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Historical Prospective

The approaches to treat patient with neurologically based movement disorder have
changed from Reflex or Hierarchical model of motor control to more contemporary
models of motor control
In most of the early approaches reflex served as the basic functional unit of
movement.
In the reflexive or hierarchical model cortex is viewed as the highest functioning
component of the system and spinal level reflex as the lowest.
The contemporary models of motor control particularly the distributed control
model, propose a neural organization of motor control in which the controller varies
depending on the task. And cortex is no longer considered the boss or highest
functional component.
Two general models of neural organization that are used to describe motor function
are:
1. Open system model and
2. Close system model
Most commonly used neurophysiologic approaches are
1.
2.
3.
4.

Neuro developmental therapy- Bobath


Movement therapy in hemiplaegic-Brunstrom
MRP- Carr and Shephered
Rood Approach to neuromuscular dysfunction- Rood

Neurodevelopmental Therapy
NDT is an approach developed by Dr. Karel Bobath and English physician and his
wife Berta Bobath a physiotherapist in the late 1940s.
History:
NDT has evolved from assessing localized spasticity to evaluating patterns of
movement. Dysfunction was seen as the result of loss of control from damaged
higher CNS centers. CNS lesions are thought to release abnormal reflex activity from
higher control.
Currently NDT has incorporated new theories of motor control and has started to
address posture and its control as a result of cooperative interaction of the
sensorimotor system with other systems including the musculoskeletal system,
cardiopulmonary system and other regulatory and command systems as well as the
environment.
1

Bobath discarded the belief that voluntary movements was build on reflexive
movement hence the treatment must follow the normal developmental sequence.
NDT practitioner currently believes that neural control is not a simple hierarchial
function and that along with the nervous system, multiple body systems
participates in executing movement that is organized by the specific task and
constrained by physical laws and the environment i.e. the movement is dictated by
the specific task and constrained and the environment .
NDT also recognized that both feed-forward and feedback sensory mechanism are
equally important in different types of movement control.
Currently NDT has begun to use the Disablement model (disability model) in the
planning and implementation of treatment. In this model less focus is placed on
quality of movement and more focus is placed on the identification of impairments
in relationship of functional goals.
NDT is a living approach
As the characteristic of the population with CNS pathology change,NDT approach
will continue to evolve to meet their needs
Definition:
NDT is a problem solving approach.
It is used for examination and treatment of the impairments and functional
limitations of individuals with neuropathology like stroke or traumatic brain injury.
NDT gives importance to analysis and treatment of sensorimotor impairments and
functional limitations that Physiotherapist, occupational therapist, speech and
language pathologist can address.
In NDT patient participates actively in treatment, they actively take part in setting
the goal and initiates and completes movements that are directed towards function.
Treatment (movement) is directed towards functional objective in real life settings.

The examination begins with the identification of the patient abilities and
limitations.
In this a patient is considered as a whole (not only his disease or disabilities) and
believes that every aspect of the patient .i.e. psychological, emotional, cognitive
perceptual and physical aspects has value and contribution to the overall level of
function.
Theories on which NDT is based
2

Bobath concept is based on the system approach theory of motor control (Bernstein
1697)
The human motor behavior is based upon a continuous interaction between the
individual, the task and the environment.
It describes movement as a result of dynamic interplay between perception,
cognition and action and emphasis on the CNS, ability to receive,integrate and
response to the environment to achieve a motor goal. (Brook 1986)
Principles
Treatment principles in NDT includes
normalization of abnormal muscle tone (spasticity,flaccidity,rigidity and spasms
inhibition and or integration of primitive postural patterns and
facilitation of normal postural reactions.
This is done primarily through direct handling of the patient through key points of
control (usually proximal)
Positioning and family/caregiver education is also stressed.
A patient is considered as a whole (not only his disease and disabilities) and
believes that every aspect of the patient i.e psychological, emotional,, cognitive,
perceptual, and physical has value and contributes to the overall level of function.
Procedure
Essential tool of NDT are examination and treatment.
The examination begins with the identification of the patients abilities and
limitations.
NDT is a concept that focuses on the strengths and impairements of the individual
patient rather than a prescribed treatment of exercise.
The clinician who follows NDT observe and analyse each functional skills and
limitations of the patient to design the best intervention strategies for that patient.
They believe that goal directed examination and intervention leads to the best
functional outcome that minimizes impairments and prevents secondary disability.
Treatment is a problem solving concept and it consist of strategies flexible enough
to be adapted to the impairment of the individual patient.
The long term goal or outcome would be to include the patient into the society.

