The Bobath Concept in Adult Neurology Bente E. Bassøe Gjelsvik Physiotherapist Advanced Bobath Instructor IBITA Bergen, Norway 241 Illustrations Thieme Stuttgart · New York LibraryofCongressCataloging-in-PublicationData Importantnote:Medicineisanever-changingscience Gjelsvik,BenteE.Bassøe. undergoingcontinualdevelopment.Researchand TheBobathconceptinadultneurology/ clinicalexperiencearecontinuallyexpandingour BenteE.BassøeGjelsvik. knowledge,inparticularourknowledgeofproper p.;cm. treatmentanddrugtherapy.Insofarasthisbook Includesbibliographicalreferences. mentionsanydosageorapplication,readersmayrest ISBN978-3-13-145451-5 assuredthattheauthors,editors,andpublishershave (TPS,restofworld:alk.paper)– madeeveryefforttoensurethatsuchreferencesarein ISBN978-1-58890-621-2 accordancewiththestateofknowledgeatthetime (TPN,theAmericas:alk.paper) ofproductionofthebook. 1.Centralnervoussystem–Diseases–Physicaltherapy. Nevertheless,thisdoesnotinvolve,imply,orexpress 2.Centralnervoussystem–Diseases–Patients–Rehabi- anyguaranteeorresponsibilityonthepartofthe litation.3. Physicaltherapy. I.Title. publishersinrespecttoanydosageinstructionsand [DNLM:1. CentralNervousSystemDiseases–physio- formsofapplicationsstatedinthebook.Everyuseris pathology.2. CentralNervousSystemDiseases–re- requestedtoexaminecarefullythemanufacturers’ habilitation.3. NeuronalPlasticity.4. Neurophysiol- leafletsaccompanyingeachdrugandtocheck,ifne- ogy–methods.5. PhysicalTherapyModalities. cessaryinconsultationwithaphysicianorspecialist, WL300G5395b2008] whetherthedosageschedulesmentionedthereinor RC350.P48G542008 thecontraindicationsstatedbythemanufacturers 616.8–dc22 differfromthestatementsmadeinthepresentbook. 2007030566 Suchexaminationisparticularlyimportantwithdrugs thatareeitherrarelyusedorhavebeennewlyre- leasedonthemarket.Everydosagescheduleorevery Illustrators:GuenterBosch, formofapplicationusedisentirelyattheuser’sown M(cid:1)nsingen-Dottingen,Germany; riskandresponsibility.Theauthorsandpublishers AdrianCornford,Reinheim-Zeilhard,Germany. requesteveryusertoreporttothepublishersany discrepanciesorinaccuraciesnoticed.Iferrorsinthis workarefoundafterpublication,erratawillbeposted atwww.thieme.comontheproductdescriptionpage. c2008GeorgThiemeVerlag, Someoftheproductnames,patents,andregistered R(cid:1)digerstrasse14,70469Stuttgart,Germany designsreferredtointhisbookareinfactregistered http://www.thieme.de trademarksorproprietarynameseventhoughspecific ThiemeNewYork,333SeventhAvenue, referencetothisfactisnotalwaysmadeinthetext. NewYork,NY10001,USA Therefore,theappearanceofanamewithoutdesig- http://www.thieme.com nationasproprietaryisnottobeconstruedasa representationbythepublisherthatitisinthepublic TypesettingbyHagedornKommunikation,Viernheim, domain. Germany PrintedinGermanybyGCC—GrafischesCentrum Thisbook,includingallpartsthereof,islegallypro- Cuno,Calbe tectedbycopyright.Anyuse,exploitation,orcom- mercializationoutsidethenarrowlimitssetbycopy- rightlegislation,withoutthepublisher’sconsent,is ISBN978-3-13-145451-5(TPS,RestofWorld) illegalandliabletoprosecution.Thisappliesinpar- ISBN978-1-58890-621-2(TPN,TheAmericas) ticulartophotostatreproduction,copying,mimeo- graphing,preparationofmicrofilms,andelectronic 123456 dataprocessingandstorage. StructureoftheBook V Preface About the Author x enablingthereaderto formhypotheses throughclinicalreasoningintreatmentsitua- tionsbasedonaconceptualunderstanding I trained as a physiotherapist at the School of oftheinteractionbetweenhumansandthe Physiotherapy, Royal Victoria Infirmary, New- environment,andbetweentheCNS,themus- castle-upon-Tyne, England, in 1978. For a short culoskeletalsystems,movement,andfunction. time I worked in a newly opened hospital in Clinical reasoning cannot be learned through Newcastle, before I moved back to Norway with readingabook:itisdevelopedthroughcontinu- my husband. Since July 1978 I have worked in ous critical evaluation of one’s own practice, by Haukeland University Hospital in Bergen; for pursuing answers through experimenting and the first 7 years in medical wards, from 1985 to by improving one’s evidence-based knowledge. I 1996 in the Neurology Department, and since hope that this book may help the reader in