motor control approaches in Bobath (NDT)

From Cole, M. Applied theories in occupational therapy: a practical approach instructor's manual. Online document, http://www.efacultylounge.com,
based on Cole, M. (2008). Applied theories in occupational therapy: a practical approach. Thorofare, NJ: SLACK Incorporated.
Motor Control approaches
Neurodevelopmental Theorists/Theories:
Catherine Trombly, Task-Focused,
Motor Learning, Margaret Rood,
The Bobaths (NDT), Signe Brunnstrom, PNF,
Carr & Sheppard
Reference: Cole & Tufano, Chapter 19
‫در‬ ‫شده‬ ‫ارائه‬:
‫رویکرد‬ ‫تخصصی‬ ‫کارگاه‬‫جدید‬‫بوبات‬‫در‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬ ‫توانبخشی‬
‫ارائه‬ ‫و‬ ‫تهیه‬:‫زاده‬ ‫خیاط‬ ‫محمد‬ ‫دکتر‬
‫پاییز‬96

FOCUS
 Neuroanatomy & Neurophysiology
 Principles of Neuroscience
 Treatment of paralysis, flaccidity & spasticity
of muscles resulting from damage or disease
to the central nervous system
 Treatment of Movement disorders
 Framework focus: body structures, body
functions, process skills, contexts, and activity
demands.

Basic Assumptions
 Each theorist has a somewhat different
approach, assessment technique, and
intervention strategies.
 Most neurodevelopmental approaches
require specialized training.
 These theorists use a behavioral learning
approach to motor control based on the
sequence normal developmental.

Assumptions: Traditional Theories
 The remainder of the theories are currently
known as “hierarchical” or “traditional” theories
of motor control, including
 Rood
 The Bobaths – NDT
 Brunnstrom
 Proprioceptive Neuromuscular Facilitation (PNF)
 Carr & Shepherd

Basic Assumptions, cont.
 Margaret Rood, the earliest theorist, is both
an occupational and physical therapist. She
stresses the importance of early reflexes in
the relearning of motor control.
 Rood first used her techniques effectively with
children with cerebral palsy.
 She believed that a baby uses reflexes to
move initially but modifies them and
eventually replaces the reflexes with
voluntary movement.

Rood, 4 Basic Principles
 Sensory input is required for normalization of
tone and evocation of desired muscular
responses.
 Sensory motor control is developmentally
based.
 Movement is purposeful, engagement in
activities is required to produce a normal
response.
 Repetition of movement is necessary for
learning.

Rood, cont.
 Facilitation techniques: light stroking,
brushing, icing, and joint compression are
used to facilitate movement.
 Inhibition techniques: joint approximation
(light compression), neutral warmth, pressure
on tendon insertion, and slow rhythmical
movement are used to inhibit unwanted
movement (i.e., spasticity).

Rood identified 8 ontogenetic motor
patterns in the following sequence
1. Supine withdrawal
2. Segmental rolling
3. Pivot prone (prone extension)
4. Neck co-contraction
5. Supporting self on elbows
6. All fours movement patterns
7. Standing
8. Walking

Rood, cont.
 Positioning is a primary concern, especially
when little voluntary control exists.
 Extensive use of mats, bolsters, balls, and
other specialized equipment is common in the
Rood approach.
 Movement patterns can be incorporated into
games, such as tug of war, to provide an
occupational focus to regaining motor control.

The Bobaths, Drs. K. (physiologist) &
B. (physiotherapist), British - 1948
 AKA Neurodevelopment Treatment (NDT)
 Originally designed their therapy techniques
for persons with hemiplegia (caused by CVA,
or stroke)
 Also worked with children with cerebral palsy
 NDT focuses on the sensation of movement;
it is not movement itself, but the sensation of
movement, that is learned and remembered

Bobaths, cont.
 Reflex inhibiting postures are used to inhibit primitive
reflexes (RIPs).
 Sensory stimulation is regulated with great care.
 Weight bearing, placing and holding, tapping and
joint compression are used to activate normal
movement and posture.
 Compensation (such as one-handed feeding and
dressing) using the noninvolved side is discouraged
during recovery from stroke because it results in
inactivity and poor recovery on the involved
(paralyzed) side.

