Ch 24

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(1)Ch 24 Optimizing Motor Behavior Using the Bobath Approach. 職能治療技術學 2008/03/21. 劉倩秀老師.

(2) Glossary Abnormal coordination Abnormal tone Associated reactions Facilitation Flaccidity Handling Inhibition Key points of control Loss of postural control Placing response 劉倩秀老師職能治療技術學 Reflex-inhibiting pattern (RIP) 2008/03/21.

(3) 1. Introduction History and Principles Definitions of Terms and Constructs Movement control problems after stroke NeurDevelopmental Treatment of Patients with stroke Relationship to Occupational Functioning. 2. Evaluation and Treatment Planning Assessment in the NDT / Bobath Approach Treatment goals for the stages of recovery. 3. Treatment techniques: Integrating NDT/Bobath into 劉倩秀老師職能治療技術學 occupational therapy practice 2008/03/21.

(4) Bobath and B. Bobath developed a treatment approach designed to increase normal movement patterns in children with cerebral palsy (腦性麻痺)and adults with acquired hemiplegia (半側癱瘓). Their treatment is known as the Bobath approach or Neuro-Developmental Treatment (NDT). 職能治療技術學 2008/03/21. 劉倩秀老師.

(5) Introduction –. Definitions Terms and Constructs Hemiplegia is associated with two categories of motor problems: the loss of normal movement responses the development of abnormal tone and movement. 職能治療技術學 2008/03/21. 劉倩秀老師.

(6) Movement Control Problems after Stroke. Loss of normal movement responses Patients with hemiplegia may demonstrate. loss of postural control, or inability to activate muscles automatically to maintain the body in balance at rest and during movement, and loss of selective movement control of the muscles controlling movement of the hemiplegic arm and leg. Loss of postural control is associated with difficulty shifting weight, maintaining a stable body position against gravity, and activating equilibrium responses when balance is challenged. 劉倩秀老師. 職能治療技術學 2008/03/21.

(7) Cont.. F24.1 poor postural control while with a cane. 職能治療技術學 2008/03/21. 劉倩秀老師.

(8) Cont.. Bobath and Bobath identified abnormal tone as the second major problems interfering with movement control and function in hemiplegia. Muscle tone that is higher or lower than normal Patients demonstrate flaccidity, or hypotonia, when tone is lower than normal. Flaccidity is generally present immediately after the stroke. Spasticity, or hypertonia, develops gradually in selected muscles of the affected trunk, arm, and leg and is characterized by excessive muscle stiffness and slow effortful movement. 職能治療技術學 2008/03/21. 劉倩秀老師.

(9) Cont.. Spasticity is often accompanied by. associated reactions, which are involuntary, nonfunctional changes in limb position associated with the performance of difficult or stressful activities. F24.2 associated reaction in the hemiplegic arm while walking 職能治療技術學 2008/03/21. 劉倩秀老師.

(10) Cont.. Bobaths also emphasized that sensory. disturbances may contribute to abnormal coordination and decreased motor control.. 職能治療技術學 2008/03/21. 劉倩秀老師.

(11) Cont.. Bobath and Bobath recognized that sensation was necessary for motor. coordination and motor learning, and their treatment techniques use. sensory information as part of the process of reeducating normal movement.. 職能治療技術學 2008/03/21. 劉倩秀老師.


(13) 治療原則 Definition 24-2 NDT/Bobath Principles of Treatment. The goal of treatment is to retain normal movement responses on the patient’s hemiplegic side The therapist should avoid activities and exercises that increase abnormal tone or strengthen abnormal movement responses and should use treatment techniques to suppress or eliminate these patterns 職能治療技術學 2008/03/21. 劉倩秀老師.

(14) The therapist should use treatment activities and exercises that encourage or strengthen normal movement patterns in the patient’s trunk and extremities The therapist should help the patient use existing motor control on the hemiplegic side for occupational performance. 職能治療技術學 2008/03/21. 劉倩秀老師.

(15) the therapist should develop compensations and adaptations that encourage use of the affected side and decrease the development of abnormal movement and asymmetrical postures.. 職能治療技術學 2008/03/21. 劉倩秀老師.

(16) 治療手法 NDT/Bobath treatment uses manual techniques to address the problems of tone and movement control and to provide sensory messages about how movement is organized and executed. Handling Manual techniques designed to change muscle tone and normalize movement. Handling including 職能治療技術學 2008/03/21. inhibition and facilitation 劉倩秀老師.

(17) Facilitation: manual techniques and other processes including tactile and verbal feedback used to help the patient achieve a more normal quality of movement. Inhibition: manual techniques and positions used to decrease or eliminate the effects of spasticity and abnormal coordination 劉倩秀老師職能治療技術學 2008/03/21.

