Remediating Motor Control

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""""""""""" 24Remediating notor Control andPerformance Through TraditionalTherapeutic i lpproaches

Four programs of treatment for patients with motorcontrol problems caused by brain damage were developed in the mid-1950s and early 1960s based onneurophysiological and developmental research of thetime as well as careful observation of the responsesmade by patients when being handled, positioned,touched, or moved in various ways. These traditionaltherapeutic approaches are1. Rood Approach2. Neurodevelopmental (Bobath) Treatment3. Movement Therapy of Brunnstrom4. Proprioceptive Neuromuscular Facilitation (PNF)Approach of Kabat and Voss

This chapter consists of an introduction and foursubchapters, one for each of the four approaches.Each approach is described as it is presented in theliterature. Primary sources of information have beensupplemented by the writings of others when necessary.INTRODUCTION

The approaches discussed in this chapter sharethe idea of the importance of sensation to the controlof movement and the need for repetition for learning,but they differ on other points. The differences have todo with whether conscious attention should be directedtoward the movement itself (Brunnstrom and PNF) oronly toward the goal of the movement (Rood and Bobath), whether spinal and brainstem reflexes should(Brunnstrom) or should not (Bobath) be used to elicitmovement when the patient cannot otherwise move,and whether redevelopment of motor control should besought in an ontogenetic sequence (PNF and Rood) orin a proximodistal sequence (Bobath and Brunnstrom).None of the approaches addresses methods of developing skilled movement. All emphasize the develop

ment of basic movement and postures, with the assumption that when movement is "normalized" then skilledmovement would occur automatically. These approaches are aimed at reorganizing or permanentlychanging the central nervous system.More contemporary neurophysiological and movement science research and clinical observation havecalled into question some of the assumptions of theseapproaches (Horvak, 1991). For example, one assumption is that sensory InWI! commis motor outeut(periph-erat motor control theoa). Information, gathered from

s t i m u l u s ~ r e s p o n s e (reflex) research that Was conductedon anesthetized, decorticalized animals provided thesupport for this. This assumption was applied in neurorehabilitation by applying sensory stimulation to elicitmotor responses (Marteniuk et al.. 1987).Another assumption is that control of movementis hier . that the hi her motor centers controlmid-level ce ers that in turn nt(central motor control This hierarchical modelwas app ied in neurorehabilitation by assessing atwhich level of control the patient moved. The hierarchical model guided the developmental aspect of treatmentalso. Therapists sought to "integrate" lower-level spinaland brains ern reflexes by eliciting higher-level righting and equilibrium reactions. And they progressed theirpatients through developmental "motor milestones. "Modem technology has allowed the study of hrainfunction in awake, functioning animals and people. Ithas been seen that, given a goal, many areas of aperson's brain begins to be activated and that this.ilctivation precedes movemevt and sensory feedbackfrom movement (ChoIIet et al., 1991). Muscles begincontracting before movement starts. Different musclescontract to different levels under various circumstancesto achieve the same goal (Trombly & Cole, 1979).Kinematic analysis of normal babies found that their433


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434 Section IV Treatment Principles and Practices


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24 Retnediating Motor Control and Performance 435

movements represent elegant attempts to solve themotor problem of accessing a particular goal (von Hof-sten, 1984). Their movement shows no evidence ofobligatory motor responses. Reflexes detected by Sher-rington and other early neurophysiologists in decortica-lized specimens may simply reflect the basic wiring ofthe brainstem and spinal cord that can be employed inmyriad ways to accomplish the goal. It is the goal ofmovement and the biomechanical constraints on theperson and his or he r environment at the moment thatappears to organize the sensorimotor responses. Thisorganization is not hierarchical but heterarchical, i.e.,distributed around the various parts of the brain, eachresponsible for .its little piece of the whole action(Chollet et aI., 1991).

The other major belief of the traditional ap-proaches is that peo le who have ex erienced no IUU)yemept but who ave "regresse " because of braindamage should "recapitulate ontogeny," i. e. , start toredevelo control at the earliest motor milestone.,!,lormal infant development that they are now una e to_ accomplish. However, pat ients with motor dysfunction

do not regress to baby ike movement. Patients do notmove in the nice fluid movements that babies do whenthey are trying to obtain their goal. Stroke patients,on the contrary, have described attempts to move as"extraordinarily effortful" and as "heavy" (Brodal,1973), and their movements demons trate' stereotypedqualities-a loss of the many sources of control athigher levels that gives lightness and fractionation tonormal movement. Furthermore, newer developmentalresearch has discovered that the universality of themotor milestones does not even exist in normal babies.Rather, development is much more flexible and individ-ual (Touwen, 1978). Some children learn to walk verywell without first learning to creep. This implies, e.g.,that creeping is not a prerequisite to walking (VanSant, 1991). Finally, some of the developmental motortasks are not only socially inappropriate for adults bu tprobably also neurologically inappropriate for (hem,because they had already attained mature movementskills before brain trauma

On the other hand, modern motor developmentalresearch has demonstrated newer explanations for 50 -


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called developmental phenomena. For example, Thelenand Fisher (1982) discovered an alternate, biomechanical explanation for the "U-shaped phenomenon" ofmotor development in which the automatic, reflexivemovements of newborns (e.g., the stepping reflex) wasbelieved to go through a period of decline and absencebefore the onset of the "mature" movements of theolder child (e.g., walking) as was proposed by McGraw(1945). The decrease seems to be the result of theadded weight of the child who has inadequate strength,and if the weight is supported, stepping is evident.Thelen and Whitley-Cooke (1987) have shown thatpractice of primitive stepping in infants results inearlier independent locomotion. This finding might actually support Brunnstrom's idea of starting stroke patients' motor relearning by using the primitive stereotyped movements they exhibit. The developmentalconcept should not be totally disregarded. Van Sant(1991) pointed out usefulness of intratask developmental sequences as opposed to the intertask developmental tasks represented by the motor milestones. Anexample of intratask developmental sequences arethose associated with development of eye-hand coordination or grasp and release.These newer observations and theories, in effect,invalidate specific procedures used in the traditionalapproaches presented in this chapter, especially because there are few to no outcome studies supporting

the clinical effectiveness of these approaches. Thereare aspects of these traditional approaches that havebeen supported and some that have not been improvedon, and so we may want to hold on to these aspects. Allapproaches included procedures to enable the patient tolearn to move voluntarily. While newer motor learningresearch has specified the parameters for teaching andlearning in greater detail, that research has not yetbeen extended to patients with central nervous systemdysfunction. The skilled therapists who developedthese approaches presented solutions to a problemthat current human movement scientists have not yetencountered: how to teach voluntary, "willed" movement 0 people who can move only in involuntary,stereotypical patterns. The methods these therilpistsused to teach patients to gain volitional controlover their movements need to be reexamined andtested.Still another aspect of these approaches needsto be preserved: the attention paid to subtle patientresponses that indicated his inability to cope withoverwhelming stress. When the challenge exceeds thepatient's ability to cope, these approaches advocatereducing the task or environmental demands. ''Thetherapist controls the environment, allowing the patientto be a successful problem solver, thereby maintainingor enhancing his molor control and dignity" (Minor,1991, p. 139).


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24 Remediating Motor Control and Performance 437

, , , , , , , , , , , , , , , , , , , , , , 24A ROOD ApPROACH

HISTORY Rood was both an occupational therapist and aphysical therapist. One of her major contri.butions wasthe example she set for using research. She kept abreast

of research developments of the time. She attemptedto bridge between what she learned from basic neuro-physiological research and the treatment of brain-injured patients. She invented ways to apply the inde-pendent variables that were used in animal studies topeople, with the expectation that the results would bethe same. She persisted in developing a wonderfullyintegrated treatment approach.Rood's treatment was originally designed for cere-bIgI L'alsx, but she believed it was applicable to anypat ient with motor control problems (Rood, 1976). Asnoted in the introduction to this chapter, the peripheralmotor control theory has been supplanted. Becausesome of Rood's assumptions were based on this theoryand because no clinician has reported the effectivenessof treatment based on those assumptions, some ofRood's approach is considered invalid. Nonetheless,:"as anyone who watched her treat patients could attest,she got results. However, those results may have beenthe result of her responsiveness to patients and herability to present them with what is now called the"just right challenge" rather than the physiologicalstimuli and handling she was applying. Without clinicalresearch, it is impossible to know the reasons forRood's success.

Rood's approach includes three components: (1)~ controlled sensory stimulation, (2) the use of develop-mental sequences, and (3) the use of activity to demanda purposeful response. All were part of each treatment

Catherine A. Trombly

(Ayres, 1974; Curran, 1960). Rood shared her ideaswith others through clinical and classroom teaching butpublished very little. Some of the ideas reported hereare based on interpretations of her method by therapistswho studied and trained with her.