Brunnstrom, Signe - physical therapist,
1950-1970s
 Focuses on reflexes which provide the components
of normal movement
 Proprioceptive (resistive) & exteroceptive (tactile)
stimulation are used to elicit reflexes in the
recovering adult hemiplegic
 Patients are encouraged to think about the
movement and to gain control
 Brunnstrom also uses associated reactions and
synergies
 A synergy is a total flexion or extension movement of
a joint or limb

Brunnstrom’s 6 Stages of Recovery
1. Flaccidity, no voluntary movement
2. Synergies or minimal voluntary movement
3. Synergies performed voluntarily
4. Some deviation from synergy
5. Independent or isolated movement
6. Individual joint movement nearly normal with
minimal spasticity

Proprioceptive Neuromuscular
Facilitation (PNF)
 Developed by Herman Kabat, PhD, MD and
modified by many contributors since the ’40s
 Uses diagonal & spiraling patterns of
movement
 Guides thinking about the sequence of
normal development
 Eleven basic principles (see Cole, p. 242)
 Uses two diagonal patterns crossing the mid-
line for each major body part, often
incorporating verbal commands.

Carr & Shepherd’s Motor Relearning
Programme (for persons with stroke)
 Contemporary approach (1990s)
 Uses dynamical systems model of motor
control
 Emphasize interaction between performer
and environment
 Does not accept the hierarchical sequence of
motor relearning proposed by other theorists
 Like other theorists, Carr & Shepherd
discourage the early use of compensatory
strategies

Carr & Shepherd, cont.
 Clients taught to avoid abnormal
compensation for weak muscles
 Treatment techniques based on extensive
study of how normal movement occurs during
functional tasks
 Acknowledge critical role of cognition in motor
learning
 Movement patterns practiced in context of
tasks, rather than exercises

Carr & Shepherd, 7 Categories of
Functional Daily Activities
1. Upper limb function
2. Orofacial function
3. Sitting up over the side of the bed
4. Balanced sitting
5. Standing up & sitting down
6. Balanced standing
7. Walking

Function and Dysfunction
 Function assumes the ability to plan and
execute normal voluntary movement
 Dysfunction is viewed as neurophysiologically
based; CNS deficits result in abnormal
muscle tone and lack of voluntary purposeful
movement
 Each theorist has a separate way to measure
the extent of dysfunction

Change
 Changes in motor control are physiologically induced.
 Engagement in activity can produce physiological
change leading to motor control
 Individuals relearn movement patterns in a
predictable developmental sequence
 Theorists differ in the use of early reflexes to produce
movement
 Handling, sensory stimulation, and manipulation of
affected muscles can facilitate motor relearning

Assessment and Treatment
 Specific to each theorist
 These “traditional” models have also been
called “reflex-hierarchical” or
“neuromaturational” because they are based
on “relearning” movement in a normal
developmental sequence.
 New evidence tends to disprove the
effectiveness of these approaches.

Transition from Motor Control to
Motor Learning
 Began in 1990s with classic article by
Mathiowetz & Bass Haugen, and Trombly’s
Slagle Lecture.
 The following introduces Trombly’s model as
changing OT’s thinking about establishing or
restoring voluntary movement.

Task Focused Approach: Trombly
 Occupational Functioning Model – introduced
in 1995
 Descending hierarchy of tasks & roles
 Goal is to develop competency & self-esteem
 Context & environment surround and -
permeate all levels of the hierarchy
 When clients have mastered the foundation
capacities, they move on to task-focused
interventions (individual or group)
 Trombly calls this “occupation as end”

Task Focused Approach, cont.
Five general principles:
 1. Client centered focus
 2. Occupation based focus
 3. Person & Environment – enablers/barriers
 4. Practice & Feedback - encoding
 5. General treatment goals – role fulfillment,
problem-solving skills re: best way to
accomplish valued tasks

Dynamical Systems Theory &
Trombly
 Applied to physical disabilities, this theory
combines reflexive and voluntary motor
control
 CNS receives/interprets multiple cues from
the environment and involves multiple
subsystems when planning to reach desired
goals (preferred tasks & roles)
 Occupational performance is a product of the
interaction between the person, the task, and
multiple environmental factors.

Assumptions: Task Focused Approach
 Trombly’s task focused approach is based on
theories of motor learning and dynamical
systems theory.
 Meaningful tasks are graded and sequenced
according to each client’s needs & abilities.
 Each task requires experimentation using
different strategies & contexts in order for
motor skills to be learned.
 Currently the preferred approach in OT for
intervention after stroke/CNS damage

The End
 Next time: Motor Learning Frame of
Reference in OT

‫تخصصی‬ ‫کارگاه‬
‫جدید‬ ‫رویکرد‬‫بوبات‬‫توانبخشی‬ ‫در‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬
‫سپاسگزاریم‬
www.farvardin-group.com
@farvardin_group_channel
@neuroscience4family
@farvardin_group96

motor control approaches in Bobath (NDT)

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