this then in the Department of Physical Medicine process. andRehabilitation.Ihavebeeninvolvedindiffer- The book is written for physiotherapists and ent projects, one of which was the development occupational therapists, students, and qualified of a rehabilitation network in Norway. This led professionals. It is mainly aimed at the clinician to the opening of what is now the Department working with neurologically impaired indivi- ofPhysicalMedicineandRehabilitationin1996. duals. I have taken part in many research projects andIhaveco-authoredseveralarticles. ItrainedasaBobathInstructorwiththe Brit- ish Bobath Tutor Association (BBTA). I was ap- Structure of the Book proved by the International Bobath Instructors Training Association (IBITA) as a Bobath Instruc- torin1991,andasanAdvancedBobath Instruc- The book is meant to be read in the way it is tor in 2004. I am a specialist in neurorehabilita- structured. The chapters build on each other, tion and have been a member of the Norwegian and the reader may miss important information Physiotherapist Association since 1995. I have and discussions if it is primarily used as a refer- extensive teaching experience and have taught encebook.Idohope,however,thatitwillbeuse- courses in many countries in Europe. Currently, fulasareferenceonce readthrough. IamtheChairpersonofIBITA. Chapter1,AppliedNeurophysiology,isdivided intothreeparts: x 1.1SystemsControl:Thisdealswith some systemsandstructuresconcernedwith Aims of This Book movementandsensorimotorintegration.This parttakesabrieflookatthestructureand functionofpartsoftheCNS,anddescribesthe To improve the therapist’s competency in the interactionbetweenCNSfunction,muscle treatment of individuals with neurologic condi- function,function,andmovement.Conse- tionsby: quencesofCNSlesionsandclinicalreflections x building bridgesbetween: arediscussedthroughout. – thestructureandfunctionofthecentral x 1.2Plasticity:Thispartoutlineschangesinthe nervoussystem(CNS),theneuromuscu- CNSasaresultofnatureandnurtureand loskeletalsystems,andtheabilityfor asaconsequenceofCNSlesions.These change(plasticity); changesformthebasisforlearningandare – posturalcontrolandmovement;andthe thereforeimportantto understand.Implica- – treatmentofneurologicconditions. tionsfortherapyarediscussed. VI Preface x 1.3ConsequencesofandReorganizationafter Chapter 2, Physiotherapy, discusses normal CNSLesions:Thispartattemptstoputthe balanceandmovement,anddeviationsfromnor- consequencesofCNSlesionsandplasticity malmovementaswellaschoicestherapistsmay intoaclinicalcontext.Thispartdiscussesand haveforinterventions. formulateshypothesesaboutthecauseand Chapter 3, Assessment, looks at the Interna- effectoflesions andthesensorimotorprob- tional Classification of Functioning, Disability, lemsthatpatientsexperience.Clinicalsymp- and Health as a basis for assessment. Some out- tomssuchasspasticityandassociatedreac- comemeasuresarealsobrieflydescribed. tionsarediscussed. Chapter 4, Case Histories, presents the case studiesoftwoindividuals,SisselandLisa. I have used the pronoun “he” for the patient and “she” for the therapist except where photos show differently, although in real life the situa- tion isoftenreversed. Foreword VII Foreword At this time we know more about the central Bobath Concept and its current interpretation of nervous system than ever before, but to bring movement control. The basis of the text is to about the reality of a functional recovery after a understand thestructureand function of the or- lesion is still a very serious clinical challenge to ganism, which is expressed through an under- both patients and therapists. In this book Bente standing of posture and movement control. It is Gjelsvik, an acknowledged Bobath Instructor a clinically oriented text concluding with two and Clinical Specialist in Neurology, brings all detailed case histories that will be of significant herskillstoexplainaconceptwhichhasevolved interest to all professions involved in the man- over decades to address the complexities of agementofneurologicdisability. neuro-disability. She adopts a problem-solving approach consistent with the definition of the MaryLynch-Ellerington VIII Acknowledgments Acknowledgments