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NDT

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-referred to as Bobath approach because developed by Berta & Karel Bobath -1940s, continues to develop today -postgraduate certification (8wk ped, 3wk adult, 3wk baby)

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clinical use of NDT

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-children w/ neurological deficits (CP) -adults w/ hemiplegia (stroke, TBI)

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assumptions of NDT

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-models of motor control -dysfunction from CNS damage results -function improved via use of effective mvmt patterns

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motor impairments result in mvmt dysfuntion

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+ signs: spasticity impaired muscle activation impaired motor execution - signs: insufficient force generation - weakness impaired anticipatory postural control hypokinesia: poverty of mvmt loss of fractionated or dissociated mvmts

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spasticity

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-UMN disorder -velocity-dependent increase in tonic stretch reflexes w/ exaggerated tendon jerks & clonus -measured by MAS scale -EARLIER thought to be primary impairment creating mvmt dysfunction -NOW thought to be related to strength, timing, & sequencing

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spasticity enhanced excitatory input

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-increased depolarization from segmental afferents, -enhanced regional exitatory interneurons -enhanced monosynaptic descending pathways

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spasticity reduced inhibitory input

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-reduced reciprocal inhibition of antagonist motor neuron pools by Ia afferents -decreased presynaptic inhibition of Ia afferents -decreased nonreciprocal inhibition by Ibafferents

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impaired motor activation due to:

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-excessive co-activation -impaired muscle synergies

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excessive co-activation

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-creates joint stiffness -reduction in DOF strategy ----referred to often in NDT as 'fixing'

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impaired muscle synergies

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-functional linking/ coupling of muscle groups -patterns can be so strong (stereotypical) that they restrict adaptation to conditions for variable & fluid movement ie. synergirstic pattern= bilateral pull w/ arms & extension of legs to rise to standing of spastic diplegic

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impaired motor execution due to:

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-modulation & scaling of forces -timing -sequencing -overflow

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modulation & scaling of forces

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-difficulty executing appropriate force & tension for grasp & release -difficulty controlling acceleration & deceleration

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timing dysfunctions

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difficulty initiating, slow performance, & difficulty terminating movement

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sequencing dysfunctions

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-muscles firing in opposition to the mvmt -prolonged contraction in a mvmt -firing wrong muscle

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overflow impairments

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-widespread contractile activity in same body segment or far removed (eg. controlateral) -part of normal development -used therapeutically (associated mvmts)

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another term for insufficient force generation?

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weakness

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primary causes of weakness:

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-insufficient descending motor message converging on final neuron pool -reduced # of MU caused by atrophy -difficult modulating firing frequency

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secondary causes of weakness:

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-atrophy from disuse -atypical development of fiber type & dispersion in CP

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impaired anticipatory postural control

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-generation of force prior to intended mvmt to set posture -anticipate force, velocity, & direction of intended mvmt & objects involved

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hypokinesia

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poverty of mvmt

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child w/ CP hypokinesia mvmts:

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-lack fluidity, variety, or complexity -ROM small -usually flexion & extension w/out rotation

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adults w/ stroke hypokinesia mvmts:

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-do NOT automatically adjust postural position in sitting (risk of decubiti) -do NOT spontaneously practice movements

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loss of fractionation/dissociated mvmts:

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-difficulty making precise, independent joint mvmts -results in stereotypical patterns as loss of both hand dexterity & trunk rotation

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sensory impairments result in mvmt dysfunction inability to:

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-detect & identify incoming information -interpret input -modulate inputs to match task & environmental demands -match information w/experience, memory, & specific tasks

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secondary impairments in musculoskeletal system result in mvmt dysfunction of:

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-joints -muscles -skin & fascia

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joint dysfunctions:

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-hypermobility: hypotonia (chronic stretch and malalignment) -hypomobility: hypertonia (contractures) ------common in feet of kids w/ CP -different joints are prone to one or other depending on pattern of hypo & hypertonia involved

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muscle dysfunctions:

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-loss of sarcomeres with atrophy from disuse or restricted movement -restricted mvmt can occur w/ orthotics

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skin & fascia dysfunctions:

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become tight & adhere to muscles, tendons, & bones

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principles of tx:

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-GOAL: retrain efficient movement responses on pt's hemiplegic side -AVOID activities that increase abnormal tone or strengthen abnormal mvmts -techniques to suppress/ inhibit mvmts -activities that STRENTGHEN normal mvmt patterns (co-contraction) -existing motor control on hemiplegic side for occ. performance (ACTIVE mvmt) -ADAPTATIONS & compensations that encourage use of affected side & decrease abnormal mvmt patterns

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wear bearing exercises for spasticity produce?

