PRINCIPLES OF BOBATH APPROACH

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PRINCIPLES OF BOBATH APPROACH

• BY
• GAJANAN BHALERAO

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What is Bobath therapy?

• Bobath therapy is an interdisciplinary approach
  to the management of cerebral palsy involving
  occupational therapy, physiotherapy and speech
  and language therapy. Bobath therapy is a
  holistic approach pioneered by Dr and Mrs Bobath.
  The basis of the approach is to give children an
  experience of normal movement by enabling the
  child to respond actively to specialised handling.

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Who were the Bobaths?

• Berta Bobath was a physiotherapist, who had
  initially trained in remedial gymnastics. She
  understood normal movement and posture, and
  together with her husband Karel, who was a
  pediatric neurologist, Berta developed an
  approach to the treatment of cerebral palsy that
  would encourage a child to move and function as
  normally as possible, while Karel researched the
  neurological implications of the Bobath approach.
  

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Why is it used for strokes?

• Because Bobath therapy is a useful treatment for
  neurological-based movement disorders. Having a
  stroke can cause cerebral palsy in babies and
  young children, but there is a major difference
  between children and adults who have had a
  stroke adults who have lost certain abilities
  can tap into their previous experiences to
  relearn skills, whereas young children will have
  no previous experience of a normal movement to
  tap into, and have to be taught.

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What effect does it have?

• Bobath therapy helps the child to gain more
  control of their bodies, to interact with their
  environment, and to achieve a greater level of
  independence. Bobath therapy also aims to reduce
  the problems that develop as the child gets
  older.

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• Nothing is more
• powerful than a
• idea

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Basic idea of Bobath approach

• sensation of movement are learned, not movement
  per se
• Basic postural movement patterns are learned
  which are later elaborated on to become
  functional skills.
• Every skilled activity takes place against a
  background of basic patterns of postural control,
  righting, equilibrium other protective
  reaction, reach, grasp release.

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Basic idea of Bobath approach

• When brain is damaged, abnormal patterns of
  posture movement develop which are incompatible
  with the performance of normal everyday
  activities.
• The abnormal pattern develops because of
  sensation is shunted into these abnormal patterns.

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The law of shunting

• A phenomenon of efferent inflow being short
  circuited either temporarily ( the athetoid
  patient) or more permanently ( the spastic
  patient) into patterns of abnormal co ordination
  released from higher inhibitory control.
• A patient with abnormal motor out put who moves
  abnormally in response to motivation normal
  sensory inputs will still only experiences
  memories the sensation of of his abnormal
  movement of excessive efforts lack of co
  ordination.
• He will therefore be unable to develop lay down
  the memory of normal sensory motor patterns.

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• What
• To
• do?

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Basic idea of Bobath approach

• The abnormal patterns must be stopped not so much
  by modifying the sensory input, but by giving
  back to the patient the lost or undeveloped
  control over his out put in developmental
  sequence.
• The basic patterns of posture movement , the
  righting reaction equilibrium responses are
  elicited by providing the appropriate stimuli
  while the abnormal patterns are inhibited.
• In this way patient the patient is given the
  opportunity to experience normal movement.

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Basic idea of Bobath approach

• The sensory information of correct movement is
  absolutely necessary for the development of
  improved motor control.
• Treatment therefore, concentrate on handling the
  patient in such a way as to inhibit abnormal
  distribution of tone abnormal postures while
  stimulating or encouraging the next level of
  motor control.
• The abnormal postures tone are controlled at
  key point (proximal body parts, I.e. head neck
  trunk, sometimes distal parts I.e. thumb
  fingers), using reflex inhibiting movement or
  patterns called as RIPs.

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Basic idea of Bobath approach

• If the patient lack s tone, sensory stimulation
  or tapping is used while the RIPs is applied so
  the is sensory inflow will not shunt into
  abnormal patterns.
• Bobath believes that once the patient can move in
  out of normal basic patterns of posture
  movement he will automatically be able to
  elaborate on these patterns to learn the more
  skilled activities required in daily living.

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• Todays success today's defeat are just
  another step in the long journey of your life

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INTRODUCTION

• Bobath treatment has undergone many changes from
  the time of its inception, but the underlying
  concept has not changed.the main problem of
  patient with upper motor neuron lesion is that
  of abnormal co ordination of movement patterns
  combined with abnormal postural tonus.
• Problems of the strength activity of individual
  muscles and muscle group is secondary to that of
  the co ordination of their action.

