CORE CURRICULUM FOR PAEDIATRIC

BOBATH / NDT COURSE.

Draft document

EBTA SENIOR TUTOR WORKING GROUP MEETINGS:

LISBON 2002, LONDON 2003, BERLIN 2004,

NETHERLANDS 2005, LEUVEN 2006, LONDON 2007.

Amended for consistency and language by UK NTO June 2012.

Please note that adding the hours for each module, these total more than 240 hours specified in the Minimum Standards. This needs to be addressed.

Contents: Page numbers are not accurate at present

Title Page

Title 1

Contents 2

Instructions for using the manual 4

Bobath/NDT Concept 5

Facilitation (including tone management) 7

(i) Analysis and facilitation of typical/normal movement 8

(ii) Facilitation of basic elements of postural control 9

(iii) Management of variations in tone 10

Classification 11

(i) Spastic hypertonia 12

(ii) Hypotonia 12

(iii) CP associated with extreme prematurity 13

(iv) Dyskinetic (Athetosis) 13

(v) Ataxia 14

Typical Development 14

(i) Foetal development 15

(ii) Neonatal development 15

(iii) 0-3 months 16

(iv) 3-6 months 17

(v) 6-9 months 18

(vi) 9-12 months 18

Neuroscience (including pathophysiology) 19

Assessment and clinical reasoning 20

Clinical case studies (formerly problem solving) 22

Practical treatment sessions 24

Occupational therapy 25

  1. Occupational therapy in relation to participation.
  2. Play as a human occupation
  3. Sensation and sensory processing in children who have cerebral palsy
  4. Vision in children who have cerebral palsy
  5. Perceptual impairments often seen in children who have cerebral palsy
  6. Development of hand function and its relevance for the child’s participation

in a variety of activities.

  1. Adapting the environment for participation

Speech and language therapy 29

  1. Typical communication
  2. Typical development of eating and drinking
  3. Typical development of breathing/voicing
  4. Observation and analyzing typical eating and drinking
  5. Oral motor/sensory assessment
  6. Assessment of eating & drinking and goal setting for intervention
  7. Intervention for eating and drinking
  8. Oral motor control
  9. Breathing and voicing pathology and intervention
  10. Dysarthria
  11. Augmentative & Alternative Communication
  12. Therapeutic tooth brushing & nose blowing
  13. Reflux, aspiration, saliva control, alternative feeding

.

Appendix 3 :Literature reference list 35 .

Other topics : to be contained in another document

  1. Guidelines for demonstrations
  2. Orthopaedic aspects
  3. Assessment of course participants

INSTRUCTIONS FOR USING THE MANUAL:

  1. Course duration is 240 hours in keeping with EBTA Minimum Standards.

In this document all hours refer to a full hour (60 minutes), not a “teaching hour” (45 minutes).

  1. The following topics are agreed course requirements, all topics covered in this manual must be included in all EBTA recognised Bobath Basic Courses in order to receive the EBTA stamp.
  1. The aims and objectives for each section of the course are specified in this document:- content and minimum hours are outlined, recommendations for placement of the module in the course, the prerequisite modules, teaching methodology, and evaluation where appropriate are stated.
  1. The placement of topics in the course as indicated in this document is only a suggestion. It is recognised that courses may be organised differently and flexibility is necessary.
  1. The outline currently uses the ICF framework but it is recognised that use of ICFCY (ICF specifically for child/youth) might be preferable when the ICFCY becomes internationally accepted.
  1. It should be noted that the ‘live’ demonstrations are considered to be the first choice as a means for providing clinical examples for teaching the Bobath /NDT Concept and it is essential that they are included within the course. Ideally all topics will include a live demonstration (rather than use of a video) but it is understood that in certain cases videos will need to be used.

7. A reference list/recommended reading list for each module is in the Appendix.

8. The term ‘child’ is used throughout the document. We recognise that the term individual or adult may also be applied.

BOBATH/NDT CONCEPT

Minimum hours:

