The Bobath concept - a model to illustrate clinical practice

ボバースフレームワーク:をむのにするシステマチックサイエンスのアプローチ

現在、発達領域で推奨されているボバース臨床推論フレームワーク(Bobath Clinical Reasoning Framework: BCRF)によるボバース実践を、システム科学のレンズによって概念化し、小児期発症の障害に関連する様々な変数の相互関係・相関依存に対する全人的観点を提供する。BCRFはICFの各領域間の関係性を理解し、それぞれがどのように影響を与え、どのように影響を受けるのかを理解する助けとなる臨床推論の詳細なフレームワークである。BCRFは介入計画へとつながる観察に基づく学際的なシステムであり、実践的な推論のアプローチである。BCRFにより脳性麻痺(Cerebral Palsy: CP)などの障害における複雑な状況を全人的に理解し、神経学的障害がある人々の生涯にわたるマネジメントおよびハビリテーションの基盤を持つことができる。BCRFが用いる臨床推論は、個々人およびその社会的環境、とくに家族単位で見られる重要な文脈的要因を重視している。定型発達・非定型発達、病態生理(感覚運動・認知・行動)、神経科学の相互関連性、および、心身機能・身体構造レベルの構成要素がどのように活動・参加レベルに影響を与えるのか、BCRFはその理解に根差している。BCRFにとって不可欠なシステム科学system science※1)のモデルはCPの複雑性を理解および対応を進める有用な方法であり、何よりも大切な目標とはあらゆる文脈であらゆる個々人の生きた経験を最適化することである。.

Postextubation dysphagia management in Danish intensive care units: A national survey

BACKGROUND

Postextubation dysphagia (PED) is a common complication to endotracheal intubation in critically ill patients and may lead to pneumonia, prolonged ventilation, longer hospital stays, and increased mortality. Recognizing dysphagia is paramount to preventing adverse events. The aim of this study was to describe PED management by investigating practice in Danish intensive care units (ICUs) focusing on current practice in 2023 (screening, prevention, and treatment), perceived best practice (barriers and facilitators), and when possible, to compare practice in 2017 and 2023.

METHODS

Self-reported, cross-sectional survey of dysphagia practice in Danish ICUs administered from April to May 2023. In addition, data were compared with the 2017 Dysphagia in Intensive Care Evaluation study, when possible.

RESULTS

Only half of Danish ICUs reported to have a PED protocol, and less than half routinely screen patients for dysphagia after extubation. Most common screening methods were the oral mechanism examination, water test, and Facio-oral tract therapy. Nurses and physicians often relied on an overall physical assessment of the patient. Best treatment methods were uniformly agreed to be patient positioning, modification of food and fluids, use of ergonomic utensils, and compensatory maneuvers. Key barriers to dysphagia management were lack of specialized staff, under-recognition of dysphagia as a health issue, and lack of standardized protocols.

CONCLUSION

Awareness of PED is increasing and identification, prevention, and treatment is slowly improving, but systematic implementation of protocols for dysphagia screening and treatment could enhance dysphagia management in Danish ICUs.

Le cadre de raisonnement clinique Bobath: un modèle de science des systèmes pour aborder la complexité des troubles neurodéveloppementaux, y compris la paralysie cérébrale

La pratique Bobath actuelle telle qu'elle est recommandée dans le cadre du Bobath Clinical Reasoning Framework (BCRF) se base sur une application clinique de la science des systèmes. Elle offre une perspective holistique des relations entre les variables qui sont associées à l'apparition d'un handicap chez l'enfant. Le BCRF est un cadre de raisonnement clinique qui peut aider à comprendre les relations entre les domaines de la Classification Internationale du Fonctionnement, du Handicap et de la Santé. C'est un système d'observation transdisciplinaire de raisonnement pratique qui vise à proposer un plan d'intervention. Plus généralement, le BCRF permet une compréhension holistique de la complexité des situations associées à des troubles tels que la paralysie cérébrale et indique des choix d'adaptation et de prise en charge tout au long de la vie des personnes vivant avec des troubles neurologiques. Ce raisonnement clinique se base sur les facteurs contextuels importants de l'individu et de son environnement social, principalement la cellule familiale, et sur une compréhension des relations entre le développement typique et atypique, la physiopathologie (sensorimotrice, cognitive, comportementale) et les neurosciences, ainsi que sur l'impact des fonctions et des structures corporelles sur les activités et la participation. Le modèle de la science des systèmes du BCRF permet d'aborder la complexité de la paralysie cérébrale, avec l'objectif global d'optimiser l'expérience vécue par chaque individu dans chaque contexte.

