Intervention Implementation in Children with Cerebral Palsy Based on ICF

1. کارگاه تخصصی رویکرد جدید بوبات در توانبخشی کودکان مبتلا به فلج مغزی Intervention Implementation in Children with Cerebral Palsy Based on ICF Dr. Mohammad KhayatzadehMahani, Assistant Professor in OT Ahvaz Jundishapur University of Medical Sciences Tehran, oct 2017

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 New 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 New 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

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 New 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. New 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. New 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. New 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 New 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. New 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. New 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. New 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. New 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. New Bobath Concept

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

16. کارگاه تخصصیرویکرد جدید بوبات در توانبخشی کودکان مبتلا به فلج مغزیسپاسگزاریم www.farvardin-group.com @farvardin_group_channel @neuroscience4family @farvardin_group96 New Bobath Concept