PRINCIPLESRood's basic premise was that

motor patterns are developed from fundamental reflexpatterns present at birth which are utilized and graduallymodified through sensory stimuli until the highest controlis gained on the conscious cortical level. It seemed to methen, that if it were possible to apply the proper sensorystimuli to the appropriate sensory receptor as it is utilizedin normal sequential development, it might be possibleto elicit motor responses reflexly and by following neuro-physiological principles, establish proper motor engrams(Rood, 1954, p. 444).

t e use of certain a ro riatel i d senso stim-uli. orrect sensory input is necessary for the eve lop-~ n t of correct motor responses. Controlled sensoryinpnt is used to evoke muscular responses reflexively,the earliest developmental step in gaining motor control(Rood 1954, 1962).~ Sensorimotor control is developmentally based,and therefore, therapy must start at the patient's currentlevel of development and progress sequentially tohigher levels of control (Rood, 1962; Minor, 1991).Rood identified several developmental sequences,which are illustrated in Table 24A.1.

3. Movement is purposeful (Ayres, 1963, 1974;Rood, 1962). Rood used purposeful activity to demanda response from the patient to elicit subcortically (un-consciously) the desired movement pattern. The re-sponses of agonists, antagonists, and synergists werebelieved to be reflexively (automatically) programmedaccording to a purpose or plan. The cortex does notdirect each muscle individually. When the cortex com-mands "pick up the glass," for example, all the subcor-tical centers involved in picking up the glass causefacilitation or inhibition of required muscles to allowthe accomplishment of the goal in a coordinated man-ner. The patient's attention is drawn to the goal, or


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Table 24A.l. Integration of Ontogenetic Motor Patterns with Levels of Motor ControlaLevel I: Mobility level 11: Stability level Ill: Mobility on Stability level IV: Skill

Skeletal Vital Skeletal Vital Skeletal Vital Skeletal Vital1. Supine with 1. Inspiration 4. Pivot prone (held) 5. Phonation b 6. Neck cocontrac 4. Swallow 9. Prone on elbows 5. Phonationdrawal 2. Expiration 5. Neck cocontraclion 3. tion (orient head fluids is doing 8. Speech2. Roll over 7. Prone-on-elbows in space) 6. Chewing move3. Pivot prone 10. Quadruped 8. Prone on el 7. Swallow ment and onethe 13. Standing bows, (shift from solids arm is free forside to side, skilled USei bellypush backward crawling)and pull for 12. Quadrupedward, unilateral (one arm freeweight bearing) for skilled use)11. Quadruped creeping, trunk(rocking, shift rotation and re-ing, unilateral ciprocal moveweight bearing) ment, crossed di14. Standing (weight agonal}

shift, unilateral 15. Standing andweight bearing) walking"The steps ore numbered sequentialty, but they blend together, i.e., one step is not completely mastered before the next begins at the most basic level.bAlthough out of sequence, phonation is facilitated in the pivot prone position.

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purpose, not the movement per se. The sensation thatoccurs as a result of the movements involved in theactivity helps the patient learn the movements.

4. Repetition (practice) of sensorimotor responses is necessary for motor learning (Ayres, 1974;Rood, 1956). Activities are used not only to elicitpurposeful responses but also to motivate repetition.

EVALUATIONRood evaluated the patient to determine what the

distribution of muscle tone was and to determine whatlevel of motor control, according to her developmentalsequences, the patient had achieved. Evaluation andtreatment planning involve the following points.

1. Identi' he atient's developmentalleveUn Table 24A.l the steps are num ere sequentially for the skeletal and vital function sequences andthe motor control sequence, indicating the order usedfor evaluation and treatment planning. The point atwhich the patient is easily able to do the task representshis highest level of development. Treatment startsat the point at which the patient has to struggle alittle.

2. The plan includes what ths,.activity should beand how the patient should be pregreSf;d to thelevel of the sequence. u s i n ~ a variation of the saws;"'activity or a different one. Treatment is planned so thatas the patient is perlecting a lower-level skill, he beginsto learn the next (higher-level) skill. The therapist'sdetermination of whether it would be necessary to assistthe patient into the desired pattern or if a purposeful

Figure 24A.l. An electrical vibrator being applied to the trioceps of a patient in the quadruped posture to facilitate elbow extension.


actIvIty that demanded the movement and/or posturecould be used to obtain the desired outcome on asubconscious basis is part of the plan. Even if placed,the patient is immediately presented with an activitythat demands the desired sustained posture or repeated movement.

3. Identification of which of the patient's m u s c l ~ sneed to be facilitated to effect the pattern desired."Because facilitation involves use of particular stimuhto obtain the desired response (tonic or phasic), theplan includes identification of these stimuli and theorder of their application. I f the patient is spastic,the therapist would have to plan to use inhibitiontechniques to normalize the tone first.

TREATMENTControlled Sensory Input

Rood invented tools and methods to administersensory input, based on the studies of the effects ofstimuli on animals and her own clinical practice. Sheused cutaneous (tactile), thermal, olfactory, gustatory,auditory, visual, and proprioceptive (stretch, resistance) stimuli to facilitate or inhibit motor responses.The mechanisms of how these stimuli worked wereexplained according to the peripheral motor controltheory of the 1940s and 1950s. Because that theoryhas been supplanted by newer knowledge, and becausethere is little research concerning the effects of any ofthese stimuli on normal subjects or patients, they willnot be described in detail here.

The facilitation technique of fast brushing hasbeen researched. Fast brushing is described as brushing the hairs or the skin over a muscle with a softcamel hair paintbrush that has been substituted for thestirrer of a hand-held battery-powered cocktail mixerto produce a high-frequency, high-intensity stimulus(Hams, 1969; Huss, n.d.; Rood, 1962; Stockmeyer,1967). Rood hypothesized that the effect of fast brushing is nonspecific (i.e., not confined to one muscle),has a latency of 30 sec, and does not reach its maximumpotency until 30 to 40 min after stimulation, becauseof processing by the relicular activating system. Incontrolled studies of normal and poststroke individuals,however, it was demonstrated that although fast brushing produced a significant immediate facilitatory effect,the postapplication effect lasted only 30 to 45 sec(Mason, 1985; Matyas & Spicer, 1980; Spicer & Matyas, 1980) and was not functionally significant. Moreover, the facilitatory effect was seen only in the lowerextremity, not in the upper extremity, of normal subjects.

Rider (1971) also examined fast brushing, amongother stimuli. She foum\ a statistically signifIcant (P


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= .01) increase in the strength of both triceps of eightchildren with bilateral upper extremity flexor spasticitycompared with eight children who had normal upperextremities, following a 2-week period of treatmentconsisting of brushing, stroking, rubbing, icing, andsqueezing of the triceps of one limb. She reported asignificant mean decrease in strength of both elbowextensors of those children, from both groups, who hadbeen facilitated on the nonpreferred arm following a2-week period of no facilitation.Stretch, in the form of muscle or tendon tapping,is used successfully in the clinic to evoke a strongerresponse in a muscle that is contracting without addedstretch (see Fig. 24C.4). V i b r a t i o n ~ delivered by anelectric personal vibrator (Fig. 24A.l), is a form ofstretch. Its effects are apparent even in classroomdemonstrations using normal students. It evokes a tonicholding contraction and adds to the strength of contraction of an already weakly contracting muscle. Stretchto the intrinsic muscles of the hand or foot, anotherfacilitation technique, is used to facilitate cocontraction of the proximal stabilizer muscles (Ayres, 1974;Stockmeyer, 1967). This technique requires the patientto grasp a handle forcefully. It is hypothesized that thebest response is gained from use of a cone-shapedhandle (with the widest part of the cone at the ulnarborder of the hand) or a spherical handle, both ofwhich increase intermetacarpal stretch. I f activitiesthat use such handles can be combined with weightbearing positions, the proximal stabilizers are believedto be further facilitated through the demand placed onthem for cocontraction. For example, to develop shoulder cocontraction, a patient can lean on his elbow ina modified prone-on-elbows position while using anelectric drill to drill holes in a vertically placed project.Zimny (1979) studied whether scapulohumeral musclesof normal adults showed increased cocontraction in theprone-on-elbows position in combination with resistedgrasp. The electromyographic results revealed only alow level of response from these muscles under thiscondition. It has not yet been tested on patients.Clinical observation suggests resisted grasp is an effective technique to obtain scapulohumeral contraction insome cases.

Prolonged manual stretch is used to inhibit spastic muscles so that the patient may move more easily(Carey, 1990). The limb is held so that the musclesare steadily kept at their greatest length for 1 or 2 minuntil a "letting go" is felt as the muscles adjust to thelonger length. It may be that this procedure rebiasesthe spindles to a longer length and makes them lesssensitive to stretch during movement. It certainly alsomechanically lengthens the muscles, changing theirviscoelastic configuration.