El marco de razonamiento clínico de Bobath: Un modelo de ciencia de sistemas para abordar la complejidad de los trastornos del neurodesarrollo incluida la parálisis cerebral

La actual práctica de desarrollo Bobath recomendada dentro del Marco de Razonamiento Clínico Bobath (BCRF) puede conceptualizarse utilizando la visión de la ciencia de los sistemas. Proporciona, así, una perspectiva holística de la interrelación e interconexión de las variables asociadas con la discapacidad aparecida durante la infancia. El BCRF se define como un marco exhaustivo de razonamiento clínico que puede aplicarse para ayudar a comprender las relaciones entre los dominios de la Clasificación Internacional del Funcionamiento, de la Discapacidad y de la Salud, cómo se puede influir en esos dominios y cómo influyen entre sí. El BCRF es un sistema de observación transdisciplinario y de razonamiento práctico que da lugar a un plan de intervención. Esto proporciona una comprensión holística de la complexidad de las situaciones asociadas a trastornos como la parálisis cerebral (PC) y la base para la gestión y habilitación a lo largo de la vida de personas que viven con trastornos neurológicos. El razonamiento clínico utilizado por el BCRF se basa en los importantes factores contextuales del individuo y su entorno social, principalmente la unidad familiar. Se basa en la comprensión de las interrelaciones entre el desarrollo típico y atípico, la fisiopatología (sensoriomotora, cognitiva, conductual) y la neurociencia, así como el impacto de funciones y estructuras corporales sobre la actividad y la participación. El modelo de ciencia de sistemas del BCRF es una forma útil de comprender y responder a la complejidad de la parálisis cerebral, con el objetivo global de optimizar la experiencia vivida de todo individuo en cualquier contexto.

O Quadro de Raciocínio Clínico Bobath: Uma abordagem de ciência de sistemas para a complexidade das condições do neurodesenvolvimento, incluindo a paralisia cerebral

Esta revisão descreve um modelo de prática pediátrica recomendada do Bobath, o Quadro de Raciocínio Clínico Bobath (QRCB), e explica como esse conhecimento contribui para a área de habilitação em distúrbios pediátricos. A ciência de sistemas proporciona uma nova maneira de concetualizar a paralisia cerebral como uma condição complexa. Ela foi aplicada ao QRCB para ilustrar uma perspetiva holística sobre a inter-relação e interconexão das variáveis associadas à PC. O modelo de ciência de sistemas adotado pelo QRCB é uma forma promissora de construir uma estrutura abrangente que engloba a complexidade da PC e possibilitará pesquisas mais robustas.

Bobath Klinik Gerekçelendirme Çerçevesi: Serebral palsi dahil nörogelişimsel durumların karmaşıklığında sistemler bilimi yaklaşımı

Bobath Klinik Gerekçelendirme Çerçevesi (BKGÇ) içerisindeki önerilen güncel gelişimsel Bobath uygulaması sistemler bilimi merceği kullanılarak kavramsallaştırılabilir ve bunu çocukluk çağı engelliliği ile ilişkilendirilen değişkenlerin birbirine bağlılığı ve etkileşimine bütüncül bir bakış açısıyla sağlar. BKGÇ, İşlevsellik, Yetiyitimi ve Sağlığın Uluslararası Sınıflandırması (ICF)’nın alt boyutları arasındaki ilişkiyi ve bu alt boyutların birbirini nasıl etkilediğini anlamak için uygulanabilen derinlemesine bir klinik gerekçelendirme çerçevesi olarak tanımlanmaktadır. BKGÇ, bir tedavi planı ile sonuçlanan klinik gerekçelendirme ve transdisipliner gözlemsel bir sistemdir. Bu sistem ise, serebral palsi (SP) gibi bozuklukların karmaşıklığını anlamak için bütüncül bir anlayış sunar ve nörolojik bozukluğu olan bireylerin yaşam boyu tedavisi ve rehabilitasyonu için temel oluşturur. BKGÇ tarafından kullanılan klinik gerekçelendirme, başta aile birimi olmak üzere bireyin ve sosyal çevresinin önemli bağlamsal faktörlerine dayanmaktadır. Tipik ve atipik gelişim, patofizyoloji (sensorimotor, bilişsel, davranışsal) ve sinirbilim arasındaki karşılıklı ilişkilerin ve bu vücut yapı ve fonksiyonlarının aktivite ve katılım üzerindeki etkisinin anlaşılmasına dayanır. BKGÇ'nin ayrılmaz bir parçası olan sistemler bilimi modeli, SP'nin karmaşıklığını anlamak ve buna yanıt vermek için yararlı bir yoldur; kapsayıcı hedef, herhangi bir bağlamda herhangi bir bireyin yaşadığı deneyimi optimize etmektir.

