New Bobath Concept (NDT)

1. کارگاه تخصصی رویکرد جدید بوبات در توانبخشی کودکان مبتلا به فلج مغزی New Bobath Concept (NDT) Dr. Mohammad KhayatzadehMahani, Assistant Professor in OT Ahvaz Jundishapur University of Medical Sciences Tehran, Oct 2017

2. Origins of Theoretical Approach New Bobath Concept • NDT, first known as “The Bobath approach” was originated and developed by Berta Bobath, physiotherapist, and Dr. Karel Bobath in the late 1940s • Name Bobath is still used in many countries, NDT is the name commonly used in North America

3. NDT New Bobath Concept • Advanced hands-on approach to the examination and treatment of individuals with disturbances of function, movement and postural control due to a lesion of the central nervous system(CNS) • Used primarily with children who have cerebral palsy (CP) and adults with cerebral vascular accidents (CVA) • Practiced by OT, PT, SLP who completed advancedtraining in NDT

4. NDT Definition New Bobath Concept NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. The therapist uses the ICF model in a problem-solving approach to assess activity and participation, thereby to identify and prioritize relevant integrities and impairments as a basis for establishing achievable outcomes with clients and caregivers.

5. Therapist’s Prerequisite skills in NDT New Bobath Concept Analytic skills, including the ability to see relationships among participation, activity, and posture/movement multi- and single-body system integrities under a variety of contexts using basic and applied sciences, experience, and expertise. Clinical reasoning skills. The ability to determine a range of prognoses, taking all factors into account and correlating to outcomes. The ability to set functional and measurable outcomes for intervention.

6. Therapist’s Prerequisite skills in NDT New Bobath Concept The ability to plan general intervention strategies that will address participation restrictions, activity limitations, and body system impairments. The ability to determine a realistic episode of care to meet the outcomes. The ability to design a home program to reinforce and practice effective posture and movements within daily routines. Knowledge of assistive technology that facilitates participation and activity. The ability to work on a team and value the opinions and priorities of others. The ability to plan reexamination, reevaluation, and discharge.

7. NDT Subsystems New Bobath Concept • An in-depth knowledge of the human movement system and motor control • Principles of motor learning • Understanding of typical and atypical development • Expertise in analyzing • Postural control • Movement • Activity, and participation (ICF)

8. Philosophical Tents of Bobath Concept New Bobath Concept Therapy works Treat the Individual as a Whole The Purpose of Therapy Is to Increase the Individual’s Participation and Activity Build on the Individual’s Strengths while Addressing Impairments Individualize Intervention Treat in the Past, Present, and Future Simultaneously Teamwork Is Critical for Best Care Typical Development Provides an Important Framework for Examination and Intervention Active Carryover throughout Daily Life Is Important for Best Care NDT Reflects a Hands-on Intervention Process to Enhance Outcomes The Living Concept: The Integration of Classic NDT Tenets with Current Scientific Findings and Principles of Neuroplasticity, Motor Control, Motor Development, and Motor Learning

9. Therapy works New Bobath Concept • Evans-Rogers et al reported on outcomes of short-term intensive NDT intervention based on parental perspectives and functional outcomes • Girolami and Campbell reported on the efficacy of NDT treatment for infants born prematurely and found improved motor control • Arndt et al report on the effectiveness in an NDT based trunk protocol in infants. • Tsorlakis et al showed the effectiveness of NDT and underline the need for intensive application of the treatment.

10. NDT Critics New Bobath Concept • Butler et al(2001) • More intensive therapy did not seem to confer a greater benefit • There was also no clear evidence that NDTproduced other potential benefits such as enhancement ofsocial–emotional, language, or cognitive domains of development, better home environments, improved parent–childinteractions, or greater parent satisfaction • There was notconsistent evidence that NDT changed abnormal motoricresponses, slowed or prevented contractures, or that it facilitated more normal motor development or functional motor activities

11. NDT Critics New Bobath Concept Diane L. Damiano(2009) Therapies that involve multiple types of exercises, such as NDT are an issue from a scientific standpoint because they each have multiple components that are likely to have varying degrees of evidence. These programs should be dissected so that the active ingredients can be identified and retained if superior to other alternatives and ineffective ones discarded. The fact that NDT has failed to demonstrate superiority over any alternative treatments to which they have been compared is also a concern

12. NDT Critics New Bobath Concept Novak et al(2013) regarding contracture, high-quality RCTs showedthat casting was a superior treatment to NDT regarding tone reduction, the highest quality evidence suggested that NDT was ineffective for this indication and other evidence shows BTX exists as a highly effective alternative NDT is time-consuming and expensive for families, and, what is more, a high-quality RCT shows that substantially better functional motor gains are achieved from motor learning than from NDT at equal doses

