理論架構 王湉妮 2022 Neurorehabilitation

NEUROREHABILITATION FOR CHILDREN

PART I: NDT

一、 Introduction
– The Bobath approach: in the late 1940s
• Berta Bobath (PT): 臨床技巧與經驗
• Karel Bobath (神經精神科醫師):
• 目前看來發展得很完整的治療手法
– Developed from observations, practical applications and desire to
find better solutions for client’s problems
– Early motor control theories emphasized on hierarchical and reflex model of motor control
– Name Bobath is still used in many countries, NDT is commonly used in North America

二、 Important concept of NDT

1. Normal, voluntary & functional motor performance
- Inhibition (抑制原始反射) V.S. involuntary movement
A. Normal muscle tone, posture tone
B. Normal automatic posture reaction
• Righting reactions
• Protective reactions
• Equilibrium reactions
C. Normal reciprocal innervation
• Coordination: agonist &
antagonist

2. Developmental sequence
– Reflex level
– Millstone
• Planes of movement (S→F→T)
• Proximal-distal
• Cephalocaudal (head → trunk → pelvic → limb)
• Automatic to voluntary (reflex → voluntary)
• Gross to fine (mass pattern → dissociated)

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三、 Theoretical foundation of NDT

– The Bobath approach: in the late 1940s
– Developed from hierarchical theory (reflex), maturation theory, and clinical observation; now
combined with Dynamic Systems Theory; Neuronal Group Selection Theory as well as
Motor Control, Motor Learning, and Motor Development Theories

1. Hierarchical/Maturation Theory:
– CNS hierarchical maturation (sequence, Ex. reflex)
– Cephalocaudal (head → trunk → pelvic → limb)
– Proximal-distal (shoulder → arm → forearm → fingers)
– Automatic to voluntary (reflex → voluntary)
– Gross to fine (mass pattern → dissociated)

2. Dynamic System Theory:

– Movement is an interactive process between multiple systems
– All the other body systems interact dynamically with children’s contexts and the task goals
• bony restrictions, limited flexibility in soft tissues and fascia, varying levels of arousal,
poor sensory processing, and movement impairments
– Reject the hierarchical top-down theory
➢ NDT: Practicing a wide variety of movement strategies- by repeating and
reinforcing new movements in a variety of contexts and tasks

3. Neuronal Group Selection Theory:

– The brain is dynamically organized into neural networks or neuronal groups that share
connections related to their function (experience).
– Engagement with the environment and tasks as well as repeated experience shape these
neuronal groups
– primary variability → selection → secondary or adaptive variability
➢ NDT uses handling as its key treatment strategy with additional neurochemical
information to reinforce the neural mapping process
➢ Repeating valuable adaptive movement experiences in therapy of creating new
neuronal maps

4. Motor Control Theory

– NDT provides the child with enriched motor experience and opportunity to practice
movements emphasizing sensorimotor feedback and providing possibilities for
problem-solving movement strategies using anticipatory motor control.

5. Motor Learning Theory

– Motor learning theory is a set of processes that directly relate to practice or experience,
leading to relatively permanent changes in the capability for movement
• goal-directed tasks; verbal/nonverbal feedback; variability of practice; meaning context
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6. Motor Development Theories

– Through careful analysis and knowledge of typically developing children
– These principles are embedded within handling and positioning techniques provided
throughout NDT sessions teaching the child typical adaptive motor patterns for function

A. Kinesiological and Biomechanical Concepts: theoretical foundation for analysis impairments

– alignment of the body
– the base of support (stability-foundation of movement)
– weights shift (ability to change the distribution of the body weight)
– postural control (controlling the body’s position in space)
– range of motion, muscle strength, stability and mobility

B. Movement Dysfunction
(1) Atypical Muscle Tone: the muscle’s resistance to being lengthened
• Rigidity: simultaneous cocontraction of agonists and antagonists muscles
• Hypotonia: diminished resting muscle tension; decreased the ability to generate
voluntary muscle force; excessive flexibility and postural instability
(2) Impaired Muscle Recruitment Activity
• Excessive cocontraction of muscles
✓ Cocontraction refers to simultaneous activation of agonist and antagonist
muscle groups around a joint
• Excessive Overflow of Muscle Contractions
✓ Overflow is observed during normal movement production, typically as a
movement is first learned or performed with effort.
• Delayed initiation and termination of muscle activity
(3) Impaired Muscle Synergies
• ineffective muscle synergies as their stereotyped patterns of movements
✓ Synergies function to simplify the demands upon the central nervous system,
creating the possibility for more efficient motor production
(4) Impaired Timing, Sequencing, and Scaling of Forces in Motor Execution
• Latency in initiation, slowness, problems in terminating muscle contractions
(5) Insufficient Force Generation
• Muscle weakness and imbalance between agonist and antagonist
• Muscle weakness is associated with all varieties and distributions of atypical muscle
tone and is one of the most significant motor control impairments.
(6) Impaired Anticipatory Postural Control
• Difficult in initiating and timing anticipatory muscle activity