Developmental Sequences of Motor Control and Use of Purposeful Activities

Rood identified several sequences that she usedinterrelatedly but that will be presented separately herefor clarity. One sequence was already mentioned in thelist of the principles of the Rood method. To reiterate,a muscular response is first evoked reflexively using cDsensory stimulation, then responses so obtained areused in developmental patterns, and then the patientuses the response purposefully to gain control over it.A second sequence that Rood identified was useof muscles in particular patterns according to their ~classification (Goff, 1972; Rood, 1962). Muscles wereclassified as light-work or heavy-work muscles basedon their anatomical design. Light-work muscles liesuperficially, laterally, or distally and have a tendinousorigin and insertion. They are multiarthrodial, they areunder more voluntary control, and they do phasic work.Rood identified the light-work,. or mobilizing, musclesas primarily the flexors and adductors, but multiarthrodial finger and wrist extensors also are includedin this category. These muscles are termed physiologi-cal flexors even though their action is extension of thefinger, thumb, or wrist joints. Heavy-work muscles aredeep, lie close to the joint, and are uniarthrodial. Inthe body, they are located proximally and medially.Heavy-work muscles are tonic stability muscles capab leof prolonged, sustained contraction. These are primarily the trunk musculature and proximal limb extensorsand abductors but also include such muscles as theinterossei of the hands and feet. Rood believed that ifthe normal first response of a muscle was a stabilizingcontraction, it should first be facilitated to contract inthis manner and not in a mobilizing pattern. However,there is no convenient listing of what the originalontogenetic function of each muscle was to guide thisaspect of treatment. Therapists are guided by Rood'sdefinitions of heavy-work and light-work muscles inplanning treatment. ~Another sequence reflects the development of0muscle responses. In this sequence, flexion precedesextension, adduction precedes abduction, ulnar patterns develop before radial ones, and rotation developslast (Huss, n.d.).Another sequence that Rood identified has to do ,with development of motor controL There are four 'phases.

L Movement first appears a s ~ i c , reciproc!! ortening and len ning contract' s ormuscles that ause move me t at su serves a protectIve unction.

Musc es contract to cause movemen roug u range,which, according to Sherringtonian physiology, pro-duces reciprocal inhibition of the antagonists (Ayres,


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1974; Rood, 1962). Stockmeyer (1967) termed this themobility p h a ~ The movement of an infant waving hisor her extremities back and forth when shown a desiredobject t ~ Y h a s i c movement.2. onic holding contractions are next to developand are t e basis for maintaining proximal posture toallow exploration of the environment and developmentof skill by the distal segments of the head and limbs.Stability is obtained through cocontraction, i.e., theftmuscles around the joint contract simultaneously' J .lA.(Ayres, 1974; Stockmeyer, 1967). Development of....-! ':.jproximal stability should precede work on developing ,,\t-skilled movement (Rood, 1956). However, this assumption appears not to be true. Research has shown that tithe proximal and distal motor systems are controlledseparately (Freund & Hummelsheim, 1984; Lawrence& Kuyphers, 1965) and, while correlated, follow aseparate developmental sequence (Case-Smith, Fisher,& Bauer, 1989; Wilson & Trombly, 1984).

3. Proximal muscles contract to dosu erim osed 0 (Ayres, 1974;ood, 1962). "Mobility superimposed on stability" isStockmeyer's (1967) way of designating this level ofmotor control in which the distal segment is fixed andthe proximal segment moves. This phase is used todevelop controlled mobility of the proximal joints. Anexample of this kind of motion occurs when an infantlearns to assume the quadruped position but has notyet learned to move in that position: He or she rocksback and forth with the knees and hands planted firmlyon t h e ~l4. Skill 's the highest level. At this level of motorcontrol, e proximal segment is stabilized and thedistal segment moves (Ayres, 1974; Rood, 1962). Examples of this level include walking, crawling, andreaching as well as activities that require coordinateduse of the hands.SKELETAL FUNCTIONS SEQUENCE

These four levels of motor control are developedas the patient is paced through the skeletal functionssequence (c,wlOecqctk motor patterns) that are pictured in Figure 24A.2 (Rood, 1962; Stockmeyer,1967). The eight functional patterns will be described,then the interrelationship between these patterns andthe levels of motor control may be studied, usingTable 24A.1. .

1. Flexor withdrawal supine (Minor, 1991), alsocalled supine flexion, is a position of total flexiontoward the vertebral level ofTlO' The upper extremitiescross the chest, and the dorsum of the extended handstouch the face. The lower extremities flex and abduct.This posture demands heavy work of the trunk andproximal parts of the extremities but allows light work

Figure 24A.2. Skeletol functions sequence occording toRood. 1. Flexor withdrowol supine. 2. Roll over. 3. Pivot prone.4. Neck cocontroction. 5. Prone on elbows. 6. Quadruped. 7.Standing. 8. Wolking.

of the distal parts of the limbs. It is used to obtainflexor/adductor responses when the patient has nomovement or is dominated by extensor responses. I t is .also used to develop trunk and proximal limb stabilityor to develop reciprocal phasic movement through normal range. It is thought to integrate the tonic labyrinthine reflex (TLR) by requiring the voluntary contraction of the flexors in spite of reflex facilitation ofthe extensors.To elicit the flexor withdrawal supine motor pat-tern, Rood used the following method. First, the lowback and the dermatomes of Cl _ were fast brushed.4Second, small wedge pillows were placed under thehead and the pelvis to stretch the short extensors ofthe back and to put the neck flexors and abdominalsin a shortened position. The shortened position allowedthe spindles to rebias. Rebiasing the spindles to a shortposition was believed to make them more sensitive tostretch, and therefore, the muscles were more apt tocontract if the patient reverted to a trunk extendedposition as a result of the influences of the TLR.Finally, after the heavy-work response of the trunk wasobtained, a light-work response of the limbs would heelicited by stroking (tactile) or icing (thermal) thesole or palm and immediately demanding a light-work


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flexion/adduction pattern of the limbs through an activity. The force of the activity is directed toward flexionladduction, even though reciprocal movement in theopposite direction would be involved. Some examplesare tetherball, squeezing a toy accordion, using acylindrical balloon blower, playing table tennis (forehand shot), and stirring batter in a counterclockwisedirection using the right arm or in reverse directionusing the left.According to Rood, this motor pattern also helpeddevelop bowel and bladder function, eye convergence,and respiratory patterns.

If the TLR extensor response in supine was toostrong to permit flexor movement, Rood recommendedstarting treatment with the patient in a side-lying position.2. Roll over is a movement in which the arm andleg on the same side flex as the trunk rotates. Thispattern is used for patients who are dominated by theprimitive tonic reflexes or need mobilization of theextremities or activation of lateral trunk musculature.Attempts at rolling over integrate the asymmetricaltonic neck reflex (ATNR), because the top-mostlimbs--in this case the skull side limbs-flex andadduct proximally and tend to extend at the elbow andknee, which is opposite to the typical ATNR skull-sideresponse. Activity examples are rolling over to reachan attractive or needed object and turning to lookat something enticing. To elicit the response on asubconscious level, move the object the person islooking at around to the side, thereby causing thepatient's head to turn to maintain visual contact; thebody will automatically follow the head, if the rightingreactions are developing.3. Pivot prone, also called prone extension, is aposition in which the patient lies prone and extendsupper trunk and head; abducts, extends, and externallyrotates his shoulders; and extends his hips and kneesoff the sudace so that he rests on the pivot point atapproximately the level ofT lO (Figs. 24A.2 and 24A.3).Assumption of the position is a phasic, reciprocalmovement. Holding the position involves a shortened,held, resisted contraction (SHRC) of the extensor/abductor muscles. An SHRC used in combination withthe pivot prone position is thought to be a importantpreparation for weight-bearing postures. Gravity exertsa constant resistive force against holding the position,which causes the central nervous system (CNS) toreprogram more and more motor units. It is reasonedthat immediately following an SHRC in prone extension, the spindles of the extensor/abductor muscles arebiased short and are, therefore, responsive to smallincrements of stretch. If the patient moves into a proneon-elbows or quadruped position, the shoulder and hipextensor/abductor muscles are stretched relative to

Figure 24A.3. Scooter boord being used on on incline andeliciting the pivot prone position automatically_

their new shortened range and are facilitated to contract. When this position can be maintained, it indicates that the symmetrical tonic neck reflex (STNR)and TLR are integrated and the labyrinthine rightingreactions are developing.The procedures to achieve the whole pattern willbe described, although for an adult who has trunkcontrol this is modified to a partial pattern. The patientis placed prone on a firm, padded sudace large enoughto support the trunk only, e.g., on a low stool, bolster,

or scooter board (Fig. 24A.3). The area over thedeep back extensors is fast-brushed, taking care toavoid the LI _2 and S2_3 areas (believed to cause bladdervoiding or retention respectively). The skin over theposterior deltoids, latissimus dorsi, trapezii, proximalhamstrings, and glutei is also fast brushed. Simultaneously with the activity that demands the pivot proneposture, vibration is applied to the deep hack andneck extensors and other extensor muscles involved inthe pattern, starting at the midline. The pivot proneposition is held for gradually increasing periods of timeup to at least 1 to 2 min. Activities are presented todemand and resist the response. Activity suggestionsare doing leather lacing or macrame, using a slingshot, stirring batter in a clockwise direction with theright arm or in the opposite direction with the left(unilateral pattern), riding prone on a scooter board(Fig. 24A.3), playing with a "button-on-string" toy,rowing; and tearing apart strips of cloth for rag rugs(bilateral pattern)_ Note that the force of the activity isin the direction of extension and abduction, althoughother movements are also involved in the activity.4. Neck cocontraction is the pattern used to'develop head control and is first activated in the proneposition_ In the prone position, the labyrinth rightingreaction stimulates alignmenl of the head so that the


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eyes are parallel and the nose is perpendicular to thesurface. Before putting the patient in a prone position,it is necessary to activate the flexors if they are notalready active. Rood believed that the short neck flexors could be activated by fast brushing the dermatomaldistribution of C2. Next, the long neck flexors, thesternocleidomastoids, are stimulated. The patient isthen placed prone and given an activity that promptshim to raise his head against gravity. Sucking a resistive liquid through a straw or playing games in whicha small object is picked up by sucking it onto the endof the straw are also activities that result in reflexivecocontraction of the neck muscles. As the patientattempts to maintain neck extension, the upper trapezius is facilitated to maintain the extension by fastbrushing and repetitive muscle tapping. When thecontraction lets go, the head bobs into flexion andthe neck and trunk extensors are stretched, therebyfacilitated to contract. Neck extension is again sought.

