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

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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

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motor control approaches in Bobath (NDT)