C. Secondary Impairments in the Neuromuscular and Musculoskeletal Systems

– Joints: hypermobility, hypomobility, deformation
– Muscles: muscle length changes, soft tissues lose length and flexibility
– Skeletal: Delay maturation, low bone density, and diminished linear bone grow
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四、 Evaluation: Function-Dysfunction Continua

1. Postural tone
– Function
• Ability to sustain muscle activation for postural
support against gravity
– Dysfunction
• Hypertonicity in trunk and extremities when
attempting to sustain posture against gravity
• Hypotonicity in the trunk and limbs when attempting to sustain posture against gravity
• Presence of “fixing” or compensatory muscle synergies when attempting to sustain
posture or to perform movements against gravity
• Increased postural tone or stiffness to “hold on and stay put” at the expense of
movement against gravity

FIGURE 8.1 FIGURE 8.2 FIGURE 8.3

FIGURE 8.1 Atypical muscle synergy pattern observed in the jaw and neck as the child
attempts to hold himself up against gravity. FIGURE 8.2 Limitations in postural tone
prevent antigravity movements away from the support surface. This child is unable to
right his head in alignment with his trunk during transitions from supine through
sidelying to sit. FIGURE 8.3 Atypical alignment of the joint segments in the frontal plane.
This child is unable to align his neck or spine over a neutral pelvis due to decreased
postural tone.

2. Alignment and patterns of weight bearing

– Function
• Alignment of body parts in relation to each other and to position in space
• Able to push off on the weight bearing side of body to adjust or maintain body alignment
– Dysfunction
• Lack of postural alignment
✓ Anterior pelvic tilt, spinal
hyperextension
✓ Posterior pelvic tile, spinal
flexion
• Asymmetrical posture
• Inability to push off on the weight bearing side of body to maintain body alignment
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3. Dissociation of movement
– Function
• Full range of PROM
• Actively elongate muscles to achieve full AROM in involved joints
• Rolls with rotation between shoulders and pelvis
• Use of reciprocal leg movements in creeping and crawling
• Pull to stand using combination of flexor and extensor muscle groups
• Hold a toy with shoulder and elbow remained relaxed and in proper alignment
– Dysfunction (synergy pattern)
• Contractures and deformities
• Unable to actively stretch two-joint muscles to achieve full range
• Log rolling, bunny hopping
• Pull to stand with extensor synergic in lower extremities
• Hold a toy with flexor synergy pattern: shoulder retraction and elbow flexion

4. Postural control and balance

– Function
• Dynamic postural control
• Ability to assume and maintain positions during static and dynamic movement
– Dysfunction (compensatory postural control)
• Wide or excessively narrow base of support
• Attempts to gain postural control by moving away
from the base of support unsuccessfully or inefficiently
• Use of upper limbs for stability beyond developmentally appropriate age
• Compensatory patterns: high guard, asymmetrical patterns, various fixation patterns
• Exclusive use of w sitting position for postural control in sitting
• Unable to maintain balance in an upright position

5. Coordination
– Function: Perform tasks in a smooth, efficient fashion
• Reach for an object with accuracy and efficiency
• Hold object in hand with just right force
• Walk with typical gait patterns
• Use of varied repertoire of movement patterns based on the demands of the activity
– Dysfunction: Perform tasks in an awkward, uneven, clumsy, and inaccurate fashion
• Overshoot or undershoot the object when reaching
• Hold object in hand with excessive grip force
• Walk with atypical synergies
• Stereotypical movement patterns.
• One or both LE persist with extension, add, and internal rotation in all positions
• One or both UE persist with shoulder elevation and retraction in all positions
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五、 Postulates regarding change

– General Postulates Regarding Change
1. If a therapist handling a child during movement facilitated in a functional context, then it
would enable a child to have a greater chance to develop functional skills.
2. If a therapist adapts the environment incorporating a child’s developmental level, needs,
and interests, then the motor skills will be facilitated under the most optimal condition.
3. If a therapist uses handling techniques embedded in play activities, then it is more likely
for a child to respond with an automatic movement pattern.
4. If a therapist is responsive to a child’s needs (i.e., sensitivity to movement, familiarity
with situation or environment) and allows time for children to initiate movements during
treatment, then a child will be more likely to initiate an
active movement to engage in purposeful activities.
5. If a therapist provides preventative measures such as
adaptive equipment and orthotic devices, then a child will
less likely develop secondary deformities and limitations.