13. New Bobath Concept

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15. ICF Model New Bobath Concept

16. Body structure and function New Bobath Concept Body functions are physiological functions of body systems, including psychological functions Body structures are anatomical parts of the body, such as organs, limbs and their components Impairments are problems in body functions or structure such as a significant deviation or loss

17. Body Function New Bobath Concept

18. Activity and participation New Bobath Concept Activity is the execution of a task or action by an individual Participation is involvement in a life situation. Activity limitations are difficulties an individual may have in executing activities Participation restrictions are problems an individual may experience in involvement in life situation

19. Activity New Bobath Concept

20. Participation New Bobath Concept

21. Contextual factors New Bobath Concept Personal factors: These factors may include gender, race, age, other health conditions, fitness, lifestyle, habits, coping styles, social background, education, profession, past and current experience. Environmental factors: These factors are external to individuals and can have a positive or negative influence on the individual’s performance as a member of society, on the individual’s capacity to execute actions or tasks, or on individual’s body function or structure

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23. Body structure and function New Bobath Concept

24. Activity and participation New Bobath Concept

25. Contextual factors New Bobath Concept

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27. Body structure and function New Bobath Concept

28. Activity and participation New Bobath Concept

29. Contextual factors New Bobath Concept

30. NDT Assumptions Based on Theories of Motor Control New Bobath Concept Movement is organized around functional activity. Human motor behavior/function emerges from ongoing interactions among multiple internal systems of the individual, the characteristics of the task, and the specific environmental context. The critical systems to be addressed during examination and intervention will vary client to client, as well as vary with the same client in different environments or on different days.. All individuals have elements on the health or wellness end of the spectrum in all of the various domain described in the ICF.

31. NDT Assumptions Based on Theories of Motor Control New Bobath Concept A hallmark of human motor function is the variability of posture and movement organization to meet functional demands. The neural control for movement is distributed throughout various levels of the central nervous system (CNS), all contributing to the final motor outcome. Plasticity in all systems exists across the lifespan. The brain can maximize remaining functions and/or compensate for the loss of function in the event of neuropathology. The nervous system has the ability to reorganize in response to intrinsic or extrinsic stimuli.

32. NDT Assumptions Based on Theories of Motor Control New Bobath Concept Intervention strategies can be designed to capitalize on the brain’s ability to modify functions based on experience and the environment. There are anatomically and functionally distinct yet overlapping and interactive structures and function to control and coordinate posture and movement during activity. The postural system provides the ability to maintain the upright position against gravity through vertical lift. Postural responses also maintain the center of mass (COM) over the base of support (BOS). In addition to the whole body responses, the postural system maintains the integrity of the joint structure. The term stability describes much of the goal of the postural system.

33. NDT Assumptions Based on Theories of Motor Control New Bobath Concept The movement system is a primary controller to overcome inertia and is also needed when a wider range and faster speed of motor responses are required. The term mobility describes the goal of the movement system. Posture and movement represent a continuum but are organized by different descending systems. Posture is organized through the medial descending systems and movement through the lateral descending systems. There are distinctions between motor unit types as well as muscle architecture that correlate with a postural versus a movement system.

34. Motor Control Approaches New Bobath Concept Neuromaturational theories Reflex/Hierarchical Theory Generalized Motor Program Theory Dynamic System Theory Neuronal Group Selection Theory

35. Reflex/Hierarchical Theory New Bobath Concept This theory assumed that the structures of the brain were organized and developed in a hierarchy and that there was a fixed relationship between function and structure. Each successively higher level of brain structures provided more precise movement integration. Therefore, as these structures developed, function changed accordingly.

36. Reflex/Hierarchical Theory New Bobath Concept The lowest level of fundamental movement patterns were sensory-elicited reflexes, which were then integrated into the automatic postural reflex mechanism as the higher brain levels developed. These automatic movements, including righting and equilibrium reactions, were considered to be the basis for skilled voluntary movements.

37. Reflex/Hierarchical Theory New Bobath Concept The R/HTs helped to explain the stereotypic movements and postures seen in persons with neuropathology. These were acceptable neural control models until the late 1960s and, although they did offer explanations for predictable movement seen in cerebral palsy (CP), their limitation was that they did not account for context-based movement, variability, individuality, novelty, and context-based behaviors.