4 hours - minimum 2 hours contact time
4 hours – self study
Prerequisite for the module:
Reading of required and recommended literature
Recommended placement in the course:
At the beginning of the course and at the end
Aims:
1. To understand the history and evolution of the Bobath/NDT Concept
2. To define and explain the Bobath/NDT concept
3. To explain the principles of the Bobath/NDT concept
Objectives:
The participant will be able to:
1.1. Explain the process of change in the Bobath/NDT Concept in relationship to current scientific knowledge (i.e. neurophysiology, activity and participation and task orientation )
2.1. State the difference between a concept and a method of treatment.
2.2. Define and explain the Bobath/NDT Concept.
2.3. Discuss the differences and similarities of the Bobath/NDT concept with other therapeutic
approaches (discussion at end of the course).
3.1 Demonstrate an understanding of the relationship between tone, patterns of movement, sensory, perceptual and cognitive aspects of activity, participation and independence
3.2 Give an example and demonstrate an understanding of the forward looking philosophy of the Bobath/NDT Concept.
3.3. Explain the team approach within the Bobath/NDT Concept.
3.4. Understand the importance of including the family in goal setting, and to understand the need for carry-over and the process of re-evaluation.
3.5. Understand the importance of carry-over to optimise participation.
3.6 Show an understanding of the Bobath/ NDT Concept as a problem solving approach which is applied to assessment, treatment and management of individuals with limited ability to fully participate in daily life. Note: At the beginning of the course participants are required to have a basic understanding; at the end of the course participants are required to be able to demonstrate their understanding.
Session format:
Theoretical / interactive

Teaching methodology:

Interactive lectures, power point presentations, group work and videos, with the use of The Bobath Interview video as a resource.

Content :
  1. Definition of Bobath/NDT Concept used as the basis for the lecture, (e.g. a forward looking problem solving approach based on assessment and reassessment for treatment planning and management; see below **)
  2. Short history of the founders, Karel and Berta Bobath
  3. Neuroscientific background and theoretical assumptions when the concept was developed
  4. How concept has changed over time
a) Changes are possible / neuroplasticity
b) Explain history from Reflex Inhibiting Postures to Tone Influencing Patterns
c) Child development: from hierarchical sequential to horizontal analysis including the concept of preparation for functional activities.
d) Work within an multidisciplinary team; or as a transdisciplinary therapist
e) From working for righting reactions and equilibrium reactions to treatment aimed towards specific function and work within that function
f) Importance of quality of activity but not at the expense of function
g) Expansion of parent training into goal setting with parents and individuals
h) From only neurophysiologic considerations to acknowledgement of the influence of biomechanical constraints
i) Increased use of environment
j) Influenced by other ideas e.g. Petð, Rood etc
  1. Acknowledge the recognition of adjuncts which maybe needed in treatment such as other therapy modalities e.g. muscle strengthening, fitness training, etc.
  2. Emphasise the use of outcome measures e.g. GMFM.
  3. Summary of what has changed and what remains the same
** Bobath definition: The NDT/Bobath Concept offers a forward looking interdisciplinary problem solving approach to the assessment, treatment and management of any individual with limited ability to fully participate in daily life due to impairment of motor (including tone and patterns of movement), sensory, perceptual and cognitive function, resulting from a CNS disorder (Ratified at EBTA General Meeting, Berlin, 2004)
Qualifier statements :
  • Analysis of activity and participation based on an understanding of the relationship between tone, quality of movement and posture. Activity and participation within the appropriate (usual) environmental context (both internal and external).
  • Carry-over into daily life depends on the involvement and education of the client (child/adult), their family, carers, educators and all people involved in the child/person’s life and providing the opportunity for practice in different contexts.
  • Goal setting should be shared with the client and family. They should be functionally oriented and measurable.
  • The Bobath/NDT Concept is based on problem solving approach which provides a framework for assessment, treatment and management (intervention) of people with neurological impairment.
  • Relies on a team approach which emphasizes both interdisciplinary and transdisciplinary assessment and intervention which regards child and family as integral members.
  • Acknowledges the evolving nature of both the individual’s CNS pathophysiology and development.
  • Living working hypothesis, but with the Concept remaining the same.
  • It is hypothesised that by changing the quality of tone (neural and non-neural components), posture and movement you can optimise the person’s participation.
  • Minimise and prevent secondary problems (contractures and deformities) where possible.
  • Applies a holistic/multi-systems approach which recognises the inter-relationship between posture, movement, sensory, perceptual, cognitive and behavioural factors.
  • Emphasises the person’s potential for activity and participation
  • Considers the essential aspects of child development which enable the child/client to learn necessary skills
  • Treatment prepares individuals for specific functional activity by means of handling that facilitates and stimulates more normal patterns of movement and influences tone; as a foundation for practising and contextualising activities
  • Equips the therapist with knowledge of the natural history of different types of CP (i.e. how the child may develop over time).

