Some of the things we learned at Bobath were some simple principles to help Charlie ‘organise’ his body. Charlie has been able to overcome a large amount of his high-muscle tone and for many positions and situations his tone appears ok. We learned the difference between ‘passive’ and ‘dynamic/active’ tone- ‘passive’ being when Charlie is relaxed and comfortable and ‘active’ when he is performing complex movement, tasks or is scared. It is in this ‘dynamic’ tone that Charlie struggles and Bobath helped show us some activities to help Charlie overcome it.
Generally dissociation refers to positioning; often one limb extended whilst another is extended. It is a super way of helping the brain ‘split’ the signals between limbs and it can also help focus attention on the core, the tummy and back and their effect on hip tilt. It is a way of helping break up high muscle tone and exposure to these dissociated positions can help Charlie learn to overcome his tone.
A simple example is half-kneeling; one knee down, one up. Performing activities in such a position can help Charlie tolerate the positions and his brain to ‘learn’ them while he plays. Most kiddies with no movement issues would perform the activities spontaneously from being a baby- with Charlie we have to provide the opportunity for his body to experience them and so to learn them. Initially, the positions were ‘alien’ to Charlie and his tone shot up making it very difficult for him to maintain the position but also made performing any action almost impossible. However, with further exposure he has become increasingly tolerant to the positions and more able to do more activity with his hands. Practice makes permanent!
We also have found that as Charlie concentrates on leg activities, his arms and trunk flex and he becomes increasingly tight. We were shown a simple method of opening his arms up and out to his sides, while turning his palms up- this extends his shoulders back but it also aids the required hip tilt, pulling Charlie’s bum in standing him in a much straighter position, reducing his tone.
Other examples are; standing with one foot on a raised step whilst one is one the floor, sitting on the side of bed with one leg on it and straight whilst the other hangs off the bed.
Obviously weight-shifting is a vital part of walking which when broken down is almost a series of controlled ‘falls’. When Charlie is uncomfortable or not confident in an activity his body extends and his tone increases- this makes his ability to balance and shift his weight much more difficult.
Side-stepping, bridging and high-reaching are all activities which encourage Charlie to move his weight to enable his body to move in a more free way. Encouraging Charlie to side-step is developmentally taking him back to cruising like a baby; it encourages his brain to dissociate between his two legs but also so put his weight on his standing foot to enable him to move his other leg out and away from his midline. Particularly when Charlie started these activities his high tone meant he tended to bring his shoulders too far forward- flexing at this tummy. As we practiced we encouraged him to keep his hands on the wall and ‘scoot’ along- keeping his hands on the wall pulled his shoulders back and moved his head carriage into a much more stable position. This eventually has straightened him up and has enabled him to ‘rock’ side to side, shifting his weight as he steps. We have also had to be aware of his feet in relation to the wall- he had a tendency to bring his feet away from the wall so he could lean his bum on the wall- again flexing his trunk making weight-shifting harder. Now we keep his feet back by encouraging his awareness and putting an obstacle in front so not to let him step too far forward, away from the wall.
Bobath showed us how bridging can be a beneficial activity too. With Charlie’s back to the wall we ask him to keep his shoulders back and thrust his hips forward to allow an object to be passed behind him. We then progressed to putting an object behind his bum and making him push it against the wall to stop it dropping; we then get him to bridge forward again and allow the object to drop- much to Charlie’s amusement. Extending the time putting objects behind him keeps Charlie in a dynamic position. We have also progressed to reaching high above him, making him bring his bum forward so not to be in contact with the wall- without him knowing it getting him to balance for longer periods, even without his AFOs. By putting objects out to the side and reaching high we can also get Charlie to shift his weight out to the side, combining the benefits of the exercises.
Obviously just doing these exercises are not going to spontaneously enable Charlie to immediately achieve his walking aims but they provide some of the basic ‘building blocks’ to build the foundations required to learn. We have noticed since Bobath that Charlie’s tone is much lower in his legs generally but specifically when he is trying hard to do something or getting about. Even on his walking frame we see his heels on the floor so much more- previously he tip-toed.
By enabling Charlie to experience different positions regularly his brain can benefit from the sensory input and learn the ‘accidental connections’ that he missed as a baby. Again, the more the better!