(18) Procedures for practice 24-1 NDT Handling Techniques. Inhibition techniques are used to: Decrease abnormal muscle tone that interferes with passive and active movement Restore normal alignment in the trunk and extremities by lengthening spastic muscles Stop unwanted movements and associated reactions from occurring Teach methods for decreasing the abnormal posturing of the arm and leg during task performance 職能治療技術學 2008/03/21. 劉倩秀老師.

(19) Facilitation techniques are used to: Provide the sensation of normal movement on the hemiplegic side Provide a system for relearning normal movements of the trunk, arm, and leg Stimulate muscles directly to contract isometrically, eccentrically, or isotonically. Allow practicing movements while the therapist maintains some constraints. Teach ways to incorporate the involved side into functional tasks and occupations. 職能治療技術學 2008/03/21. 劉倩秀老師.

(20) Key points of control Hand placements used to influence the quality of posture and movement Proximal key points are used to influence posture and movement of trunk, shoulder girdle, hip Distal key points are used to control the position of the distal extremities F 24.3 職能治療技術學 2008/03/21. 劉倩秀老師.

(21) B. Bobath believed that therapists should not attempt to retrain normal movement response until spasticity is minimized…. 先抑制痙攣，在訓練正常動作….. Inhibition techniques often use reflex-inhibiting. patterns (RIPs) , a term for patterns that counteract the pull of tight or spastic muscles. Spasticity may also be inhibited by using weight bearing and trunk rotation to lengthen shortened muscles. 職能治療技術學 2008/03/21. 劉倩秀老師.


(23) Relationship to Occupational Functioning. 1. Occupation-as-end 1. Occupation-as-means. 職能治療技術學 2008/03/21. 劉倩秀老師.

(24) Relationship to Occupational Functioning. Occupation-as-end activities such as dressing, grooming, and bed mobility These techniques are designed to maintain symmetry and bilaterality and to encourage patients to activate their trunk muscles and incorporate their involved extremities into task performance.. reject. NDT/Bobath approach s the use of one-sided compensations, emphasizing instead that patients should perform tasks in ways that use the hemiplegic 劉倩秀老師 side. 職能治療技術學 2008/03/21.

(25) Occupation-as-means The NDT therapist frequently uses actual tasks or parts of tasks in occupation-as-means treatment to increase postural control or improve strength and coordination in hemiplegic arm. For example, in the sitting position, the therapist may use activities that require weight shifts over the body’s base of support to increase control of the postural muscles of the trunk and the lower extremity. F24.4 職能治療技術學 2008/03/21. 劉倩秀老師.

(26) F24.4 Patient swinging a tennis racquet to increase control of trunk. 職能治療技術學 2008/03/21. 劉倩秀老師.


(28) Procedures for practice 24-2. NDT/Bobath Evaluation and Treatment Planning. 1. Identify abilities and functional capabilities. Include movements of both the arm and leg, postural patterns of the trunk, and functional independence in life skills. How does the patient accomplish these functions? 2. Identify functional limitations, including functions that the patient cannot perform that are necessary for improved independence and quality of life. 職能治療技術學 2008/03/21. 劉倩秀老師.

(29) 3. Determine what problems interfere with movement control and functional performance, such as : Abnormal tone Abnormal coordination Loss of postural control Loss of selective movement control Loss of or changes in sensation. 職能治療技術學 2008/03/21. 劉倩秀老師.

(30) 4. Establish functional goals and treatment goals. Identify the functions that the patient will be able to learn to perform within an established timeframe. Indicated whether performance will involve compensation or use of the involved side with normal coordination. Identify the impairments that you will need to address to meet the functional goal. 職能治療技術學 2008/03/21. 劉倩秀老師.

(31) 5. Based on the patient’s response to handling, determine where to begin treatment. What techniques of inhibition and facilitation will be used?. 職能治療技術學 2008/03/21. 劉倩秀老師.

(32) The NDT therapists uses handling to identify…… For example, the therapist tests postural control by facilitating trunk movements, equilibrium reactions, and protective responses with the patient sitting and standing F 24.5 therapist using handling to test equilibrium reactions 職能治療技術學 2008/03/21. 劉倩秀老師.

(33) Placing response 置放反應 Part of the normal system of postural adjustments to changes in position, characterized by automatically maintaining a position when support is removed. B. Bobath referred to this as the placing is possible when muscle. tone is in the normal range and muscle strength is available to support movement 職能治療技術學 2008/03/21. 劉倩秀老師.

(34) Quiz 對象？ Handling Facilitation technique Inhibition technique. Key points of control RIP Placing response 職能治療技術學 2008/03/21. 劉倩秀老師.


(36) Treatment Goals for the Stages of Recovery NDT goals focus on increasing independence in self-maintenance roles, preventing the development of abnormal tone and abnormal movements, and increasing motor control on hemiplegic side.. 職能治療技術學 2008/03/21. 劉倩秀老師.