The first book that I published with Thieme was MyhusbandOlavGjelsvikisacloseandcriti- in German: Form und Funktion. It is thanks to calcolleague.HeisaphysiotherapistandBobath my German editor, Eva Maria Gr(cid:1)newald, that Instructorandhasgivenmevaluablesupport,en- her colleague Angelika-M. Findgott at Thieme couragement,andinputthroughoutthisprocess. Publishers, the English branch of Thieme Verlag, MygreatfriendandmentorMaryLynch-Eller- became interested in publishing an English edi- ington is a Senior Bobath Instructor and the tion—the book you are holding in your hands professional leader of BBTA. She has, over many now.Mythanksgotobothmyeditors. years, given me the basis for my conceptual This English edition is based on the German understanding of the Bobath Concept. She is an one, but it has been revised and updated. A sec- extremely generous person, sharing her insight ond German version with the same updates and andknowledgewithcolleaguesandcourseparti- revisions has already been published. I have cipantsallover theworld. done the revision and translation (from Nor- Last but not least, a special thank you to the wegian) into English myself, with great help patients and colleagues who were willing to be frommyEnglishcolleaguesattheBritishBobath includedinthisbook. TutorsAssociation(BBTA):LynneFletcher,Janice Champion,andLinziSmith. BenteEBassøeGjelsvik Contents IX Contents Introduction.................. 1 ActiveMovement;LearnedNonuse; The Bobaths: AHistorical Overview.. 1 Neglect;PassiveMovement......... 125 The International BobathInstructors ControlofAssociatedReactions...... 127 Training Association—IBITA......... 1 Feedback ....................... 128 IBITA’sTheoretical Assumptions Carry-over ...................... 130 andClinical Practice .............. 3 2.3 OtherInterventions:SomeKeyPoints 132 StrengthTraining................. 132 1 Applied Neurophysiology...... 5 TreadmillTraining ................ 133 1.1 Systems Control: Systems and MultidisciplinaryTeamwork ........ 135 StructuresConcernedwithMovement AssistiveDevices ................. 135 andSensorimotor Integration ...... 6 MedicalInterventionfortheTreatment TheNeuromuscularSystem......... 6 ofSpasticity ..................... 141 TheSomatosensorySystem,Vision, andBalance ..................... 14 3 Assessment................... 145 TheBrainandSpinalCord.......... 23 3.1 The International Classification of 1.2 Plasticity ....................... 47 Functioning, Disability, andHealth .. 145 Neuroplasticity................... 49 3.2 Physiotherapy Assessment ......... 147 1.3 Consequences of andReorganization History ......................... 148 after CNS Lesions................. 56 Functional Activity................ 149 UpperMotorNeuronLesions........ 58 Body FunctionsandStructures ...... 151 TheComplexProblemoftheUpper Sensation,Perception,and MotoneuronSyndrome ............ 60 LearnedNonuse .................. 154 Pain ........................... 156 2 Physiotherapy ................ 67 ClinicalReasoning ................ 157 2.1 Balance andMovement ........... 68 TheAimofAssessment ............ 158 HumanMovementControl ......... 68 3.3 OutcomeMeasures ............... 163 Balance......................... 69 BodyStructureandFunctionMeasures 163 DeviationsfromNormalMovement ActivityMeasures ................ 164 andBalance Control............... 81 Self-ReportMeasures.............. 165 2.2 Intervention—Considerations and ObjectiveGoalSetting ............. 165 Choices......................... 90 AssessmentDiagram .............. 165 PosturalSets .................... 90 EvaluationandDocumentation ...... 166 AnalysisofBasicPostures Conclusion ...................... 166 andPosturalSets ................. 91 KeyAreas ....................... 108 4 Case Histories ................ 169 SelectiveMovementandFunctional 4.1 CaseHistory: Sissel ............... 169 Activity......................... 110 PastMedicalHistory,SocialHistory, TheRelationshipbetweenAutomatic Activities,andParticipation......... 169 andVoluntaryMovement .......... 112 HistoryofPresentIllness........... 169 Handling........................ 116 Assessment...................... 170 ClinicalReasoningandHypothesis ... 175