– Specific Postulates Regarding Change

1. Postural Tone
• If a therapist grades his or her touch and directional cues, then the child will prepare his
or her body for active participation in movement activity
• If a therapist uses graded distal and proximal key points of control with varying ranges
to modulate tonal properties, then the child will be less likely to use compensatory
muscle synergies and “fixation” of muscle patterns for stability.
• If a therapist minimizes the impact of gravity through handling,
positioning, or equipment, then the child will experience potential
muscle activation because of these changes within movement task

2. Postural Alignment and Patterns of Weight Bearing

• If a therapist facilitates proper postural alignment in preparation, then a child will use
appropriate muscle activation to maintain postural control during activities.
• If a therapist assists a child in maintaining proper postural alignment throughout the
functional task, the child will sustain muscle activation for posture and movement.
• If a therapist provides aligned weight bearing and proper weight shifting experience
(deep pressure and joint compression), a child will be
encouraged to perform cocontraction of musculature around a
joint, have potential to develop proximal muscle strength, and
be able to initiate movements from the base of support.
• If a therapist provides handling to promote weight shifts and
transitional movements, then a child will learn to move in and
out of positions with proper alignment
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3. Dissociation of Movement
• If the therapist prepares the child’s muscle length and joint ROM with various forms of
handling (traction combined with joint alignment into end ranges of joint mobility),
then the child has the potential to increase muscle activation (potentially prepare the
muscle length and soft tissue mobility for muscle recruitment).
• If the therapist provides handling to promote weight shifts and transitional movements
(support alignment and dissociation of joint segments), then the child moves in and out
of positions with proper alignment.

FIGURE 8.7 Handling that promotes weight shifts,

transitional movements, alignment, and dissociation
of joint segments help the child to develop range of
motion and active muscle recruitment.

4. Postural Control and Balance

• If a therapist facilitates smooth interplay between agonist and antagonist muscles, then
a child will be able to achieve postural control in relationship to gravity.
• If a therapist uses appropriate positioning, equipment, and therapeutic handling
techniques, to provide sustained holding of the trunk against gravity, then a child will
have potential to improve postural control.
• If a therapist facilitates postural control during functional activities, then the child will
be able to integrate these movement patterns into their own movement strategies.
• If a therapist uses graded handling techniques combined with analysis of a child’s
response, the child will potentially develop greater strength, stability, and control over
time during increasingly complex movements.
• If a therapist facilitates movements in all three planes with the specific facilitation of
weight shifts into the transverse plane, then the child will experience axial rotation,
elongation of multiple muscular systems simultaneously, dissociation of intralimb
/interlimb couples, and activation of postural control.

FIGURE 8.8 Weight shifts in the transverse plane

with alignment provide the opportunity for concentric
and eccentric trunk muscle activation facilitating
motor recruitment for postural control against gravity

5. Coordination
• If a therapist provides proper support during isolated movements that require
precision, a child will be able to perform dissociation movements.
• If a therapist chooses appropriate tasks demanding bimanual coordination, a child will
develop patterns of integrated interlimb movements.
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Practice:
Knowing typical development
Alberta Infant Motor Scale (AIMS)

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六、 Intervention strategies of NDT

1. Therapeutic handling: Primary intervention technique of NDT
– The therapist places hands purposefully and precisely upon the child’s body to apply graded
external forces.
– Combined with directional cues child can potentially feel and learn new movement patterns
– Grading handling by changing hand placements, directions of forces, and among of sensory
information provided.
– Correction of alignment and muscle length-tension allows the client to bring muscles on line.
– Handling progresses: from passive elongation and alignment adjustment → active assisted
movement → resistive activities (ensures desired muscle synergy during task performance)
– The placement of the therapist’s hands needs to be preplanned and monitored ensuring
against unnecessary and potentially confusing sensory information
✓ Light pressure touch: feel insecure of confused about the movement expectations
✓ Heavy pressure: block or minimize the movement.
– Therapist’s hands serve to guide rather than control
✓ The therapist’s hands can be placed across joints to ensure alignment, facilitate
movement, or initiate weight shifting
✓ The therapist’s hands are also placed directly on muscles to recruit muscle activity
– Initially, hands-on placement is necessary for all of the child’s movements. In time as the
child develops greater internal motor control, the therapist reduces the handling intensity
promoting increasingly independent problem solving and motor execution
– Mrs, Bobath called the hand placement used during facilitation” key points of control”
✓ Proximal hand placements: can provide stability with some techniques, or mobility if
the technique demands active movement of distal segments.
✓ Distal key points of control: only when child possesses sufficient proximal control
✓ A therapist may withdraw feedback or control over the movements by moving the
key points of control gradually from proximal to distal.
• Each hand possesses a distinct role
✓ One hand required to guide movement, while the other hand assists.
✓ The role of each hand may shift numerous times throughout a handling session.
✓ Use your hands (body) purposely.

