faciliationfor spastic and flaccid pts
Howdo you perform trunk mobilisation?
- rot of one set of key points against another
- to enable pt to take up BOS
- to reduce tome from proximal to distal
- to reintroduce movement between the CKP and PKP- realign the key points, movement from symmetry through to assymetry
- facilitate right reactions and regain balance activity