Effectiveness and efficiency of telerehabilitation on functionality after spinal cord injury: A matched case-control study

BACKGROUND

Telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and health outcomes in patients with spinal cord injury (SCI). The clinical effectiveness of teleSCI is not known.

OBJECTIVES

To compare independence in activities of daily living and mobility capacity in patients following teleSCI and matched controls undergoing traditional rehabilitation.

DESIGN

Matched case-control study.

SETTING

TeleSCI occurring in home setting (cases) versus traditional rehabilitation on inpatient unit (controls).

PARTICIPANTS

Forty-two consecutive patients with SCI followed with teleSCI were compared to 42 historical rehabilitation inpatients (controls) matched for age, time since injury to rehabilitation admission, level of injury (paraplegia/tetraplegia), complete or incomplete injury, and etiology (traumatic/nontraumatic). The teleSCI group (n = 42) was also compared to the complete cohort of historical controls (n = 613).

INTERVENTIONS

The teleSCI group followed home-based telerehabilitation (3.5 h/day, 5 days/week, 67 days average duration) and historical controls followed in-person rehabilitation.

MAIN OUTCOME MEASURE(S)

The Functional Independence Measure (FIM), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI). We formally compared gains, efficiency and effectiveness. International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association Impairment Scale (AIS) were used.

RESULTS

The teleSCI group (57.1% nontraumatic, 71.4% paraplegia, 73.8% incomplete, 52.4% AIS grade D) showed no significant differences compared with historical controls in AIS grades, neurological levels, duration, gains, efficiency and effectiveness in FIM, SCIM, or WISCI, although the teleSCI cohort had significantly higher admission FIM scores compared with the complete cohort of historical controls.

CONCLUSIONS

TeleSCI may provide similar improvements in mobility and functional outcomes as traditional rehabilitation in medically stable patients (predominantly with paraplegia and motor incomplete SCI) when provided with appropriate support and equipment.

The Bobath concept (NDT) in adult neurorehabilitation: a scoping review of conceptual literature

PURPOSE

This scoping review aims to describe how Bobath concept is conceptualized, operationalized, and studied in adult neurorehabilitation.

METHODS

The Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Scoping Reviews (PRISMA-ScR) guidelines were adopted. Non-scientific and research articles were searched in electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science, ScienceDirect, and Physiotherapy Evidence Database (PEDro), with the keywords "Bobath" or "Neurodevelopmental Treatment", published in English, Spanish, and Portuguese, between 2013 and 2023.

RESULTS

Of the 78 publications identified, 31 articles addressed the conceptual underpinnings of Bobath concept (seven theoretical papers, seven Delphi/surveys/mixed methods studies, four qualitative studies, one scoping review, 10 letters to the editor, and two editorials), comprising five themes: (a) theoretical principles; (b) clinical principles; (c) clinical reasoning; (d) conceptualizing movement; and, current (e) evidence debate. The revised definition and the Model of Bobath Clinical Practice provide a clarification of the unique aspects of Bobath concept. A new clinical skill was identified beyond facilitation - visuospatial kinesthetic perception - as well as how Bobath experts conceptualize movement, which are all integral to clinical reasoning.

CONCLUSIONS

This review provides an updated Bobath clinical framework that gathers the theoretical foundations and clinical practice principles that require careful consideration in the design of future intervention studies.Implications for rehabilitationThis scoping review consolidates the clinical and theoretical principles of contemporary Bobath practice, providing a clear framework for clinicians.The Model of Bobath Clinical Practice (MBCP) framework enables detailed documentation of movement analysis and movement diagnosis, guiding clinical reasoning and interventions.This review identifies fundamental principles and practices to inform future Bobath intervention studies, ensuring their clinical relevance.A framework with specific recommendations has been developed to guide Bobath intervention studies, enhancing the integration of clinical practice, education, and research.

Sensory training combined with motor training improves trunk proprioception in stroke patients: a single-blinded randomized controlled trial

OBJECTIVES

Inadequate trunk function is the underlying cause of many problems such as impaired balance and mobility. Although there have been trunk-based physiotherapy approaches in recent years, almost all of these approaches focus on motor problems. This study aims to investigate the effects of sensory training combined with trunk-centered Bobath exercises on trunk control and proprioception, balance, gait, and the activity of daily living (ADL).