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2. Qualities of touch
• The levels of touch provided during handling
are direct, shaped the child’s body.
✓ Light touch is used when child
demonstrates greater degrees of
independent motor control

✓ Deep touch provides increased

support and direction.
• Compression and traction
provide sensory data through
both the touch and
proprioceptive system
modifying tonal properties,

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alignment and muscle activation.

✓ Compression is employed to create cocontraction of muscles
– created alignment of joint segments
– compression can either relax or activate.
✓ Traction is often introduced to
– elongate stiff muscles
– align joint segments
– facilitate the initiation of movement

FIGURE 8.14 Compression forces directed from the knee joint toward the feet with
aligned ankles provide deep sensory input to the foot against the support surface. This
technique potentially relaxes the musculature of the ankle in preparation for active weight
bearing in standing.
FIGURE 8.15 Traction along the length of the humerus creates an elongating force to the
musculature between the scapula and the humerus extending the excursion of reach.

3. Preparation, Facilitation, and Inhibition

Handling consists of a combination of techniques designed to prepare the child’s body, facilitate
active movement, and inhibit unwanted movement pattern.
A. Preparation
• Preparatory activities: mobilizing or elongating tight structures, promoting alignment of
body segments and in relationship to gravity.
• The end result of preparation is a state of
readiness for active initiation of posture and
movement.

B. Facilitation
• Following the preparatory activities, active or automatic movement patterns are
facilitated
✓ Hypertonic: benefits from facilitation that uses full ranges of movement.
✓ Hypotonic: benefits from slow, controlled handling. Higher level antigravity
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positions (eg. Sitting/standing) requiring increased activation of proximal musculature

• Facilitation: principle of weight bearing and weight shifting to activate motor control.
✓ Weight bearing:
– developing cocontracton of stabilizing muscles
– enhancing proximal stability.
✓ Weight shifting
– All postural movements occur with a shift of weight in various degrees of
amplitude and planes (e.g., anterior-posterior, laterally, and diagonally)
– Hypertonic: difficulty in initiating a weight shift;
– Hypotonic: tends to have greater difficulty grading weight shifts

• Deep compression:
Deep compression to the large muscles of the trunk toward the weight-bearing surface
is specific facilitation technique enlisted to increase stability and postural control
using ground force reactions to assist the initiation of muscle
activation from the base of support.
• Facilitation can be slow, moderate or fast in speed.
✓ Slow: Provided when a child is fearful of movement or
sustained muscle contractions are required
✓ Fast: Unmotivated or not aroused child (alert a nervous system)
• All children need to experience varying speeds of
movement to develop response to multiple variables
within their environment.
C. Inhibition
• Inhibition is provided coincidentally with facilitation
• Reduction of specific underlying impairments that interfere with function.

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• Inhibition is targeted toward the prevention or redirection of components of movement

that are unnecessary.

4. Learning the process of Therapeutic handling

– The therapist must be able to conceptualize a movement sequence before the actual execution
of the handling facilitation.
– The goal of handling is to provide the child with the experience of independent, smooth and
efficient movement within a functional outcome.

5. Integration of Neuro-Developmental Treatment into Activity

– Play activities are key because children who have motor impairments frequently have limited
or altered play experiences.
• Movement goals are embedded into a play schema.
• Stimulate movements required for ADL activities.
• Continuously alter the demands of environment to assist child to learn in various context

6. Positioning and Adaptive Equipment

– Adaptive equipment is used as an adjunct to handling
– A therapy ball, bolster, or bench can be of tremendous support.
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– Positioning on equipment can also facilitate postural alignment and stability without hands
on contact by the therapist.
– The external stabilization provided by the equipment potentially facilitates greater
independence of movement in distal body segments.
補充資料:Therapeutic positioning
• Principles 1. Change position regularly (an hour)
2. Keep appropriate position in every ADL (diaper, feeding, dressing)
• Modalities: Wedge, rollers, feeding seat, standers, towers, pillows…

Sequence of Intervention
• Preparatory activities for passive movement or body alignment
• Selection of the key points for therapeutic handling according to the child’s postural tone and
facilitation of active or automatic movement patterns by applying graded and varied tasks.
• Inhibited unwanted movement patterns