5. Prone on elbows is a pattern of vertical trunkextension, which is thought to inhibit the STNR. Whenthe shoulders are brought into forward flexion from apivot prone posture, so that the patient can bear weighton his elbows, the extensor/abductor muscles of theproximal upper extremity are stretched and facilitatedto coconttact with the flexors and adductors in theprone-on-elbows position. A normal infant can be observed assuming the pivot prone position just beforegoing into a prone-on-elbows position, as if to "prime"his or her system.

A procedure to achieve the prone-on-elbows pattern is as follows. The back and neck extensors arefast brushed, as are the glenohumeral extensors andabductors. The patient is asked to assume the pivotprone position or given an activity that demands thepivot prone position. Resistance, for greater facilita-tion in the pivot prone position, may be added manually by pushing the thighs and upper trunk toward thesupporting surface. Then the patient is placed in orgiven an activity to do that demands the prone-onelbows position. One suggestion is for the person to lieon the floor to watch television; the television set isplaced so that neck and upper trunk extension arerequired for him to look at it. Vibration can be appliedto the extensor/abductor muscles of the glenohumeraljoint as needed to gain cocontraction. An activity thatdemands resisted grasp can be introduced to obtainreinforcement of shoulder cocontraction. Other activities include playing board games or doing crafts whileprone lying. These activities begin to combine thestatic bilateral position with unilateral positioning andreaching. Unilateral weight bearing is more advanced\ than bilateral weight bearing. The activities could progress to involve some crawling, which is a higher-levelresponse (see Table 24A.1).


Treatment of adults is more likely to involve amodified prone-on-elbows position (Stockmeyer, 1967),in which the seated patient leans with his elbow on thetable or lap tray. Activities are easy to devise for thismodified posture and usually involve use of the lessaffected limb for the skilled aspect of the activity whilethe more-affected limb holds down the object beingworked on.6. The all-fours pattern, also called quadruped,occurs after the neck, upper extremities, and uppertrunk have developed stability. This position helps thetrunk an d lower extremities develop cocontraction. Atfirst, the quadruped position is static; later the personis able to shift weight backward and forward, from sideto side, and diagonally and then is able to lift one ortwo of the points of support, i.e., one arm and one leg.Finally, these activities develop into crawling.A suggested procedure to develop the all-fourspattern is as follows. The back and neck extensors arefast brushed as are the glenohumeral and hip extensorsand abductors and the elbow extensors. The patientassumes and holds the pivot prone position while resistance is added. Then the patient is placed into or givenan activity to do that demands the all-fours position ora modified version of it. Activity examples includeholding a sling shot prepared to shoot (unilateral pa tternwhile upright) (Stockmeyer, 1967), weaving on a largeloom adapted to resist elbow extension (while upright),holding wood in place while sawing it with the otherhand, painting a large mural on the floor, and playingwith a toy truck. While the activity is ongoing, muscletendon tapping and/or vibration are applied to themuscles listed above as needed to maintain the posture.

7. Standing is first done as a static bilateralposture, then progresses to shifting weight and to aunilateral posture. Activity suggestions include doingcraft activities, playing board or card games, makingpuzzles while standing at a high table, writing on awall blackboard, and painting on an easel. Throwingand catching balls, balloons, and bean bags help de-velop balance while standing.8. Walking is the skill level of standing. It con-sists of stance, push off, pick up (swing through), andheel strike. Ambulation training is the responsibilityof the physical therapist.

VITAL FUNCTIONS SEQUENCEThe vital functions sequence is related to the

skeletal functions sequence (Table 24A.1) (Huss,1971; Minor, 1991). Both sequences are handled concurrently in treatment, if appropriate. The vital functions developmental sequence leads to speech. There-fore, the occupational therapist, who facilitates thissequence with the goal of treating dysphagia, collabo


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rates with the speech-language pathologist (SLP) toachieve mutual goals. The sequence is as follows.1. Inspiration, which is effected reflexively atbirth.2. Expiration, which depends on the depth ofinspiration. The depth of inspiration depends on pat

terns of head and trunk stability set in the flexorwithdrawal supine pattern: cocontraction of the deepneck flexors and extensors and cocontraction of the lowback musculature with the rectus abdominus (Rood,1962). The depth of inspiration can be increased byapplying ice to the border of the ribs, which stimulatesdiaphragmatic contraction (Rood, 1976). Crying,sneezing, and coughing are all expiration-type phenomena that occur naturally or can be elicited reflexively(sneezing). Asking an adult patient to increase voluntarily the force of coughing is also used to improveexpiratory function.3. Sucking. According to Rood (1962), resistedsucking facilitates neck cocontraction, which in turnfacilitates sucking. I f pressure is applied to the tip ofthe tongue, then sucking will ensue after five to sevenrepetitions of applications of the pressure (Rood, 1976).4. Swallowing liquids. Rood (1956) suggestedthat swallowing can be facilitated by cutaneous stimulation of the mucous membranes of the palate, tongue,and uvula using a long, cotton-tipped applicator stick.Rood believed that the orbicularis oris was the key toswallowing because she thought that it activated, bydirect stretch, the buccinators and superior constrictorof the pharynx (Rood, 1962); therefore, in therapy theorbicularis oris muscle is facilitated by tapping andbrushing. Care is taken that.-the chin is not brushed orstroked because this will cause the patient to be unableto keep his mouth closed to swallow, resulting indrooling. A swipe with an ice cube applied from thesternal notch to the Adam's apple will cause a personto swallow reflexively.5. Phonation, defined as babbling, is controlledexpiration as opposed to the reflexive expiration ofsneezing, coughing, and crying.6. Chewing and swallowing solids.7. Speech, defined as production of recognizablewords.

To illustrate treatment planning using Rood's sequences, this example may be helpful. The evaluationof a hypothetical poststroke patient indicated that hehad some voluntary elbow flexion but his shoulderbegan to abduct. simultaneously when he flexed hiselbow. He was able to grasp, but unable to releaseobjects. He was able to roll over in bed and rotate histrunk while sitting. In sorting these data out, thetherapist noted that the elbow flexors, considered lightwork muscles, were contracting in that capacity butthe shoulder abductors, heavy-work muscles, should

have been contracting in a tonic pattern first, not inthe phasic pattern that they were. She reasoned that ifthey were active in a stabilizing pattern, they would beprevented from reflexively contracting phasically duringelbow flexion. Knowing the developmental sequence,the therapist knew that because flexion developed atthe elbow, extension would be the next movement tobe sought at that joint. The therapist also knew thatprone extension would be the next pattern in the functional sequence to work for, because roll over is alreadywithin the patient's repertoire. Therefore, treatmentof this patient would begin with controlled sensorystimulation of the extensors/abductors of the shoulderand scapula and with an activity to demand a staticpivot prone response at least unilaterally of the affectedside. It would proceed to a prone-on-elbows or quadruped position to develop elbow extension as the patientwas able to progress.Huss (n.d.; 1971) suggested some treatment planning guidelines:1. Hypotonia ("floppy baby syndrome," uppermotor neuron ftaccidity) is treated by overall generalstimulation, especially swinging, rolling, spinning inall planes for labyrinth stimulation, and specific exteroceptive and proprioceptive stimulat ion for specific muscle stimulation. Activities are used to elicit specificmotor patterns in sequence.2. Hypertonia (spasticity, which may be seen,e.g., in spastic cerebral palsy, cerebrovascular accident, and multiple sclerosis patients) is treated usingnentral warmth for relaxation. Exteroceptive and proprioceptive stimulation of the antagonists of the spasticmuscles are done. Activity is used in developmentalsequence to reinforce normal movement.3. Hypertonia (rigidity such as seen in Parkinson's disease) is treated using neutral warmth forrelaxation. Reciprocal movement patterns are stimulated and reinforced using activity.4. Hyperkinesis (uncontrolled movement such asseen in athetosis, chorea, and ataxia) is treated byslow stroking for relaxation. Maintained holding patterns are stimulated at first and then mobility on stability patterns that involve keeping the distal segmentstabilized while the proximal segment moves are used.When control of mid range movement is developed inthe proximal joints throughout the functional sequence,the patient is progressed to skill level.