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-co-contraction pattern on muscles -sustained stretch

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postural alignment

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how body parts relate to each other & gravity -FIRST thing you need to do w/pt

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postural control

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-ability to assume & maintain postures during static & dynamic activity -essential for ALL mvmts

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base of support

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-CANNOT move a part of the body you are weight bearing on

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weight shift

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to unweight the part of the body we want moved we need to know where it's going next

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reflex inhibiting postures

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-patterns that counteract the pull of tight or spastic muscles -used to reduce tone(spasticity) to prepare for mvmt

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keys points of control

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places to put hands that are most effective for controlling the patient's movement - proximal & distal

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inhibition

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prevent mvmt

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facilitation

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create mvmt

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dissociation of mvmt

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-ability to DIFFERENTIATE movements between various parts of the body -part of developmental process -part of breaking up fixed patterns to increase DOF

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stability

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axial-POSTURAL muscles

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mobility

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-DISTAL muscles -dependent on stability as distal mvmts activate a postural adjustment

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rotation

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-DIAGONAL mvmts around trunk which requires dissociation -common in PNF

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role of sensation

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-normal mvmt is learned by experiencing what normal mvmt feels like -now adapted contemporary motor control & motor learning theory for effective mvmt -initially feedback is focused on proprioception -now incorporating +sensation ie. vision

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T/F? motor learning is a PASSIVE process

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false; ACTIVE

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muscle tone of NDT

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-assumption you CANNOT impose normal mvmt on abnormal tone -prepatory task to align

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co-contraction

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simultaneous contraction of all muscles around a joint to block movement (reduce DOF)

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fixing

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voluntary cocontraction

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underlying tone

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generally hypotonicity occurs during mvmt

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use of inhibition techniques

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-decrease abnormal muscle tone interfering w/ passive & active mvmt -restore normal alignment in the trunk & extremities by lengthening spastic muscles -stop unwanted mvmts & associated reactions from occurring during mvmt & function -teach methods for decreasing the abnormal posturing of the arm & leg during task performance

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main focus of inhibition techniques

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-keep ACUTE angle of hip or ANTERIOR pelvic tilt to inhibit spastic legs -always position hips FIRST

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passive elongation

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-shortened muscles lose strength because they are contracting at end ROM -passive ROM gently done to prepare muscles

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proximal dissociation

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-synergistic (attractor) patterns are strong -dissociating or breaking up patterns helps inhibit synergy

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reflex inhibiting patterns

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-positioning to inhibit attractor patterns -position that counteracts the pull of spastic muscles -used to inhibit abnormal tone & to facilitate more normal patterns of muscle activation

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weight shifting

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-wt shifting over small ranges relaxes tone -can be trunk over proximal BOS -can be body over distal BOS -mvmt over BOS you want at end of mvmt -unweight over current BOS -simulates muscles to contract reciprocally rather than static wt bearing

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limb oscillation

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shaking limbs reduces tone ie. arms, fingers

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joint traction/compression & pressure tapping

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facilitates mvmt

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sweep tapping

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-quick brisk slaps of muscle belly in upward sweep -most frequently used on abdominals

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placing & lowering

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-positioning limb & asking client to hold it -start in antigravity position -work up to holding against gravity/ resistance

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points of control

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-therapist facilitates from (where place hands) -proximal or distal control

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key points of control for inhibiting postures

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hips, shoulders, neck

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inhibition of spasticity in hemiplegic arm using RIP steps:

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1 position patient in sitting 2 place hands on hemiplegic arm, use key points of control, pts arm flexed& adducted 3 correct adduction of humerus first, leaving elbow flexed 4 maintain humerus in neutral rotation by side of body & use pressure on top of forearm to extend elbow gradually, if forearm is supinated, pronate it first. 5 when tension in biceps has decreased, slide your hand from top of forearm to wrist & hand; extend wrist to neutral first, leaving fingers flexed 6 when tension in wrist flexors decreased, open fingers, keeping wrist in neutral 7 maintain arm in extension & proceed to weight bearing or guided mvmt

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process of facilitation steps:

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1 restore alignment using key points of control 2 assist desired movement using light hands 3 proceed slowly & feel for pt's response 4 repeat mvmts until pt can actively assist 5 lighten messages of your hands so that the pt moves w/ less assistance; give verbal feedback 6 gradually withdraw control; pt's mvmt control may decline but should NOT produce an abnormal response 7 provide practice opportunities via use of activities

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research on NDT

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-mixed info -bottom line is studies have NOT shown treatment to be effective -concerns about study methodology -more research needed

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