FACILITATION MODULE, including TONE MANAGEMENT

Minimum hours: 30 hrs direct contact
Pre-requisites: see separate modules
Recommended placement in course: see separate modules
Overall Aims:
  1. To enable the course participant to develop handling skills, knowledge of movement and the environment, to enable them to facilitate more efficient and effective activities in children with movement disorders, as a basis for improved participation.
  2. To give the course participant an understanding of, and ability to analyse, all possible variations of movement and posture, and to recognise the relationship between patterns of movement and changes in tone during activities.
  3. To guide the course participants’ ability to use their hands, body and voice to enable the child to interact effectively within an appropriate environment.
Facilitation module will comprise three components / modules:
(i) Analysis and facilitation of normal / typical movement
(ii) Facilitation of basic elements of postural control (including specific aspects of head control, arm support, trunk control and balance)
(iii) Management of variations in tone (tone influencing patterns, techniques of proprioceptive and tactile stimulation)
Teaching methodology:
Mainly practical
Limited lectures (theory / introductions)
Peer group work
Problem solving
Evaluation:
Handling skills assessed during module, clinical practice and clinical workshops
Clinical reasoning for use of different aspects of facilitation assessed during clinical case studies
(i) ANALYSIS AND FACILITATION OF TYPICAL/NORMAL MOVEMENT
Prerequisite for the module: Bobath Concept
Recommended placement in Course: Synchronised with typical (child) development
Aims:
  1. To develop the course participant’s ability to recognise the variations and commonality of patterns of posture and movement, and accompanying changes in tone.
  2. To enable the course participants to use their hands, body and voice to facilitate another individual to interact effectively within his/her environment and recognise the resultant changes.
  3. To enable the course participants to understand the importance of being able to identify and interpret the individual’s response to being facilitated and adapt their response accordingly.

Objectives:
The course participant will be able to:
1.1Observe, analyse and explain human movement taking into account individual variations of posture and movement.
1.2Identify and explain patterns of movement and variations in tone, and analyse how, when and why they occur.
1.3Explain alignment, base of support and influence of gravity, in the context of efficiency of movement.
1.4Demonstrate an understanding of the influence of the environment on human movement e.g. nature of the task, ambient noise, texture of support, proximity to other people.
2.1Demonstrate the ability to facilitate sequences of movement and be able to adapt handling to the individual response.
2.2Select appropriate Key Points of Control to modify the individual’s typical movement strategies.
3.1Demonstrate an ability to adapt the use their hands, body and voice to interact effectively and safely with the individuals.
4.1Describe and reflect (observe, analyse, evaluate) on their own and others’ posture, movement and sensory experience when facilitating and being facilitated.
4.2Recognise when the individual being facilitated can control his/her own posture and movement; as the facilitator grade his/her input accordingly i.e. know when “hands off” is indicated.
4.3Explain how new experience of movement will enable an individual to adapt their future self-initiated activity through feedback and feed forward mechanisms.
Content:
Normal Movement (introductory lecture, sequences of movement)
  • Observation of normal posture and movements in other course participants, e.g. alignment, variation between individuals and variation in task, base of support, anthropometric characteristics and relationship to gravity. Also refer to typical development for observation of babies and children.
  • Ways of using different key points of control to influence patterns of movement and tone, and the criteria for using them.
  • Facilitation of sequences of movement and their variations e.g. rolling, crawling, walking, and moving in and out of different positions.

(ii) FACILITATION OF BASIC ELEMENTS OF POSTURAL CONTROL
Recommended placement in course:
Synchronised with typical (child) development and spread throughout the course.
Aim:
To enable the course participant to identify specific components of movement and posture that may need to be facilitated to enhance the individual’s ability to initiate and control their activity more effectively.
Objectives:
The course participants will be able to:
1.1 Show the ability to apply their knowledge of normal/typical movement to identify specific components of movement and posture that may need to be facilitated to enhance the individual’s ability to initiate and grade their activity more effectively.
1.2 Demonstrate a variety of ways in which head control, trunk control, arm support and balance can be facilitated using appropriate key points.
Content:
Head control, arm support, trunk control and balance
Identify specific components of postural control that may be facilitated to enhance the individual’s ability to initiate and control their activity more effectively.
Demonstrate, using appropriate key points, a variety of ways to facilitate the following:
head control and trunk control,
arm support
balance in all positions
(iii) MANAGEMENT OF VARIATIONS IN TONE
Recommended placement in course:
Ideally synchronised with classification (spastic hypertonia) and before clinical practice sessions.
Aim:
To enable the course participant to adapt his/her facilitation to individuals with atypical tone thereby optimising activity and participation and minimising secondary impairments.
Objectives:
The course participants will be able to:
  1. Identify atypical patterns of movement and quality of tone in individuals with CP and allied movement disorders and recognise how, when and why these patterns change.
  2. Demonstrate techniques that will modify tone, posture and movement as a preparation for more effective activity; and discuss how and why these would be used in the treatment and management of CP and individuals with allied movement disorders i.e. Tone Influencing Patterns, techniques of proprioceptive and tactile stimulation.
  3. Demonstrate the use of appropriate key points of control for influencing different types, degree and distributions of tone.
  4. Hypothesise how these techniques might achieve their effect.