EFFECTIVENESSThere are no studies of the effectiveness of theentire approach. Parts of it have been researched. Ascited above, Mason (1985), Matyas and Spicer (1980),Spice and Matyas (1980), and Rider (1971) testedfast brushing and determined it was facilitating as


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24 Remediating Motor Control an d Performance 445

\ redicted, but that it did not have the lasting effectsexpected by Rood. Carey (1980) verified that prolongedmanual stretching results in inhibition of spastic mus-cles. VanSant (1988, 1991b) observed that the develop-mental motor sequence was not followed invariably bydeveloping children nor adhered to by adults whenrising from supine, as expected.


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HISTORYK. Bo.bath and B. Bo.bath, British neuro.lo.gist andphysiotherapist, respectively, develo.ped metho.ds fo.r

the evaluation and treatment of cerebral palX andadult hemiplegia. Their treatment appro.ach is knownas bo.th the Bobath approach and neurodevelopmentaltreatment (NDT). This chapter provides an introductio.nto. NDT/Bo.bath theo.ry and treatment as they apply to.the adult with hemiplegia fro.m stroke or Qther neurolog-ical cQnditio.n. A co.mplete descriptio.n o.f the treatmentapprQach and its techniques Qf treatment can be fQundin Bo.bath (1990).

BQbath and BQbath began to. develo.p their treat-ment apprQach in the 1940s. B. Bo.bath, trained inGermany as a gymnast and remedial mo.vement special-ist, came to. England to. avoid persecutio.n and beganto. wo.rk with neuro.lo.gic patients. When wo.rking withan adult hemiplegic patient, she nQted the stiffness o.fthe patient's arm and leg and his inability to. plan andexecute no.rmal mo.vement patterns. In her treatmentsessio.ns, B. BQbath tried to. help this patient and Qtherslike him regain no.rmal patterns Qf cQo.rdinatiQn in hisaffected limbs. Through trial and erro.r, she devisedtechniques to. influence the abnQrmal to.ne of stro.kepatients and to. retrain mQre no.rmal patterns of mo.ve-ment in their hemiplegic side. Her method o.f remedia-tio.n o.f mo.vement fo.r the adult stro.ke patient was notbasedQn the develo.pmental sequence, but on her

24B NEURODEVELOPMENTAL(BOBATH) TREATMENT

Kathryn Levit

analysis Qf the mQvement cQmpQnents impQrtant fQr usein life tasks.As the treatment evolved, K. aQbath, a neuro.lo.-gist, reviewed the available neuro.physio.lo.gic researchto. pro.vide a scientific. explanatio.n fo.r B. Bo.bath'streatment. Altho.ugh the clinical techniques were devel-o.ped first, Bo.bath and Bo.bath presented a scientificratiQnale fo.r their appro.ach based o.n the theo.ries thatwere current in the 1940s. The first article describingthe appro.ach was published in 1948. Over the next 42years, at least 70 additio.nal publicatio.ns were prQ-duced. The third editio.n o.f B. Bo.bath's (1990) bo.o.kwas published mo.nths befo.re her death.In their appro.ach, Bo.bath and Bo.bath rejectedthe traditio.nal therapy co.ncept o.f co.mpensatQry trainiDgbtc'i"use it neglected the po.tential o.f the hemiulegicside fo.r no.rmal functio.n. They also. believed that tech-niques such as passive"'";'tretching and exercising indi-vidual muscles were o.f little value to. the stroke patient,because these mo.vements did no.t address the pro.blemso.f abno.rmal to.ne and abno.rmal co.o.rdinatio.n. Similarly,they disagreed with the techniques o.f Kno.tt and Brunn-strom because they reinfo.rced abno.rmal reflex activityand increased spasticity in the hemiplegic side. Bo.-bath and Bo.bath stressed that po.tential fQr mo.re no.rmalmo.vement patterns and impro.ved functio.nal use o.f thehemiplegic side was present in all stro.ke patients andthat this sho.uld be the go.al of treatment. Their treat-ment techniques were designed to. decrease the influ-ence o.f spasticity and abno.rmal coordinatio.n and im-pro.ve co.ntrol o.f the invo.lved trunk, arm and leg.

PRINCIPLESThe NDT/Bo.bath appro.ach is directed to.ward the

go.al o.f ~ t r a i n i n g no.rmal, functio.nal patterns of mO\e-m..1t in the adult stro.ke patient. To. retrain mo.vementin the stroke patIent, the therapist must change, or"nonnalize," the abno.rmal to.ne and eliminate un-wanted muscle activity. When muscle to.ne and patternso.f muscle co.ntractiQn are normalized, the therapistintroduces and trains no.rmal mo.vement patterns in thetrunk and extremities. The training of no.rmal mo.vementpatterns includes the activatio.n of po.stural respo.nsesthat must be available on an automatic: level for func-tion. It also includes reeduc:al.io.n of muscles in thehemiplegic arm and leg for w e j g h t - b ~ a r i n g and no.n-
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weight -bearing functions. Muscle reeducation is done gravity,but low enough to prevent resistance and allowboth at the level of a single muscle group, i.e., wrist normal speed and timing of movement (Bobath, 1990).extensors, and at the level of synergistic muscle groups, l'l\1uscle tone or tension fluctuates in everyone, dei. e., wrist extensors with shoulder and elbow flexors ;p.ending on the situation one is in and the demands ofand finger grasp to bring a toothbrush to the mouth. I the task. However, in most situations muscle toneBobath and Bobath believed that eermanent reduction / matches the demands of the task being performed.in spasticit cannot be achieved unless the atient is I During passive movements, bodies with normal tonea e act ivel to move is involved side in nor a c t i v e ~ s s i s t and follow movements. I f passive move-patterns of coordination (Bobath, 1990). Full potenti ment i:)rrested and the therapist's hands removed,has not been reached until the patient can use the ~ Y segment will not fall but will remain brieflynormal movements in the performance of functional ac- in the position in which it was placed. Bobath andtivities. Bobath called this the placing response.

The following principles of treatment apply to all In the adult stroke patient, muscle tone may beNDT/Bobath treatment activities: higher or lower than normal, both at rest and duringmovement. In the acute stage, flaccidity or low tone1. Treatment should avoid movements and actlvIlles is generally present in the affected trunk and limbs.that increase muscle tone or produce abnormal Flaccid limbs feel heavy or floppy and relaxed; theyresponses in the involved side. provide no resistance or assistance to passive motion.2. Treatment should be directed toward the develop Placing responses are not present. Active motion isment of normal patterns of p o s t ~ r e and movement;difficult because flaccid muscles are weak and cannotmovement patterns selected are not based on the easily contract with enough force to lift the weight ofdevelopmental sequence but on patterns important the limb against the pull of gravity.for function. After a stroke, hypertonicity or spasticity devel3. The hemiplegic side should be incorporated into all ops in the muscles of the arm, leg, and trunk ontreatment activities to reestablish symmetry and the affected side. Spasticity produces stiff limbs thatincrease functional use. assume abnormal postures. Spastic muscles resist4. Treatment should produce a change in the quality lengthening during passive motion but may assist pas-of movement and functional performance of the sive movements that require the spastic muscles toinvolved side. shorten. Similarly, placing responses may be possiblein patterns of muscle shortening. In the patienl withspasticity, increased muscle tension may not be evenlyEVALUATION AND TREATMENT distributed throughout the body. Hemiplegic patientsPLANNiNG frequently have hypertonic arms with hypotonic trunkmuscles and may show tightly flexed elbows with flaccidProblems in the Adult Stroke Patient wrists and fingers. When the spastic patient attemptsAccording to Bobath and Bobath, strokes and actively to move his arm or leg, the movements areother types of adult brain damage result in abnormal slow and inefficient and limited to mass patterns ofpatterns of posture and movement. These abnormal f1exion and extension. patterns must be eliminated through treatment because In the stroke patient, muscle tone fluctuates a:.rthey prevent the patient from regaining normal function cordins to the situatiog and demands of th e task. Theon his involved side. The writings of B. Bobath identify hemiplegic side may appear to have low tone at restfour components to the motor disturbance in adult but may assume spastic positions during difficult activi hemiplegia. These problems and their relationship to ties. For example, when the stroke patient walks, thenormal movement are discussed below. hemiplegic arm assumes an abnormal, flexed posture.The hemiplegic leg often stiffens severely during the

ABNORMAL TONE transition from sit to stand, so that the patient is unableAbnormal tone is present in almost all patients to bend it to take a step. Bobath and Bobath called

with central nervous system (eNS) dysfunction and these nonfun tio and involuntary chan es in I iinterferes with the production of normal movement position and muscle tone associate reactions, Synerpatterns. Musclee) ,nay be defined as the amount 0(.. gistic posturing of the limbs may vary from position totension in the muscle. Bobath and Bobith quoted position. It may also. occur when the patient yawns or

Sherrington (l913) to support their view that normal sneezes and as painful spasms during sleep. Becausetone is necessary for the production of normal move the flexor posturing of the arm and extensor posturingment. To be considered normal, muscle tone must be of the leg are involuntary, the patient cannot changehigh enough to allow movement against the pull of the position of his arm and leg in response to verbal


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448 Section TV Treatment Principles and Practices

commands such as "Straighten your elbow." Associ-ated reactions appear to be linked to the loss of >postural control, described below, and begin to dis-appear when balance has improved.