38. Generalized Motor Programs (GMPs) New Bobath Concept Instruction are specified by the CNS Control process is managed by a motor program Motor program organizes, initiates, and carries out intended actions Linear changes in movement behavior

39. Generalized Motor Programs (GMPs) New Bobath Concept Keele proposed the existence of a set of commands in the CNS named Generalized Motor Programs (GMPs) , which were assembled and initiated without sensory input and performed in the absence of peripheral feedback. GMPs contain the abstract representation of movement, including the commands for movement, codes of action, and general features of movement sequences as well as the recruitment of appropriate agonists and synergists with adjustment of antagonists of peripheral feedback.

40. Generalized Motor Programs (GMPs) New Bobath Concept There could be basic motor plans for reaching and grasping and rhythmic movements for walking or speaking that are assembled prior to the need to move. Simple sequences could then be linked together to produce complex actions, such as walking down a slope or singing. The richness of the GMPs developed from both experience and learning.

41. GMPs and CPGs New Bobath Concept GMPs renewed the interest in the concept of Central Pattern Generators (CPGs) Neural networks in the spinal cord capable of producing rhythmic movement even when isolated from the brain and sensory systems. There was increasing evidence that specialized neural circuits do exist in the brain stem of vertebrates for breathing, chewing, and swallowing, and in the spinal cord for locomotive functions.

42. Body Weight Support Treadmill Training New Bobath Concept Partial body-weight-bearing (PBWB) gait training is one intervention that gains support from CPGs.

43. Dynamic System Theory New Bobath Concept Movement is produced from the interaction of multiple sub systems within the person, Task, and environment. No sub system is most important Dynamic system(DS) is complex Development is in a non-linear rate, not steady A movement pattern emerges (self-organizes) as a function of the ever-changing constraints placed upon it.

44. Application in NDT New Bobath Concept The clinicians can identify constraints that limit functional change and develop intervention strategies which directly target these constraints. For example, in early infancy, the mass of the child’s head relative to the size of the rest of the body places constraints on, or limits, the rate at which head lifting and visual following can occur. Delays in independent sitting constrain the foundations for manual development, mother–infant face to face interactions, and reaching behavior by 6-month-old infants. In adults with CP, moderate weakness, increased muscle tone, bone and joint deformities, and progressive asymmetry in posture are independently responsible for limitations in independent ADL.

45. Transitions or phase shift New Bobath Concept Specific motor skills emerge from a series of states of stability, instability, and phase shifts in which new states become stable aspects of behavior. During development, as the subsystems of developing systems change, motor behaviors can either become more stable or destabilize. These periods of destabilization are referred to as transition states. During these times, new forms of movement are most likely to occur. These transitions are characterized either by an increased latency in time to return to a stable state after perturbation, or by increased variability in behavior.

46. Application in NDT New Bobath Concept As a child with hemiplegia experiences a normal growth spurt at age 2, he may appear clumsy, fall more frequently, stand with more of his weight on the less involved side, or even walk without placing the heel (on the more involved side) on the ground during the stance phase. This is a time to increase the intensity of intervention to take advantage of the variability in gait and balance

47. Neuronal Group Selection Theory New Bobath Concept When hundreds of thousands of strongly interconnected neuronal circuits act as structural/ functional units, called neuronal groups, they increase their effectiveness. Neural structures are determined by the competition among neural elements to assure variation(Diversity) in neuroanatomical structures. Primary motor repertoires are movements characterized by variability and are not connected to either sensory inputs(feedback) or function. These connected neuronal groups initially develop by genetic encoding (Evolution).

48. Primary motor repertoires New Bobath Concept Orienting the head and eyes to light and sound. Orienting the head to clear the airway when prone. Coordinating suck and swallow. Bringing the mouth to the hand. Following moving objects with the eyes. Projecting the arm toward objects. Reciprocal kicking. Sensory elicited reactions and responses (sometimes referred to as primitive reflexes, such as head and body righting, palmar grasp, rooting reaction, Moro reflex). General motility. Attachment to the human face

49. Secondary Neuronal Repertoires New Bobath Concept Primary motor repertoires are basic to the infant’s development, and if they are reinforced by a supportive environment, people in it, and the infant’s success in fulfilling his or her needs, they lead to an even richer, purposeful secondary repertoire of responses. These early interactions between infants and their environment must be coupled with success to reinforce the selection of a particular set of behaviors. This success causes certain neural pathways to be selected and strengthened and results ultimately in infants with diverse ways of expressing needs and wants.

50. Change the PNR to SNR New Bobath Concept Transition occurs at function-specific ages All changes are not just changes in synaptic formation and neural circuitry. The development of secondary repertoires also depends on changes in the musculoskeletal system, perception, experience, and a gradual change in agility, adaptability, and the ability to make complex movement sequences. The development of successful reaching and grasping emerges during the first 4 months, changing from movements that are variable in path, speed, and accuracy, and only grossly directed toward the object, to reaching movements with mature kinematics involving fewer movement units