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1. Intervention Implementation
in Children with Cerebral
Palsy Based on ICF
Dr. Mohammad Khayatzadeh Mahani, Assistant Professor in OT
Ahvaz Jundishapur University of Medical Sciences
Tehran, oct 2017
1
‫تخصصی‬ ‫کارگاه‬‫جدید‬ ‫رویکرد‬‫بوبات‬‫در‬
‫توانبخشی‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬

2. Sequence of Intervention
• Preparatory activities for passive movement or body
alignment
• Selection of the key points for therapeutic handling
according to the child’s postural tone
• Facilitation of active or automatic movement patterns
by applying graded and varied therapeutic input
2New Bobath Concept

3. Single system Preparation
 Regulatory system: The child, Environmental modification,
Contextual interference
 Sensory systems: Preferred sensory system, Apply sensory
input, Multi sensory approach.
 Musculoskeletal system
 Optimize muscle/tendon/ligament/ fascia length through
active and passive stretching, using orthosis
 Improve muscle strength through gradual increase weight
(milk bottle), resistance
3New Bobath Concept

4. Single system Preparation
 Neuromuscular system
 Spasticity/stiffness: increase the types, intensity, and
frequency of inhibitory inputs with handling strategies, such as
by providing firm, sustaining, deep pressures into the muscle
belly or at its origin or insertion. / multidirectional movement
 Facilitate the activation of postural muscles, Sustain a
coactivation pattern
 Concentric, isometric, or eccentric muscle contractions
 Gradation
 Timing, sequencing, and muscle synergies
 Respiratory system
 Gastrointestinal (GI) system New Bobath Concept 4

5. Multi system Preparation
 Postural alignment
 Base of Support: small/Large, height, progressive
challenge
 Center of Mass: To maintain balance or have efficient,
effective postures and movement, the COM must be
controlled over the BOS.
 Symmetry
 Balance
 Weight shifting
5New Bobath Concept

6. Therapeutic handling
 Therapeutic handling, used during evaluation and
intervention, consists of a dynamic reciprocal interaction
between the client and therapist for activating optimal
sensorimotor processing, task performance, and skill
acquisition to enable participation in meaningful
activities.
6New Bobath Concept

7. Therapeutic Handling
 Handling involves placing the hands (and sometimes forearms or segments of
the trunk and lower extremities) in physical contact with the client to sense
the following:
 Muscle initiation and how long the muscle stays in contraction.
 How many muscles contract together and the order of recruitment.
 Stiffness and compliance of body segments.
 Joint stability/instability.
 Reactions to graded support of a body segment.
 Active weight shifting initiated by the client, which assists in determining
which muscles and body segments participate.
 Sensitivity and reactivity to tactile and deep-pressure contact.
 Respiratory pattern, timing, and rate.
 The speed and ease (or difficulty) of change in any of the above.
7New Bobath Concept

8. Key Point of Control (KPC)
 Within the NDT framework of practice, where the therapist
places his hands is referred to as a key point of control (KPC).
 The key points can include the therapist’s hands on the individual
but can also include any avenue of contact.
 KPCs can be unilateral or bilateral, proximal or distal,
symmetrical or asymmetrical.
 The therapist’s hands should be viewed as a clinical tool; a piece
of therapeutic equipment.
 The therapist’s hands can provide minimal tactile cues to guide a
movement or can provide deeper proprioceptive information
relative to the individual’s alignment, base of support, or need
for postural stability or active movement.
 The input from the therapist’s hands can facilitate stability or
movement or can inhibit stability or movement. 8New Bobath Concept

9. Body structure and function: Intervention for Postural
System Weakness
 Position weak postural muscles in their shorter range.
 Activate an isometric contraction (holding) in the shorter
range.
 Elicit a postural response using small movements of the
center of gravity (COG) over the BOS.
 Keep resistance low during holding.
 Activate small excursion movements of the proximal
segment on the distal segment in weight bearing.
 Position weak postural muscles in their shorter range
9New Bobath Concept

10. Body structure and function: Therapeutic Principles for
Progression of Strengthening in the Postural System
 Activate postural muscles from short- to midrange
positions—avoid long ranges until holding is strong.
 Activate slow and limited-range eccentric contractions
progressing to the longer ranges.
 Increase resistance gradually.
 Increase the excursion of movement.
 Introduce higher loads of weight bearing.
10New Bobath Concept

11. Body structure and function: Therapeutic Principles
of Weakness in the Movement System
 Select activities that require shortening (isotonic)
contractions that start in the long range and go through
the full range.
 Encourage isotonic contractions at a variety of speeds.
 Keep resistance low enough that it does not prevent
movement.
 Encourage wide-excursion movements.
 Activate the movement system through the use of verbal
commands and visual and tactile stimuli.
 Rest movement system muscles in a long but not extreme
length.
11New Bobath Concept

12. Body structure and function: Therapeutic Principles for
Progression of Strengthening in the Movement System
 Vary the starting position so that movement can be initiated from any length.
 Continue with isotonic contractions through the range, varying the speed.
 Increase resistance through the use of gravity, longer levers, less assistance,
and amount of weight of grasped objects.
 Include isometric activity to strengthen movement muscles after isotonic
strength is well established.
 Use Closed chain and open chain training
 use of theraband, theratube, weight cuff, stationary bike, treadmill, medicine
ball, …
 Aerobic
 Plyometric
 Aquatic
 Whole Body Vibration (WBV)
 Core stability: Ball, TRX
 Circuit Training: treadmill walking, step-ups, sit-to-stands and leg presses. 12New Bobath Concept

13. Body structure and function: Therapeutic Principles for
Activities Requiring the Integration of the Posture and
Movement Systems
 Activate visual, auditory, and tactile orienting followed by
exploration.
 Include in the program transitional functional activities
that require integration of posture and movement.
 Activate the postural system to guide the movement
system.
 Use a sequence of stability/mobility functions to guide
the choice of integrated activities.
13New Bobath Concept

14. Carry over
 Active participation by child, with gradual reduction in
handling or assistance.
 Self correction and self initiation.
 Simulation
 Functional Task
 Training/education of parents to carry over home
activities.
14New Bobath Concept

15. Activity and Participation
 Assistive technology/ Equipment
 Home program/ modification or adaptation
 Occupation based intervention( ADL, Play, sport)
 Family centered practice
15New Bobath Concept

16. New Bobath Concept 16
‫تخصصی‬ ‫کارگاه‬
‫جدید‬ ‫رویکرد‬‫بوبات‬‫توانبخشی‬ ‫در‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬ ‫کودکان‬
‫سپاسگزاریم‬
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@farvardin_group_channel
@neuroscience4family
@farvardin_group96