MATERIALS AND METHODS

This study is a randomized controlled trial included with twenty-seven stroke patients. Participants were separated into two groups, Group 1; 'sensory training combined with trunk-centered Bobath exercises' and Group 2; 'trunk-centered Bobath exercises'. Trunk-centered Bobath exercises were used for motor training. Sensory training included transcutaneous electric nerve stimulation and a set of exercises that provide tactile and proprioceptive stimulation. Trunk Impairment Scale, Trunk Reposition Error, Berg Balance Scale, 2-minute walk test, and Barthel Index were used to assess trunk control, trunk proprioception, balance, gait, and ADL respectively.

RESULTS

Intra-group analysis results showed that trunk control, trunk proprioception, balance, gait, and ADL improved in both groups after treatment (p < 0.05). The changes in the Trunk Reposition Error values of the participants in Group 1 before and after treatment was found to be significantly higher than Group 2 (p < 0.05).

CONCLUSIONS

The findings indicated that the application of trunk-centered motor training is effective in improving trunk proprioception and trunk control, balance, gait, and ADL in stroke patients. Also, sensory training combined with trunk-centered motor training was found more effective in improving trunk proprioception than solely motor training.

The Bobath Clinical Reasoning Framework: A systems science approach to the complexity of neurodevelopmental conditions, including cerebral palsy

The current recommended developmental Bobath practice within the Bobath Clinical Reasoning Framework (BCRF) can be conceptualized using the lens of systems science, thereby providing a holistic perspective on the interrelatedness and interconnectedness of the variables associated with childhood-onset disability. The BCRF is defined as an in-depth clinical reasoning framework that can be applied to help understand the relationships between the domains of the International Classification of Functioning, Disability and Health, how those domains can be influenced, and how they impact each other. The BCRF is a transdisciplinary observational system and practical reasoning approach that results in an intervention plan. This provides a holistic understanding of the complexity of situations associated with disorders such as cerebral palsy (CP) and the basis for the lifelong management and habilitation of people living with neurological disorders. The clinical reasoning used by the BCRF draws on the important contextual factors of the individual and their social environment, primarily the family unit. It is rooted in an understanding of the interrelationships between typical and atypical development, pathophysiology (sensorimotor, cognitive, behavioural), and neuroscience, and the impact of these body structure and function constructs on activity and participation. The systems science model integral to the BCRF is a useful way forward in understanding and responding to the complexity of CP, the overarching goal being to optimize the lived experience of any individual in any context.

A stroke rehabilitation training program for community-based primary health care, South Africa

Background

With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training.

Objectives

To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa.

Method

Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described.

Results

The CHWs' scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology.

Conclusion

The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article.

Contribution

The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting.

Measuring muscle activation using electromyography during neurodevelopmental treatment in individuals with severe cerebral palsy

BACKGROUND

In the motor rehabilitation of individuals with neurological disorders, including cerebral palsy (CP), Neurodevelopmental treatment (NDT) one of the most used approaches worldwide.

OBJECTIVE

To verify muscle activation in NDT handling in individuals with severe CP using electromyography.

METHODS

This was a controlled, cross-sectional, quantitative clinical trial. The individuals were evaluated using electromyography to analyze the muscular activation of the spinal erector, gluteus medius, rectus abdominis and multifidus during different NDT handling. We evaluated 59 individuals: 39 with spastic quadriparesis CP (Gross Motor Function Classification System, level IV-V) and 20 typically-developing individuals (control group). These groups were homogeneous with respect to age and gender.

RESULTS

There was a significant difference in muscle activation of the spinal erector, gluteus medius, rectus abdominis and multifidus in the six NDT handling used in this study: side-sitting for kneeling; supine for lateral decubitus, prone position for lateral decubitus, "sitting on horseback", sitting on the roll, and proprioceptive stimulation sitting on the ball.

CONCLUSION

The results show that all NDT handling analyzed in this study were effective for muscle activation of the spinal erector, gluteus medius, rectus abdominis and multifidus in individuals with severe spastic quadriparetic CP.