LOSS OF POSTURAL CONTROLThe stroke patient has lost control of the systemof postural adjustments that forms "the necessary back-ground for normal movement and for functional skills"(Bobath, 1990, p. 6). Postural reactions can be thoughtof as the basis for control of movement because theyallow people to control the position of their bodiesagainst gravity. Normal postural reactions include therighting reactions that help maintain the correct orien-tation of the head to trunk and trunk to limbs andequilibrium reactions that help people maintain orregain their balance and keep their body mass overtheir base of support. These reactions depend on con-trol of the muscles of the trunk and pelvic arid scapulargirdles in many positions relative to the pull of gravityand on the ability to shift and bear weight on the limbsin many positions.Postural reactions also include the changes intone and adjustments in posture that precede andaccompany functional movements. For example, in thetask of standing up from a chair, people automaticallyplace their feet underneath themselves and move thetrunk forward from the back of the chair before stand-ing. Similarly, humans automatically shift their weightover the right hip when reaching to the side with the

right arm. During normal movement, postural adapta-tions and reactions occur automatically and are notunder conscious cortical control. Bobath and Bobathuse the term postural control to describe automaticactivation of muscles to maintain control of the bodyfor posture and movement.In the patient with hemiplegia, the postural sys-tem is disrupted by loss of motor control of the hemiple-gic trunk and extremities as well as damage to balancecenters in the eNS. The patient cannot move the trunkand extremities on one side of his body. Because ofpoor motor control, he develops asymmetrical posturein his trunk, shoulder girdle, and lower extremity. Heis unable to activate trunk muscles to maintain a stableposition in sitting or standing and cannot performfunctional trunk movements and weight shifts necessaryto position the limbs for function or to regain hisbalance. He cannot move his arm to use it for functionor balance or shift his weight onto his hemiplegic hipor foot. Loss of postural control forces the patient torely on his sound side during task performance and touse canes and adaptive equipment to substitute for hispoor balance. Because the patient cannot voluntarily

or automatically perform trunk movements and weigshifts in all directions, his functional movements wbe limited to the number of postural sets in which hhas control.

ABNORMAL COORDINATIONThe patient with eNS damage has abnormal paterns of motor coordination, resulting in inefficien

nonfunctional extremity movements. During normmovement of the arm and leg, coordination betweagonist, synergist, and antagonist produces smooteffortless, and efficient patterns of movement. Proximmuscle groups are used to provide appropriate stabiliztion for distal function. Limb muscles are activated sequences to position correctly the hand or foot for tdesired function. Reciprocal inhibit ion between agonand antagonist muscle groups ensures smooth controf limb movements by coordinating muscle firing that only those muscle groups that produce the corremovement are active at one time. Limb movements aautomatically accompanied by postural responses the trunk to allow full ranges of limb control aproduction of power. During normal movement, ts e ~ u e n ~ e s of muscle a c ~ i v i t y used to reach for s othmg WIth the arm, to tIe shoes, and to walk are nproduced with conscious attention. Once acquirethe plans for these movements are probably stored the eNS.In the stroke patient, the timing, sequencing, acoordination of muscle activation are disturbed. Thloss of muscle control results in the abnormal patterof limb movement and coordination typical of eNpatients. In some stroke patients, coordination is abnomal because only some. muscles have returned in tarm and leg, while other muscles that should functias synergists are too weak to contribute to movemenA common example of this is found in the hemiplegarm. The patient may have the ability to flex hshoulder and extend his elbow but be unable to positithe hand for grasp because he does not have mocontrol of the wrist extensors and forearm supinatoIn other cases, muscles are activated inappropriateor at the wrong time, producing abnormal limb patternIn these patients, strong contraction of the scapuelevators and humeral abductors may be used totempt to reach the arm forward. In a third group patients, problems of cocontraction may occur. Boagonist and antagonistic muscle groups contract duricocontraction, producing rigid limbs incapable of seletive movement. In most stroke patients, conscioustention and effort are necessary to produce any movment of the hemiplegic side. The patient mUconsciously direct his hemiplegic leg to take a st


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\ during ambulation or ask his shoulder muscles to contract to reach for an object.ABNORMAL FUNCTIONAL PERFORMANCE

The stroke patient has lost the ability to integratethe two sides of his body to perform functional tasksin normal ways. According to Bobath and Bobath,normal movement requires (1) normal muscle tone, (2)normal postural responses, and (3) normal patternsof muscle activation and coordination. Normal taskperformance is based on sequences of normal movement that integrate movements on both sides of thebody. In many functional movements and tasks, thetwo sides of the body perform the same movements,either at the same time or in alternative sequences.Walking is an example of a movement in which thetwo sides of the body perform the same movements inalternate sequences; lifting and carrying a laundrybasket demonstrates a task in which the two upperextremities do the same movements at the same time.Other tasks such as swinging a golf club or operatinga clutch require the two sides of the body to do differentmovements at the same time. Very few movements ortasks are performed completely with only one arm orhand, and those tasks require postural adjustments on. the other side of the body.With the onset of hemiplegia, the stroke patientloses the ability to coordinate both sides of his body infunctional patterns. This affects his ability to performgross motor movements such as rolling in bed, standingup, and walking. It also interferes with his performanceof functional tasks necessary for independence in selfcare and vocational or recreation activities. Eventhough one side of the body is unaffected by the stroke,the patient is unable to use his "good" side normally,because normal movement patterns require interactionand coordination between the two sides of the body.The patient may learn to use one-handed techniquesto compensate for the loss of control on the other side,but there will be many tasks that he cannot performunless he regains some use of his hemiplegic side.Because compensatory techniques tend to increase thepatient's orientation toward his uninvolved side, theymay increase both postural asymmetry and neglect ofthe involved side. Even when the patient has someability to move his involved arm and leg, he often hasdifficulty using these movements efficiently in task performance.

Common problems in the stroke patients can besummarized as follows:~ 1. Problems associated with CNS damage includesabnormal tone, abnormal patterns of extremity

movement, and atypical posture.

2. Problems associated with deficits in control of posture and movement include poor trunk control,decreased balance and protective responses, andpoor weight bearing on the hemiplegic hip.3. Loss of specific motor abilities and task-specificbehaviors such as rolling, sitting up, walking, dressing, or bathing independently.

Although the problems listed in categories 1 and 2 mayinfluence motor and task performance, elimination ofthese symptoms may not automatically result in improved independence in task performance. In otherwords, changing the tone in a tightly flexed, spasticupper extremity so that the elbow joint can be fullyextended may not result in a patient who is activelyable to extend his elbow or put his arm in a sleeveduring dressing. Similarly, training active elbow extension does not guarantee that the patient will be able touse the movement to put his arm into a shirt sleeve.

AssessmentThe NDT/Bobath method of assessment has threebasic goals:

1. To determine the presence and distribution of abnormal tone and abnormal movement patterns thatare interfering with the production of normalmovement;2. To identify deficits in normal motor responses, including both automatic postural responses and volitional movement patterns in the trunk and limbs;3. To analyze the patient's ability to perform functionalmovement patterns, including gross motor tasks andspecific self-care, vocational, and recreational activities.To gather this information, the therapist usesobservation of the patient, direct handling of the patient's trunk and limbs, and patient interview to helpidentify problem areas. For a .complete list of motor

tasks to assess see Bobath (1990).Handlin!, techniques are used to help the therapist asse1)S the patient's automatic responses to beingmoved. By using her hands to direct and facilitatemovement, the therapist can determine the movementsand positions that produce tonal changes and the movement patterns in which the patient is able to assist.The therapist will select the positions and activities forassessment according to the patient's general level offunctioning and the areas in which he expresses mostinterest and concern. For the patient who is not yetambulatory, it is important for both physical and occupational therapists to assess functioning in standing aswell as sitting. The physical therapist will use thisinformation to prepare for gait training, whereas the


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occupational therapist will be concerned with functional performance of self-care and home-making tasksin standing.

Treatment GoalsNDT/Bobath treatment is directed..t2.!!rd a c l ~ -

ng functional oaIs. .N2rmal m.ovement e.atterns arefacl 1 ated with h a n ' techniques; then racticede patient can perform t em 10 epen entl in aSi uahons an pOSItlOns. The movements t aare emphasized "dmmg t r e a t m e ~ r e those that arenecessary for the development of further independencein task performance. For example, helping the acutestroke patient regain control of trunk movements insitting will allow the patient to balance himself safelyon the edge of the bed while putting on his clothes.

Thus during the initial treatment sessions, the therapist's handling may emphasize trunk movements insitting to reestablish the postural basis for task performance before dressing. Because lack of trunk controlwill interfere with arm function as well, the therapistmay begin to facilitate arm movements in the supineposition until the patient has regained adequate sittingbalance to combine trunk and arm treatment in sitting.The occupational therapists should try to combine thefacilitation of trunk and upper extremity movementswith the performance of functional tasks as soon assome control of movement has been established. Thetherapist helps the acute stroke patient practice trunkmovements during activities of daily living (ADL) andassists him with upper extremity weight bearing duringmeal time. In this way, the development of motorcontrol can be immediately incorporated into a normalfunctional task.In her writings and courses for therapists, B.Bobath stressed the importance of retraining the following functional tasks in patterns incorporating the involved side:1. Bed mobility tasks such as rolling, moving from

supine to sitting by coming over the involved sideand using the involved arm for support, andbridging;2. Weight shift in sitting and standing with controlledshifting over the involved leg;3. Sit-to-stand and transfers toward the involved sidewithout pushing up with the uninvolved arm;4. Control of the hemiplegic arm in weight-bearingand functional non-weight-bearing patterns;5. Gait training and balance activities to increase control of the involved leg and decrease use of canesand braces;

6. Activities of daily living and vocational and recreational activities using the involved arm andavoiding patterns that will increase spasticity.