Content:
Management of variations in tone (tone influencing patterns, techniques of proprioceptive and tactile stimulation)
1. Analysis of atypical patterns of posture, movement and quality of tone in individuals with CP and allied movement disorder and recognise how, when and why they change, and their significance for activity and participation.
2. Introduce and practise techniques that will modify or optimise tone, posture and movement as a preparation for more effective task performance
(i) Tone Influencing Patterns (TIPs)
(ii) Techniques of proprioceptive and tactile stimulation
(iii) Analysis of which key points of control might be most effective
in a given situation and/or in different clinical presentations of CP and
allied movement disorders
3. Discussion of how these techniques may achieve their effect in relation to activity, activity limitation and structure and function.
CLASSIFICATION MODULE:
Minimum hours: 20hrs direct contact
Modules:
(i) Introduction and Spastic Hypertonia 6hrs
(ii) Hypotonia 3hrs
(iii)CP associated with preterm birth 3hrs
(iv) Dyskinetic 5hrs
(v) Ataxia 3hrs
Pre-requisite modules: introduction to the Bobath/NDT Concept, introduction to normal movement, introduction to typical development, Tone Influencing Patterns.
Recommended placement in the course: near the beginning of the course: after Introduction to the Bobath/NDT Concept, commencement of typical (child) development and facilitation A (normal movement) and facilitation C (Tone Influencing Patterns); classification should ideally commence before 1st practical.
Aims:
  1. Explain relevance of Bobath/NDT classification to treatment and management of people with CP
  2. To explain the Bobath/NDT classification in the context of other classification systems
  3. To discuss classification according to the different types, degrees and distribution of tone
  4. To describe the clinical features of different classifications of CP within the Bobath/NDT concept (spastic hypertonia, hypotonia, dyskinetic, ataxia)
  5. To explain the need for a common language with in the team in the terms of management and research.

Objectives:
The course participants will be able to:
  1. Explain and give examples of how the Bobath/NDT classification is used in assessment and treatment and its role in predicting future outcomes.
  2. Show an awareness of other commonly used classification systems for children with CP e.g. GMFCS, SCPE (2000), MACS
  3. Explain how abnormalities of tone (mild, moderate and severe) and its distribution relate to patterns of movement, the development of contractures and deformities, and hence both short and long term activity and participation.
  4. Identify the main clinical features of a child with CP in order to classify them using the Bobath Classification System.
  5. List the likely accompanying impairments seen in different classifications of CP and explain the implications of these for a child’s activity and participation.
  6. Explain on the basis of their knowledge of Bobath/NDT classification what a child is likely to do, how and why they will do it, what they will find challenging and why this will be so.

Teaching methodology :
Analysis of children through ‘live’ demonstrations (minimum of 4 demonstrations for the whole of the classification module) and video..
(i) SPASTIC HYPERTONIA
Minimum number of hours: 6 hrs direct contact
Aim::
To explore the consequences of spastic hypertonia to the child’s activity and participation with reference to severity, distribution and the child’s age.
Objectives :
The course participant will be able to:
1. State the difference between spasticity and spastic hypertonia
2. Explain the upper motor neurone syndrome
3. Discuss the difference between associated reactions and associated movements.
4. Describe the potential compensatory mechanisms in relation to distribution of tone (e.g. diplegia/ hemiplegia/ quadriplegia) and their impact on future activity and participation.
5. Explain how the degree and distribution of spastic hypertonia will influence intervention used to optimise activity and participation (e.g. the amount and type of preparation, TIP’s, KPCs, positions used and equipment)
(ii) HYPOTONIA

Minimum hours: 3hrs direct contact