Effect of Dry Needling Treatment on Tibial Musculature in Combination with Neurorehabilitation Treatment in Stroke Patients: Randomized Clinical Study

(1) Background: Introducing ultrasound-guided dry needling to neurorehabilitation treatments increases the beneficial effects of therapy. The aim of this study was to compare the effects of including an ultrasound-guided dry needling session in neurorehabilitation treatment on spasticity and gait-balance quality versus neurorehabilitation treatment in subjects who had suffered a stroke. (2) Methods: A single-blind, randomized clinical trial was conducted. Thirty-six patients who had suffered a stroke in the right middle cerebral artery signed the informed consent for participation in the study. Twenty patients finally participated and were randomly assigned to the control group (neurorehabilitation treatment) or experimental group (neurorehabilitation treatment plus ultrasound-guided dry needling). Pre-treatment and post-treatment data were collected on the same day. The experimental group (n = 10) first underwent an ultrasound-guided dry needling intervention on the tibialis anterior and tibialis posterior musculature, followed by neurorehabilitation treatment; the control group (n = 10) underwent their corresponding neurorehabilitation without the invasive technique. Pre-treatment and post-treatment measurements were taken on the same day, assessing the quality of balance-gait using the "Up and Go" test and the degree of spasticity using the Modified Modified Ashworth Scale. (3) Results: The patients who received neurorehabilitation treatment plus ultrasound-guided dry needling showed a greater decrease in spasticity in the tibial musculature after the neurorehabilitation treatment session (p < 0.001), improving balance and gait (p < 0.001). (4) Conclusions: An ultrasound-guided dry needling session combined with neurorehabilitation treatment reduced spasticity and improved balance and gait in stroke patients.

Time to reconcile research findings and clinical practice on upper limb neurorehabilitation

The problem

In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs.

Proposed solutions

The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions.

Conclusions

It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.

Essence of the Bobath concept in the treatment of children with cerebral palsy. A qualitative study of the experience of Spanish therapists

Objective: The aim was to explore the experiences of a group of Spanish physical therapists who apply the Bobath concept in the treatment of children with cerebral palsy, specifically to identify the components they experience as core and essential to the Bobath concept.Design: A qualitative phenomenological study.Methods: This study used purposive sampling. Non-structured interviews were carried out with 10 Spanish Bobath-trained physical therapists who treat children with cerebral palsy. Thematic analysis was applied.Results: Five themes regarding the essence of the Bobath concept emerged: 1) "normal movement" as a guide; 2) a "global" concept; 3) observation; 4) the centrality of tone; and 5) working with families. Within these themes, additional principles were reflected cross-sectionally, such as therapy being a continuous process of assessment and treatment, the application of principles of motor learning, and the importance of carryover of treatment into function.Conclusions: The results demonstrated themes traditionally identified as core to the Bobath concept, including working with families, which is also considered integral to the approach. The study participants used outdated terminology at times when discussing tone and movement. However, they reported that they no longer adhere to the theoretical perspective of pathological reflexes and reflex/tone inhibition. This study provides insight into how treatment of children with cerebral palsy based on the Bobath concept is experienced by a group of Spanish physiotherapists, who identified five main themes that they perceive as essential. The results provide grounds for further research into the application of the Bobath concept in children.

Using nominal group technique to advance power assisted exercise equipment for people with stroke

BACKGROUND

Power assisted exercise is accessible and acceptable for people with stroke. The potential for technological advancement of the equipment to improve the user experience has been identified. Involvement of end users and service providers in the design of health technologies is essential in determining how said technology is perceived and adopted. This project invited people with stroke and service providers to influence design features and determine machine selection in the preliminary stages of a codesign research programme.

AIMS

To capture the perspectives of people with stroke and professionals working with people with stroke about proposed digitalisation of power assisted exercise equipment and select machines for prototype development.

METHODS

Nominal group technique was used to capture the perspectives, ideas, preferences and priorities of three stakeholder groups: people with stroke (n = 3, mean age 66 years), rehabilitation professionals (n = 3) and exercise scientists (n = 3). Two questions underpinned the structure of the events; 'What does an assistive exercise machine need to do to allow the person with stroke to engage in exercise?' and 'Which machines would you prioritise for use with People with Stroke?' Attendees were invited to cast votes to indicate their preferred machines.

FINDINGS

Synthesis of the data from the NGT identified four domains; software and interface, exercise programme, machine and accessories, setting and service. Three preferred machines from a range of nine were identified through vote counting.

CONCLUSION

Nominal group technique directed the selection of machines to be included in the development of the proposed technology. The vision shared by users during the structured discussion shaped the subsequent steps in the design and testing of the new technology.

PATIENT AND SERVICE PROVIDER CONTRIBUTION

The opinions and preferences of people with stroke, rehabilitation professionals and exercise scientists were central to key decisions which will shape the digitalisation of power assisted equipment, influence future research and guide implementation of the new technologies.