Ideally, these tasks are introduced in the acute stageso that the patient learns to incorporate his involvedside into all movements and does not develop compensations that ignore the involved side. However, thepatient who does not receive NDT/Bobath treatment inthe acute stage may still benefit from this treatmentlater in the rehabilitation process. For this patient, thetherapist will improve function by decreasing relianceon the uninvolved side and on adaptive equipment andby increasing use of the involved arm and leg intasks that are being performed in an abnormal orcompensatory manner. For example, the therapist canincrease independence in the patient who puts hispants on lying down by increasing control of the trunkand lower extremities so that he can put his legs in thepants while sitting and pull them up and fasten themsafely while standing.NDT/Bobath treatment has three general goals forthe adult stroke patient:1. To decrease the observable symptoms of upper motor neuron lesion such as hypertonicity, asymmetrical posture, and synergistic movements, using techniques of inhibition;2. To increase the normal patterns of coordinatedmovement in the involved side and between the twosides of the body, using facilitation techniques;3. To improve functional use of the involved side anddecrease compensation and use of adaptiveequipment.ACUTE HEMIPLEGIA

During the initial days or weeks after the stroke.treatment goals for all members of the health care teanlshould be directed toward increasing function on thehemiplegic side and preventing the development ofspasticity and associated reactions. The acute strokepatient exhibits severe loss of postnral control in thetrunk and flaccid paralysis of the hemiplegic arm andleg (Fig. 24B.1). The patient has poor sitting balanceand cannot perform functional activities in sitting. Bedmobility tasks and transfers require assistance, as thepatient avoids weight bearing on his affected leg anddoes not spontaneously incorporate his affected arminto any movement patterns or activities. Because of theloss of muscle control of the shoulder, the hemiplegicshoulder frequently subluxes inferiorly.All members of the health care team will approachthese same problems with activities specific to theirprofessional expertise. For the occupational therapist,acute care treatment is directed toward:1. Regaining balance in patterns important for functionin sitting;2. Incorporating the hemiplegic arm into bed mobility

and transfers;
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Figure 24B.1. Flaccid hemiplegia with shoulder subluxationon the left side.

3. Developing strategies for self-care activities thatinvolve the affected arm;4. Maintaining alignment and mobility in the upper extremity;5. Retraining movement.HEMIPLEGIA WITH SPASTICITY

Spasticity or hypertonicity develops graduallyover a period of weeks or months after the stroke.Although some stroke patients never develop spas-ticity remaining flaccid on their hemiplegic side orexhibiting motor return without apparent tonal increases, the majority of patients will show signs ofhypertonicity in some muscle groups of their involvedside. The signs of spasticity begin to arise in conjunction with the patient's efforts to become more independent in self-care activities and with the beginning ofambulation. Initially, spastic posturing of the limbsoccurs when the patient stands, transfers, and uses


excessive effort to perform self-care activities onehanded but is not evident when he is in bed or relaxedin the wheelchair. The first muscles affected are thescapular elevators, flexors of the elbow and fingers,plantar flexors,' and extensors of the knee. Gradually,the abnormal posturing of the arm and leg persists forlonger periods of the day. At this time, the spasticmuscles resist passive stretch and may demonstrateother signs of upper motor neuron syndrome.The patient at this stage of treatment has morecontrol of his trunk and limbs than in the acute, flaccidstage. Trunk control has improved enough to allow thepatient to sit and stand without loss of balance and towalk with a brace and cane. However, the position ofthe trunk is asymmetrical, with less weight taken onthe hemiplegic pelvis and foot, lateral flexion or rotationbackward on the hemiplegic ribcage, and flexor spas-ticity in the hemiplegic arm (Fig, 24B.2). Often, thehemiplegic arm has muscle return that allows the pa-

Figure 24B.2. Spastic hemiplegia with flexor spasticity in thehemiplegic orm.


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Figure 24B.3. Flexor synergy pattern of movement.

tient to move the arm actively for the first time. However, the patient moves' with .abnormal coordinationand excessive effort in patterns of mass flexion (Fig.24B.3). The patient cannot isolate individual musclesto perform functional normal movements, nor can heeasily stop the muscles from contracting to put his armback down by his side. Tightness in the musclesconnecting the scapula to the trunk and the scapula tothe humerus limits the mobility of the scapula andblocks normal scapulohumeral rhythm needed for armelevation.During this stage of treatment, the occupationaltherapist uses NDT/Bobath techniques to inhibit theflexor posturing of the ann and to facilitate or reeducate normal patterns of upper extremity movement.Upper extremityspasticity is inhibited through scap-ula mobilization and upper extremity weight bearing.The therapist also uses NDT/Bobath techniques to trainnormal patterns of movement in the hemiplegic arm.Weight-bearing activities of the arm are often easiestfor the patient to learn, because he .does not have tocontrol the weight of the arm as when lifting it for reach.Upper extremity weight bearing activates muscles inthe trunk and arm through movements of the body overthe arm. The patient should be taught to take weighton his forearm with the arm forward on a table as well

movements with elbow e:x:t.ensiori are introduced first,and flexion and extension'movements of the elbow areadded as shoulder control increases. When the patientcan move his arm . ndependently in some patterns, heis encouraged to practice using these movements intask performance. For example, the patient who canlift his ann with elbow extension could practice usingthis movement to put his arm in his sleeve, to use asponge to clean tilt kitchen cOUnter, or to reach forwardto shake hands;At this stage of treatml'mt, the patient also shouldlearn to grasp objects with a cylindrical palmar grasp,as when holding a cane or hairbrush,


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patient to practice moving independently using theuninvolved side to provide sensory information to thehemiplegic side about how to move (Fig. 24B.5). Graspactivities should be / ncluded in treatment only whenthe wrist and forearm are positioned appropriately, sothat the patient learns to contract his finger flexors withwrist extension. As the patient develops control ofgrasp, he should practice carrying objects.THE HIGHER-LEVEL PATIENT

Many patients with hemiplegia do not progressbeyond the problems associated with spasticity anddo not develop the upper extremity control describedearlier. However, some patients never demonstratespasticity in their involved side and other patientsrespond to treatment techniques designed to inhibitspasticity and increase the motor control of their armand leg. These patients can walk well and do not showmarked asymmetries of posture, because they haverelatively good control of weight bearing on the hemiplegic leg and minimal flexor posturing of the arm.These patients are able to move their hemiplegic armswith isolated control of the shoulder and elbow and tograsp a variety of objects in their hand when the objectsare placed there. They have more problems openingthe hand to initiate grasp, extending the fingers withwrist extension for active release of grasp, and control.1ing humeral and forearm rotation for accurate handplacement. When using their arms functionally, thesepatients complain of the excessive concentration necessary to produce the desired movement and the slownessand uncoordinated quality of the arm movement. Pro-

Figure 24B.5. Bilateral grasp to reeducate arm movementsand increase arm function.


tective extension and automatic balance reactions inthe arm are usually absent or delayed.

Occupational therapy goals for these patients aredirected to improving the speed and automaticity ofarm movements, introducing variability into hand grasppatterns, and improving control of finger extensorsnecessary for controlled release of grasp. Hand movements can be practiced in isolation to reeducate specificfinger movements or in combination with movements ofthe forearm and wrist to perfect hand placement. Fingermovements and grasp patterns should also be practicedin a variety of arm and body positions and in tasksrequiring repetitive grasp and release. For the patientwhose finger dexterity and speed have improved, theoccupational therapist should introduce tasks that require manipulation of objects and bilateral coordination. At this stage of treatment, the patient shouldreplace one-handed techniques and compensatory taskperformance with use of the two hands as much aspossible. In this way, full potential of the involvedarm for function will be realized and any remainingreluctance of the patient to use his arm overcome.

TREATMENTHandling

Bobath and Bobath called their techniques oftreatment inhibition and facilitation and the implementation of these techniques, handling. The termhandling refers to the way that the therapist uses herhands on the patient's body to change the quality ofhis movement patterns. Handling is used to establishnormal alignment, to reduce or eliminate abnormal toneand movement, to reeducate muscles in normal patternsin the trunk and limbs, and to produce an acti vemovement pattern in the stroke patient. Through th eexperience of being moved by the therapist, the patientrelearns the feeling of normal movement, and uses thisas a sensory base for his attempts to move indepen-dently. Bobath and Bobath believed that the sensoryexperience of normal movement is the basis for learningnew movement patterns and assists the patient in sup-pressing unwanted abnormal patterns.