(38) Treatment techniques: integrating NDT / Bobath into occupational therapy practice. Treatment of the hemiplegic arm 1. Use of inhibition 2. Facilitation in arm treatment 1. Facilitation of weight bearing 2. Facilitation of arm movement 3. Arm treatment in supine 4. Arm movement in sitting 5. Using occupation-as-means in arm treatment. 3. Occupation-as-end treatment 職能治療技術學 2008/03/21. 劉倩秀老師.

(39) Use of inhibition Goal: Maintain muscle length and normal joint mechanics in the arm Prevent the development of spasticity and abnormal coordination. Methods 1. RIP A position that is used to inhibit spasticity by lengthening shortened muscles Practice 24-3. 2. Positioning. 職能治療技術學 2008/03/21. 劉倩秀老師.

(40) Inhibition of spasticity in the hemiplegic arm use RIP. 職能治療技術學 2008/03/21. 劉倩秀老師.

(41) Positioning Positioning the flaccid hand Elbow extension Shoulder girdle abduction and external rotation. 職能治療技術學 2008/03/21. 劉倩秀老師. Maintain muscle length Counteract the development of flexor spasticity.


(43) Facilitation of weight bearing Weight bearing of hemiplegic arm Maintaining muscle length, normalize tone, increase activity in the muscles of trunk and arm. Weight is a dynamic process, patient active muscles in the trunk by moving body weight over the stable arm Weight bearing activities Weight on the hemiplegic arm with forearm on a table while eating, reading, writing Extended-arm weight bearing activities while sitting, standing (kitchen, bathroom) 劉倩秀老師職能治療技術學 2008/03/21.

(44) 職能治療技術學 2008/03/21. 劉倩秀老師.


(46) (2) Facilitation of arm movement The process of facilitation 1. Restore alignment of the segments to be moved using key points of control 2. Assist the desired movement using light hands 3. Proceed slowly and feel for the patient’s response. The arm will feel lighter and movement easier when the patient is assisting. 4. Repeat movements until patient can actively assist and you feel the patient is active 5. Lighten messages of your hands so that the patient moves with less assistance. Give verbal feedback during this phase.. 6. Gradually withdraw control. 7. Provide practice opportunities through use of activities 劉倩秀老師職能治療技術學 2008/03/21 (occupation-as-means) or home exercise.

(47) (3) Arm treatment in supine Supine Is the easiest position for patients with loss of postural control and weakness to practice moving their arms. F 24-12 Facilitate arm movements in supine Proximal and distal key points Check scapula rotation before elevating the arm above 60 of shoulder 劉倩秀老師職能治療技術學 2008/03/21 flexion.

(48) Place and hold technique Therapist moves patient’s extended arm slowly and feels the point of patient begin to follow her movement Ask the patient to try to hold the arm in position 職能治療技術學 2008/03/21. 劉倩秀老師.

(49) Arm movement in sitting Shoulder subluxation The muscles of the hemiplegic arm are too weak to hold the scapula in the correct position on the trunk and the loss of trunk control also affects scapula alignment. 職能治療技術學 2008/03/21. 劉倩秀老師.

(50) Restoring normal joint mechanism to the shoulder subluxation. 1. Place One hand under the axilla to support the inferior portion of the shoulder joint Other hand on the patient’s scapula to correct the position of the upper trunk and to rotate the scapula upeard 職能治療技術學 2008/03/21. 劉倩秀老師.

(51) 2. Hold the corrected shoulder position with one hand, move the other hand to the distal humerus. Gently lift the humerus up into the glenoid fossa.. 3. Move the humerus into neutral or slight external rotation 4. Check that the scapula can rotate before moving the arm above 60 of foreward flexion 5. Maintain correct scapulohumeral rhythm during active and passive arm movements 職能治療技術學 2008/03/21. 劉倩秀老師.

(52) Using occupation-as-means in arm treatment Using occupation-asmeans To practice and strengthen movement control in the hemiplegic arm. 職能治療技術學 2008/03/21. 劉倩秀老師.

(53) 職能治療技術學 2008/03/21. 劉倩秀老師.

(54) 3. occupation-as-end treatment Occupational therapist incorporate NDT/Bobath principles into occupationas-end training of ADL and other task by using specific compensations that support the goals of handling Rolling in bed Dressing. 職能治療技術學 2008/03/21. 劉倩秀老師.

(55) Rolling in bed Clasped-hand grasp Maintain the hemiplegic forearm in an extended position. Rolling to the uninvolved side with clasped hand grasp Initiate rolling by actively using her trunk muscles. 職能治療技術學 2008/03/21. 劉倩秀老師.

(56) Dressing Flex the trunk foreword and reach the hemiplegic arm to the floor This passively maintain extension in the arm for some patients with flexor posturing of the arm during task performance 職能治療技術學 2008/03/21. 劉倩秀老師.

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