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NEUROREHABILITATION FOR CHILDREN

PART II: CURRENT APPROACH

一、 Constraint-Induced Treatment (CIT)單側侷限誘發療法

– 常見名詞
• Constraint-Induced Therapy (CIT)
• Constraint-Induced Movement Therapy (CIMT)
• modified Constraint-Induced Movement Therapy (mCIMT)
– 治療原則
• 原則為侷限健側手的活動，加強練習患側手主動使用
– 理論基礎
• 神經科學
✓ 使用患側手的動機被壓抑，孩童使用患側手的頻率少，導致患側手的動作與神經
連結逐漸退化
✓ 抑制健側肢體活動，將有助於雙側腦半球活化程度的平衡，改善神經損傷後健側
腦過度代償患側腦的現象
✓ 大腦可塑性 (Neuroplasticity)，大腦除了早期發展階段外，在其他時期仍擁有可
塑性，會因應環境的要求，不斷地重組，產生新的神經網絡
• 行為心理學理論
✓ 處理習得廢用症(learned nonuse)
✓ 透過適當地正增強與負增強來塑造孩童的動作行為
• 動作學習理論
✓ 大量重覆的練習：90%；6-hrs (成人方案)
✓ 結合適當的回饋系統
• 動態系統理論強調動作的形成與發展為非線性的、非連續性的，是數個次系統統合後
產生的結果
• 生態系統理論需以孩童為中心，考量環境與情境的影響，提供適當且豐富的環境，促
進孩童動作技巧的練習與發展
– 療效的機制驗證
• 單側上肢去神經的猴子研究 Taub et. al. (197X~)
• 出現習得廢用 (learned non-use); 發展性漠視(Developmental disregard)
• 侷限誘發療法：當猴子的健側肢體受到侷限時，能誘發出患側手的使用習慣，克服
習得廢用現象
• 幼猴：大動作自然發展，精細動作需經過訓練
– 治療方案：成人個案→兒童個案(Child friendly program)
Type of constraint：石膏、副木及手套等→對孩童來說較為友善的手套或背帶；治療
師口語與肢體提示的方式。
Duration of constraint
(1) 短時間、高密度的密集治療模式
(2) 長時間、低密度的分散治療模式
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– 治療原則
• 侷限：
✓ 侷限健側手的活動，迫使或增加患側手主動使用的機會
✓ 石膏,副木,手套
✓ 情境（含治療師口語與肢體提示）
• 密集訓練與動作塑造：
✓ 對動作品質的進步給予立即且密集的回饋(feedback)
✓ 隨時選擇與調整任務，以符合個案的動作練習
✓ 給予任務表現時正確的動作指引或提示
✓ 如果個案有進步，逐步系統性地增加任務難度
✓ 任務導向模式：Grading/ Just right challenge

二、 Bilateral Intensive Treatment (BIT) 雙側上肢練習療法

– 雙側訓練的起源
• 優勢手的侷限亦會造成發展學習的限制
• 日常生活任務的執行則大部分需雙手合作才可完成，應直接練習
• 家長主訴的目標中，有 85%都是雙手相關的技能
• Realistic expectation of functional outcomes directly (任務手/輔助手)
– 雙手協調的發展
• Asymmetrical movements
• Symmetrical movements
• Differentiated asymmetrical movements
✓ 交替動作 (reciprocal / alternating hand movements)
✓ 任務手輔助手
– 理論基礎與機制
• 雙側密集訓練以動作學習與神經可塑性為理論基礎 (Charles & Gordon, 2006)。
• 當個體做出對稱雙側動作時，胼胝體間會產生耦合作用 (coupling effect) 來促使腦傷
後神經路徑之間的復原。
• 2006 年，Charles 與 Gordon 團隊提出 Hand-Arm Bimanual Intensive Training, HABIT
– 訓練原則
• 訓練時提供孩童結構化的練習，任務的難度從簡單到複雜進行分級
• 訓練時提供孩童功能性的活動來練習，提供的活動為必須使用雙手才能完成的任務
• 考量在所選擇的任務中，孩童患側手所扮演的角色及動作為何
• 提供孩童友善(child-friendly)的介入方案，治療目標的設定需參酌孩童與家長之意見

三、 其他現代神經復健方案 (Hybrid, RT, MT, MI...)

1. Hybrid (CIT+BIT)
2. 機械輔助療法(Robot Therapy)
3. 鏡像療法(Mirror Therapy)
4. 動作想像療法(Motor Imagery Therapy)
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