[Rehabilitation after stroke]

Neurorehabilitation to alleviate permanent disabilities after stroke is in Germany organised within the so called neurological phase model. This article provides an overview on its organisation and content as well as the restrictions imposed by social law. As an example for therapies, evidence-based motor rehabilitation strategies are presented and linked to their neurophysiological principles. Additionally, the current recommendations for the assessment of fitness to drive are illustrated.

The influence of the trunk muscle activation on occlusion pressure and respiratory muscle strength in healthy participants: Randomized controlled trial

OBJECTIVES

The purpose of the study was to check if the trunk muscle activation done in accordance with rules of the Bobath concept affects the occlusion pressure and respiratory muscle efficacy in forced breathing manoeuvres in healthy participants.

DESIGN

Randomized controlled trial. Between-subjects design.

PARTICIPANTS

Seventy-four healthy volunteers, aged 20-26 years, were recruited from medical students, randomly assigned to the experimental or control groups.

INTERVENTION

The intervention in the experimental group was individual physiotherapy based on the Bobath concept. It was provided by qualified physiotherapist and lasted about 60 min. The Bobath concept is an inclusive, individualized therapeutic approach to optimize movement recovery, informed by contemporary movement and neuro-sciences. The control group participated in a 45-minute lecture on the importance of the stability of trunk muscle and the diaphragm position that is adequate for its respiratory work. The described interventions, in both groups, were performed once, between the initial and final measurement of the respiratory drive.

OUTCOME MEASURES

The subjects underwent two assessments of the following variables: occlusion pressure (P0.1) and the respiratory muscle strength: maximal inspiratory pressure (PImax), maximal expiratory pressure (PEmax), maximal occlusion pressure (P0.1max) with the use of MasterScope Spirometer. In experimental group, the physiotherapy assessment was carried out before intervention.

RESULTS

As a result of the applied intervention, P0.1 in the experimental group increased (p = 0.001; 82.45 vs 103.73), which was not observed in the control group (p = 0.629; 88.95 vs 85.83). The intervention did not change the results of all other outcomes including P0.1 max; PImax and PEmax.

CONCLUSION

The activation of trunk muscles such as transversus abdominis, multifidius and muscles of the pelvic floor was found to improve the effectiveness of diaphragmatic work during tidal breathing as measured with P0.1 values. Established abdominal pressure, which stabilizes the trunk and prevents chest mobility, might be the reason why forced measurements (PImax, PEmax, P.01 max) remain unchanged.

Students' Perceptions of Instructional Rubrics in Neurological Physical Therapy and Their Effects on Students' Engagement and Course Satisfaction

One of the main challenges faced by physical therapy (PT) students is to learn the practical skills involved in neurological physical therapy (PT). To help them to acquire these skills, a set of rubrics were designed for formative purposes. This paper presents the process followed in the creation of these rubrics and their application in the classroom, noting that students perceived them as valid, reliable, and highly useful for learning. The perception of the validity and usefulness of the rubrics has different closely related dimensions, showing homogeneous values across the students´ sociodemographic and educational variables, with the exception of dedication to studying, which showed a significant relationship with schoolwork engagement and course satisfaction. The adequacy of the hypothesized structural model of the relationships among the variables was confirmed. Direct effects of the perception of the rubrics' validity and engagement on course satisfaction were found, as well as direct effects of the assessment of the usefulness of the rubrics on schoolwork engagement and indirect effects on course satisfaction through this latter variable. The results are discussed taking into account the conclusions of previous research and different instructional implications.

Toward improving functional recovery in spinal cord injury using robotics: a pilot study focusing on ankle rehabilitation