Handling:
Handling is an integral part of NDT approach. Therapist use facilitation techniques in
a careful manner to establish or re-establish the posture and movements that will
enhance the individuals capacity to carry out meaningful life roles.
Therapeutic handling allows the clinician to
1) Feel the patients response to change in posture or movement
2) Facilitate postural control and movement synergies that increases patients
option for movements
3) Handling guides the movements towards the goal and prevents distraction.
4) Inhibits or prevents or control or constrains abnormal motor pattern, which if
allowed to practiced may lead to secondary deformities, further disability
and decrease community participation
The treatment selected must be able to integrate the movements developed during
treatment into the clients daily life. For active carryover patient has to practice the
task or movement throughout the day independently or with caregivers.
NDT helps patient to regain the lost posture or movement strategies or develop new
movement strategies or posture which in turn will minimize secondary impairments
which may creat additional functional limitations or disability.
Assumptions:
Treatment rational:
Functional movements as a basis for clinical reasoning
The contemporary bobath concept is based on
1)
2)
3)
4)

A system model of motor control


The concept of plasticity
Principle of motor learning
An understanding and application of functional human movement.

Bobath made a distinction between rehabilitation concept and bobath concept.


Rehabilitation concept; it is concerned with quantitatively assessing whether or not
a patient can perform a function (if a hemiplaegic is able to walk no matter how he
manages to walk will be considered.)
Bobath concept: it is concerned with quality of function (Bobath 1990)
Quality of movement is a motor performance at a behavioral level and is important
in developing more effective neuro-rehabilitation strategies (Cristea and Cevin
2009) where agonist, antagonist, synergist and fixator works normally or to a near
normal level.
4

Current rehabilitation concepts: in this therapists design treatments which are


aimed at improving the quality and quantity of posture and movements, essential to
function .(shumway-cook and woollacoot 2001)
The treatment is designed around goals, and goals are specific to each patient and
the goal directed patient specific treatment is given in the environment in which the
patient lives i.e. treatment is given in patients particular life settings.
Normal movement has always been seen as fundamental to the bobath concept but
this has been misinterpreted as being the ultimate aim of the Bobath therapist.
In intact / normal subjects movement patterns are flexible and variable but in
patient with neurological dysfunction movement patterns are stereotyped, few and
are less adaptable.
A key aspect of achieving variability of functional movement is to achieve postural
control and postural control is considered crutial in the Bobath concept.
Movement develops from the interaction of perceptual, action and cognitive
systems
Perception: sensory information eg. Body schema
Action: motor output of muscle
Cognitive System: includes attention, motivation and emotional aspect of motor
control.
Disruption of this complex integrative process leads to the patient using
compensatory strategies in order to function in any manner possible.
The patient with neurological dysfunction has far fewer options and the
compensatory strategies that they develop are stereotype and less adaptable.
These stereotype movements become more established over time and result in the
patient having limited movement choices.
Bobath concept works on both component and task level where by missing
components are identified in order to promote a more qualitative performance of
movement.
Compensatory Strategies
Changes in the nervous system can be organized or disorganized which may
produce adaptive or maladaptive sensorimotor behavior (Raine 2007).
If maladaptive sensorimotor behavior is produced by the disorganized nervous
system, then compensatory strategies are used by the patient to perform a task.

And if compensatory strategies become established or are allowed to become


established they may block potential (expected or possible) recovery.
Compensatory strategies however can be minimized to allow the patient to
realize/achieve their potential efficient long term motor recovery through the
inherent plasticity within the system. This requires a careful assessment of the
patient and his neurological deficit within their own environment
Postural control
It is the ability of an individual to orient and stabilize the body against the force of
gravity using appropriate balance mechanisms.
The recovery of balance is a critical component for achieving independence in the
activities of daily living.
Analysis of postural alignment
It is an important feature of the assessment process. Bobath practitioners analyse
postural and movement through the alignment of key points in relation to each
other and in relation to a given base of support.
Key points: are described as areas of the body from which movements may most
efficiently be controlled (Edwards 1990)
Key points are divided into
1) Proximal key points-shoulder girdle,head and pelvis
2) Distal key points-hand and feet
3) Central key points mid thoracic region
Key points are functional units (Gjelsvik 2008)
Postural setsIs the alignment of key points within a posture.
Balance Strategies
Postural strategies
Pattern of movements
Muscle Strength and Endurance
Speed and Accuracy