Episode 3: What can our patient manage to ‘do’ and what can they ‘nearly do’ and how does the Bobath therapist work to develop this using the Model of Bobath Clinical Practice?
- Clare Fraser
- May 8
- 4 min read
Written by Clare Fraser (BBTA Tutor)
As we have seen in episode 1 & 2, when a new patient comes in to the clinic for
assessment we are searching for the ‘critical cues’ that inform us of their presenting
difficulties in their movement and postural control, and we are also identifying their
potential to move and function better than they are now. We create a ‘movement
diagnosis’ that spring boards us into the treatment plan, using clinical reasoning to
formulate a clinical hypothesis.
Then we get started taking the patient into a treatment situation, based on our treatment
plan, that targets the development of postural strength and movement control skill, working through carefully set up functional tasks to achieve opportunities for practice.
How do we successfully achieve opportunities for practice that allow the patient to
strengthen and move better, compared to them just practicing things in their ‘less efficient
than normal’ way, themselves? If all it takes is practice and repetition, to move from their
newly impaired movement style, to a more ‘efficient’ movement style, then why do you
need a neurological therapist to work with you to do that?
Well, because it comes down to identifying what the patient can do, and what the patient
can ‘nearly’ do…and working in that difficult ‘can nearly do’ zone with the use of facilitation to make it achievable to do practice in a good quality way.
When a person is not able to move as efficiently as they used to (eg after they had their stroke compared to before they had their stroke) then they are likely to move in a compensatory, and less successful way; and so ‘practicing’ needs to be guided to get the best opportunity for developing useful skill. There’s not much point practicing the poor movement pattern, you need to practice the most efficient and accurate movement pattern.
Its not the pure repetition alone that matters, its the quality and performance of the repetition that matters. And through quality task performance and repetition of this ‘best practice’ then we know from the motor learning literature that neuroplasticity will drive recovery and new functional skill.
So what does this mean? What does the therapist do to facilitate this ‘can nearly do’ zone,
to make it more successful? Well, facilitation is defined as ‘to make something easier or
more likely to happen’, and a neurological therapist does this using;
Manual facilitation - that is using ‘hands on contact’ on the patient, around a certain area
of their body, to create a stimulus and a guidance to help them move more successfully
Environment facilitation - this is using the environment around you such as a kitchen
work surface, or a wall, or the back of a chair for example, to give a point of contact or a
prompt, and adapting to the environment, for improved movement control.
Verbal facilitation - such as using your voice to guide and reinforce movement responses
during the task, and giving appropriate feedback.
When we are working with a person to practice a task, such as getting up from sitting into
standing, we use our knowledge of human movement analysis (ie how a human moves,
and functions) to guide the facilitation. Knowing what the expected movement
components are in a human, during this transition from, for example, sitting to standing,
and comparing them to the patient in front of you who is struggling to achieve a successful
sit to stand manoeuvre, will inform the therapist of which movement components need to be improved.
Then applying a carefully created combination of the three different types of facilitation will
give the patient the opportunity to safely and specifically practice these movement
components and develop the skills they need for better function. Sometimes the therapist will need to adapt the guidance and facilitation of a movement or component of movement that they give the person, so that they help more, perhaps supporting more weight, or directing the movement more actively; and sometimes they will need to reduce the support and facilitation that they give, as less might be needed.
In addition to understanding the large body of literature about human movement analysis,
Bobath neurological therapists also have a depth of knowledge about the science of
neurophysiology. This informs us about how the systems of the brain, spinal cord, and
nerves create the posture and movement control in a person, together with their musculoskeletal biomechanics, needed to stay up against gravity, and move efficiently for skilled function.
So bringing it all together, in a safe and reassuring rehabilitation session, so that the patient can move through functional tasks, such as moving from sitting to standing, with the therapist facilitating them, starts the process of recovery through good performance
practice.
Working to move in a different way (a more efficient ‘normal’ way) when you
have had a neurological injury such as a stroke, is a step towards
recovery, but is sometimes scary and challenging. It is important that the therapist
supports and encourages the patient through this process and takes those bold steps with
them, step by step.
If you want to develop your clinical reasoning skills, to be a better therapist than you are right now, then why not sign up for a Bobath course on the British Bobath Tutors Association (BBTA) website? We would love to have you join us -
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