Background: Conventional physical therapy interventions are strongly recommended to improve ambulation potential and upright mobility in persons with incomplete spinal cord injury (iSCI). Ankle rehabilitation plays a significant role, as it aims to stem drop foot consequences.Research question: This pilot study aimed to assess the neurophysiological underpinnings of robot-aided ankle rehabilitation (using a platform robot) compared to conventional physiotherapy and its efficacy in improving gait performance and balance in persons with iSCI.Methods: Ten individuals with subacute/chronic iSCI (six males and four females, 39 ± 13 years, time since injury 8 ± 4 months, ASIA impairment scale grade C-D) were provided with one-month intensive training for robot-aided ankle rehabilitation (24 sessions, 1 h daily, six times a week). Clinical (10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), and Timed Up and Go test (TUG)), and electrophysiological aftereffects (surface-EMG from tibialis anterior and medial gastrocnemius muscles to estimate muscle activation patterns; and corticomuscular coherence-CMC-to assess functional synchronization between sensorimotor cortex and muscles, i.e. the functional integrity of corticospinal output) were assessed at baseline (PRE) and after the trial completion (POST). The experimental group (EG) data were compared with those coming from a retrospective control group (CG; n = 10) matched for clinical-demographic characteristics, who previously underwent conventional ankle rehabilitation.Results: the EG achieved a greater improvement in balance and gait as compared to the CG (TUG EG from 70 ± 18 to 45 ± 15 s, p = 0.002; CG from 68 ± 21 to 48 ± 18 s, p = 0.01; group-comparison p = 0.001; 10MWT EG from 0.43 ± 0.11 to 0.51 ± 0.09 m/s, p = 0.006; CG from 0.4 ± 0.13 to 0.45 ± 0.12, p = 0.01; group-comparison p = 0.006; 6 MWT EG from 231 ± 13 to 274 ± 15 m, p < 0.001; CG from 236 ± 13 to 262 ± 15 m, p = 0.003; group-comparison p = 0.01). Furthermore, the EG showed a retraining of muscle activation (an increase within proper movements, with a reduction of co-contractions) and CMC (beta frequency increase within proper movements, i.e. in a framework of preserved motor coordination). The improvements in CMC, gait, balance, and muscle activation were not correlated with each other.Conclusions: Robot-aided ankle rehabilitation improved gait performance by selectively ameliorating CMC, muscle activation patterns, and, lastly, gait balance and speed. Despite CMC, gait, balance, and muscle activation were not correlated, this pilot study suggests that robot-aided ankle rehabilitation may favor a better communication between above-SCI and below-SCI structures. This communication improvement may depend on a more synchronized corticospinal output (as per CMC increase) and a better responsiveness of below-SCI motorneurons to corticospinal output (as per specific and ankle movement focused muscle activation increases at the surface EMG), thus favoring greater recruitment of spinal motor units and, ultimately, improving muscle activation pattern and strength.Significance: Adopting robot-aided ankle rehabilitation protocols for persons with iSCI in the subacute/chronic phase may allow achieving a clinically significant improvement in gait performance.

Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial

Objective: It was the aim to assess feasibility, safety, and potential efficacy of a new intensive, focused arm-hand BOOST program and to investigate whether there is a difference between early vs. late delivery of the program in the sub-acute phase post stroke. Methods: In this pilot RCT, patients with stroke were randomized to the immediate group (IG): 4 weeks (4 w) BOOST +4 w CONTROL or the delayed group (DG): 4 w CONTROL +4 w BOOST, on top of their usual inpatient care program. The focused arm-hand BOOST program (1 h/day, 5x/week, 4 weeks) consisted of group exercises with focus on scapula-setting, core-stability, manipulation and complex ADL tasks. Additionally, 1 h per week the Armeo®Power (Hocoma AG, Switzerland) was used. The CONTROL intervention comprised a dose-matched program (24 one-hour sessions in 4 w) of lower limb strengthening exercises and general reconditioning. At baseline, after 4 and 8 weeks of training, the Fugl-Meyer assessment upper extremity (FMA-UE), action research arm test (ARAT), and stroke upper limb capacity scale (SULCS) were administered. Results: Eighteen participants (IG: n = 10, DG: n = 8) were included, with a median (IQR) time post stroke of 8.6 weeks (5-12). No adverse events were experienced. After 4 weeks of training, significant between-group differences were found for FMA-UE (p = 0.003) and SULCS (p = 0.033) and a trend for ARAT (p = 0.075) with median (IQR) change scores for the IG of 9 (7-16), 2 (1-3), and 12.5 (1-18), respectively, and for the DG of 0.5 (-3 to 3), 1 (0-1), and 1.5 (-1 to 9), respectively. In the IG, 80% of patients improved beyond the minimal clinical important difference of FMA-UE after 4 weeks, compared to none of the DG patients. Between 4 and 8 weeks of training, patients in the DG tend to show larger improvements when compared to the IG, however, between-group comparisons did not reach significance. Conclusions: Results of this pilot RCT showed that an intensive, specific arm-hand BOOST program, on top of usual care, is feasible and safe in the sub-acute phase post stroke and suggests positive, clinical meaningful effects on upper limb function, especially when delivered in the early sub-acute phase post stroke. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04584177.

Potential contributing factors to upper limb associated reactions in people with acquired brain injury: an exploratory study

PURPOSE

To determine which potential contributing factors are associated with upper limb associated reaction (AR) expression in individuals with acquired brain injury (ABI).