During handling, the therapist's hands are placedon the patient's body in selected positions. The termkey points of control describes areas of the bodythat make it easier to control the quality of the patient'smovement pattern. The shoulder, pelvis, and spinelribcage are key points to control proximal alignmentand movement patterns, and the. hand and foot aredistal key points that arft combined with proximalcontact to control extremity movement. The therapi stselects her hand placement according to the patient'sprohlems and the movement patterns she wishes to


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454 Section IV Treatment Principles an d Practices

reeducate. Proximal hand placements aHow the thera-pist to control the position and movement of the trunkand pelvic and scapular girdles and are generally usedwith an acute or flaccid patient. As the therapist feelsthe patient actively assisting in trunk movements andbalance, hand placement may move more distally,giving the patient independent control of the trunk orgirdles. A combination of shoulder or axillary controlwith control of the hand is used for training movementin the upper extremity.

Handling is done slowly, to give the patient timeto understand what movements are being performedand to organize his response. The therapist is lookingfor a change in the quality of the patient's muscle toneor active assistance from him, indicating normal muscleactivity. Strong and firm hand pressure is used tolengthen spastic muscles and to stop abnormal patternsof coordination. Light pressure is used to guide thepatient in a normal movement pattern, to teach thefeeling of normal movement, and to elicit an activeresponse from the patient. When the patient is ableactively to assist with the movements, the therapistdecreases her control and uses repetition and practiceto let learning occur. In all parts of the NDT/Bobathapproach, the patient should be an active and moti-vated participant.

The patient's hemiplegic side is incorporated intoall treatment activities. This may be either by directhandling by the therapist, or through bilateral activi-ties in which the patient supports movements of hisinvolved arm or leg with his uninvolved arm. Whentreating the patient, the therapist positions herself onthe hemiplegic side or directly in front of the patientso that his attention and visual regard are directedtoward what is happening during the treatment. Be-cause many hemiplegic patients are fearful of fallingand do not have accurate processing of sensory informa-tion from the hemiplegic side, the therapist uses verbaldescriptions and simple commands to tell the patientwhat she is doing and what his expected and actualresponses are. While it is possible to use handlingwith aphasic patients to produce movement withoutverbal interaction, verbal communication between ther-apist and patient should be used with handling to givethe patient feedback on his performance as well as toestablish a successful working relationship.

Inhibition techniques are manual techniquesand hand placements used to decrease or eliminatespasticity. In the early sLages of their treatment, Bo-bath and Bobath used passive positioning to lengthenspastic muscles, They called these positions reflexinhibiting postures. Although these patterns wereimportant because they demonstrated to a skepticalneurologic community that spm,ticity could he

changed, Bobath and Bobath soon concluded that SUCpatterns did not necessarily improve the patient's abiity to function or change the quality of his movemen(Bobath, 1990). As the treatment evolved, use of statpostures was eliminated and more dynamic handlinwas devised to simultaneously reduce spasticity anprepare for movement. The term reflex-inhibiting movement patterns describes the active movements that botinhibit abnormal tone and encourage or facilitate activmovement responses. For the stroke patient, NDTBobath inhibition techniques are used to:1. Correct alignment, lengthen shortened muscles, andecrease abnormal tone in specific muscles;2. Stop unwanted movement patterns from occurring3. Teach the patient methods of decreasing the abnomal posturing of his limbs.Inhibition techniques are not used in patients whdo not have spasticity or associated reactions.

Common techniques of inhibition include trunrotation, weight bearing, and techniques to lengthemuscles and realign joints. Rotational movementsthe spine are used to decrease spasticity in the trunkand scapular and pelvic girdles. Weight bearingused to decrease spasticity in the arm and leg, b e c amovements of the trunk over the fixed e x t r e m i t i elengthen tight muscles between the trunk and limbIn the arm and leg, the pull of spastic musclesinhibited by returning the affected' body parts to nomal alignment and slowly lengthening the tight musclin a proximal to distal sequence. Scapula mobiliztion is an example of an upper extremity inhibitiotechnique used to reposition the scapula and lengthethe tight muscles around the shoulder girdle.

Facilitation techniques are those patterns handling that help the patient move more normallyThe term is taken from the verb, facilitate, whicmeans to make easier. Facilitation handling tecniques are designed to:1. Teach the sensation of normal movement by movinthe limbs in space with proper patterns of initiatioand sequencing;2. Stimulate muscles directly to contract isometricall

eccentrically, and isotonically,;3, Hold alignment and provide postural stabil ity whithe patient practices movement;4. Reeducate normal movement patterns;5. Teach the pat ient ways to incorporate the involve

side into transitional movements and functional ativilies.


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the patient the sensation of movement, to allow thepatient the opportunity to move with the therapistbefore moving independently. In the initial stages oftreatment, the therapist establishes normal alignmentand guides the patient's body and limbs in normalpatterns of movement. The patient is encouraged toassist with the movement when he can. As the patientbegins to assist, the therapist first lightens, then eliminates a portion of her control so that the patient hasopportunities within each treatment session to moveindependently. Many patients do not know that theycan move their arms or bodies in the desired patternsuntil the handling of the therapist makes it possiblefor them to find the correct muscles. The active assistive quality of facilitation also helps to decreasethe excessive effort that many hemiplegic patients useto initiate active movement of their involved side.In cases of flaccid hemiplegia, facilitation tech-niques may be combined with stronger stimulationto increase muscle tone and produce active musclecontraction. For these patients, Bobath and Bobathdeveloped stimulation techniques, which use tactileand proprioceptive input to increase the intensity andduration of muscle contraction. NDT/Bobath stimula-tion techniques are applied directly to muscle or viajoint approximation to stimulate muscle contractionaround the joint. These techniques are performed withthe body in normal alignment and directed toward areasof the body that are critical for a normal movementpattern. For example, stiniulation teclmiques couldbe used to increase muscle contraction around theshoulder of a flaccid arm. After carefully aligning thescapula and glenohumeral joint, stimulation tech-niques (tapping over muscle bellies) would be appliedto th e deltoid and scapular muscles as the patientattempted to bear weight on the glenohumeral joint.Stimulation techniques must be used carefully toavoid producing an abnormal response in the musclesbeing stimulated. Once muscle contraction is established, the therapist returns to guided movement to usethe muscle contraction in a movement pattern.

Compensatory TrainingStroke causes long-standing muscle weakness andloss of trunk control, which interfere with the normaluse of the involved arm and leg. While many strokepatients eventually regain good use of their hemiplegic

side, they must begin the process of becoming independent in life tasks long before they have sufficient useof their arm and leg to perform these tasks normally.For this reason, compensatory training is necessary. Inthe NDT/Bobath framework, compensatory training isdirected toward 01 incorporating the involve!l arm

24 Remediating Motor Control and Performance 4.55

into task performance and (2) teaching patterns ofcompensation that do not encourage the developmentof spasticity and associated reactions.Much of the Bobath compensatory training usessymmetrical, bilateral upper extremity patterns tomaintain alignment of the upper trunk and shouldergirdle and prevent the arm from being neglected orabnormally positioned. The patient may be taught toclasp his hemiplegic hand with his other hand andmaintain the arm in a position of extension duringrolling, transfers, and other gross motor activities. Thehemiplegic arm can also be placed in a position ofweight bearing during task performance in sitting andstanding. These concepts will be presented in moredetail below..RETRAINING TRUNK MOVEMENTS

The acute stroke patient is unable to maintainhis balance in sitting and cannot perform functionalactivities such as bathing and dressing in sitting, because he has lost control of the automatic posturalpatterns that make performance of these activities possible. To help the patient improve task performance insitting, the occupational therapist must retrain patternsof trunk movement. This training is done first with thetherapist assisting the patient in performing the trunkmovements. Trunk movements are easiest to reeducatewhen the patient is seated on a treatment mat orfirm chair.The therapist stands in front of the patient andplaces both of the patient's hands against her own hipsto keep the patient's upper body symmetrical and toprotect his hemiplegic shoulder joint. Trunk movements in anterior-posterior, lateral, and rotational di-rections are then practiced, with the therapist controlling the direction and range of the movements.Movement forward toward the floor and sideways towardthe plinth should be practiced as well as movementsin upright sitting, because these movements preparethe patient to control body movements in the directionof the pull of gravity (Fig. 248.6). As muscle controlimproves and the patient begins to assist in the weightshifts, the patient can practice the movements whilesupporting his hemiplegic hand with his good handwithout the assistance of the therapist.The oceupational therapist will make the movements functional for the patient in two ways: (1) combining the weight shifts with reaching tasks and (2)helping the patient incorporate the appropriate movements with the performance of an actual task such asdressing or bathing. The hemiplegic arm is easily'positionell for upper extremity dressing by having thepatient pul h i:-;. hemiplegic hand in the sleeve, thenlean furward toward ! he /loor to a:-;sist elbow extension


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' rJU .:: e n n 11 ' 1 reatment nnc ptes an ract ces

Figure 24B.6. Retraining trunk movements with the hemiplegic arm supported on the therapist's body.

and shoulder flexion, making it easier to pull the sleeveup over the arm.INCORPORATING THE HEMIPLEGIC ARM

It is important that the hemiplegic arm be incorporated into the early training of gross motor activitiessuch as rolling, coming to sitting, and coming to standing and transfers. Including th

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