METHODS

Forty-two participants underwent three-dimensional motion analysis at self-selected walking speed to generate the AR outcome measure, quantifying their upper limb kinematic deviation compared to healthy controls. Clinical assessment included: upper and lower limb hypertonicity, spasticity and strength, balance, dynamic walking stability, arm and leg function, anxiety, arm pain/discomfort, and fear of falling.

RESULTS

Significant, moderate-to-strong correlations (r = 0.42-0.74, p < 0.05) existed between upper limb ARs and both hypertonicity and spasticity of the upper limb muscles and the knee extensors. Significant, moderate correlations to ARs (r = 0.42-0.59, p < 0.05) existed for balance, dynamic stability, upper limb strength, and arm function. The severity of AR was significantly different between those with and without hypertonicity of the four tested upper limb muscles, elbow and long finger flexor spasticity, knee extensor spasticity, and reduced dynamic stability (p < 0.05; effect sizes ≥0.80). However, these contributing factors were not present in all participants.

CONCLUSIONS

Associated reactions are complex and multi-factorial. There were several significant correlations indicating that factors may influence AR severity. While positive upper motor neuron syndrome features should be prioritised for clinical assessment, these factors are not prerequisites for ARs.IMPLICATIONS FOR REHABILITATIONUpper limb associated reactions are a complex and multi-factorial phenomenon.Upper limb muscle hypertonicity and spasticity should be prioritised for assessment; however, they are not prerequisites for associated reactions.Hypertonicity and spasticity should be differentiated as they may have differing relationships to associated reactions.Knee extensor hypertonicity and spasticity, postural stability, upper limb strength, and arm function may also be contributing factors to consider.

Added Value of Dynamic EMG in the Assessment of the Equinus and the Equinovarus Foot Deviation in Stroke Patients and Barriers Limiting Its Usage

Equinus (EFD) and equinovarus foot deviation (EVFD) are the most frequent lower limb deformities in stroke survivors. The equinus component can be triggered by a combination of dorsiflexor deficits, plantar flexor overactivity, muscle stiffness, and contractures. The varus component is typically due to an imbalance between invertor and evertor muscle actions. An improvement in identifying its causes leads to a more targeted treatment. These deformities are typically assessed via a thorough clinical evaluation including the assessment of range of motions, force, spasticity, pain, and observational gait analysis. Diagnostic nerve blocks are also being increasingly used. An advantage of dynamic electromyography (dEMG) is the possibility of measuring muscle activity, overactivity or lack thereof, during specific movements, e.g., activity of both ankle plantar flexors and dorsiflexors during the swing phase of gait. Moreover, fine-wire electrodes can be used to measure the activity of deep muscles, e.g., the tibialis posterior. An impediment to systematic use of dEMG in the assessment of EFD and EVFD, as a complimentary tool to the clinical evaluation, is a lack of evidence of its usefulness. Unfortunately, there are few studies found in literature. In order to fill this void, we studied three pairs of patients suffering from chronic hemiparesis consequent to a stroke, with EFD or EVFD. At the initial evaluation they all displayed the same clinical traits, very similar walking patterns, and an overlapping gait kinematics. However, the patterns of muscle activity differed considerably. dEMG data acquired during walking provided information that was not available from the sole clinical assessment. The contribution of this information to the subsequent clinical and rehabilitation process was discusses along with the barriers that limit the use of dEMG as a routine tool in neurorehabilitation.

Developing a revised definition of the Bobath concept

OBJECTIVE

This study was developed as a consensus-building exercise within the International Bobath Instructors Training Association (IBITA) to develop a revised definition of the Bobath concept.

METHODS

A three-phase design utilizing (a) focus groups, (b) survey methods, and, (c) real-time Delphi. This paper details Phase 1 and 2.

RESULTS

Forty IBITA members participated in five focus groups. Eight broad themes were developed from the focus groups from which the survey statements were developed. There was a high level of agreement on all nine survey statements identifying overarching constructs and on 12 of the 13 statements identifying unique aspects of Bobath clinical practice. Lower scores were attributed to lack of understanding of the term humanistic, Bobath clinical practice addressing multiple domains such as impairments, activities, and participation and limited agreement on the description of the term "placing."

CONCLUSION

Focus groups and a web-based survey were successful in soliciting the opinions of IBITA members on themes and statements of importance for the development of a revised Bobath definition. The results of Phase 1 and 2 will inform Phase 3, a real-time Delphi, to gain consensus within IBITA on statements on which a revised Bobath definition is to be based.