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INTRODUCTION

• Muscles are tools of nervous system and ,
  therefore, the activity of individual muscles
  muscle group is secondary to that of their
  coordination in patterns of activity.
• Thus, the assessment treatment of patients
  motor patterns is the only way of leading
  directly to functional use.
• In the hemiplegic patient, muscles are not
  paralyzed deficit of muscular activity can be
  remedied by their action in more normal
  functional patterns.

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INTRODUCTION

• This is still is a concept of treatment.
• What has changed is that we have found new
  techniques.
• We have discarded all static ways of treatment
  like reflex inhibiting postures, but have
  introduced a strong emphasis on movement on
  functional activity.
• From beginning the concept has been, still is,
  a holistic approach, dealing with pattern of
  coordination not with problems of muscle
  function.
• It involves the whole patient, his sensory,
  perceptual adaptive behavior, as well as his
  motor problems.

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Nature of handicap of patient with brain lesions
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Neurophysiological considerations.

• The physical handicap resulting from a lesion of
  the upper motor neuron is seen in terms of an
  interference of normal postural control.
• We are dealing with abnormal coordination of
  motor patterns.
• If we speaks of patterns of coordination, we
  mean the pattern of normal abnormal postural
  control against gravity.

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Neurophysiological considerations.

• The fundamental problem
• Abnormal patterns of coordination in posture
  movement.
• Abnormal qualities of postural tone.
• Reciprocal innervations.

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Abnormal qualities of postural tone.

• Sherringtone(1947) stated that normal movement
  need a background of normal tonus.
• Tonus the coordination of movement are
  indivisible they depend on each other.
• The abnormal types of postural tone the
  stereotyped total motor patterns we see in our
  patient are the result of disinhibition, I.e. of
  a release of lower pattern of activity from
  higher inhibitory control.
• Such release does not only produce muscular
  signs, such as exaggerated stretch tendon
  reflexes, but abnormal patterns of coordination.

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Abnormal qualities of postural tone.

• Inhibition is very important factor in control of
  posture movement.
• With increase of inhibitory control of the
  maturing brain, the organism increasingly gains
  more selective control of posture against
  gravity.
• This process fallows cephalocaudal direction.
• Although the limbs parts of body achieve a
  partial independence in this way, their
  emancipation from the total patterns is never
  complete.
• The movement of a limb remains to some extent
  always subordinate to the control of the whole
  organism.

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Abnormal qualities of postural tone.

• The action of total pattern has to be inhibited
  prior to the inhibition of a localized action.
• This means that normal functional skilled
  activity are largely a matter of inhibitory
  control.
• The quality of coordination its development in
  early childhood depends, therefore, on increase
  of inhibitory control not on increase of muscle
  power.
• Inhibition is a active at every level of the CNS.
• The difference between lower higher levels of
  integrations only the matter of complexity.

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Abnormal qualities of postural tone.

• Selective movement of parts of body limbs need
  inhibition of those parts of patterns which
  unnecessary for specific function.
• Inhibition doesn't only make selective movement
  possible, but plays a imp role in the grading of
  movement, I.e. it is an important factor in
  reciprocal innervations. It is the balanced
  activity of excitation inhibition during a
  movement which control speed, range direction.
• Inhibition on excitation changes moulds it
  for the purpose of coordination. It modifies
  control action.one might say that inhibition is
  control.

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Abnormal qualities of postural tone.

• The brain damaged patient suffers from a lack of
  inhibitory control over his movements.
• This itself show release of tonic reflex
  activity, i.e. spasticity in abnormal total
  patterns.
• Spasticity will increases, producing
  deterioration of his movements. Movements become
  slowed down, laboured, or he may become too stiff
  to move altogether.

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Abnormal qualities of postural tone

• When observing a spastic patient one is struck
  by the fact that spasticity shows itself in
  definite pattern of abnormal coordination that
  is not confined to a few isolated muscles.
• The patients posture movement are stereotyped
  typical, he is more or less fixed in few
  abnormal pattern of spasticity which he cannot
  change or can do so only with excessive effort.

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Abnormal qualities of postural tone

• Therefore, movements, which need a coastally
  changing background of postural control
  adjustment, are prevented.
• To think to posture as separate from movement is
  highly artificial, for posture is in fact, in
  constant flux should be regarded as
  temporarily arrested movement.

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Reciprocal innervation

• In intact organism, spinal inhibition becomes
  modified by higher central nervous influences
  allows reciprocal innervation, a more adequate
  response to the multitude of stimuli which enters
  the central nervous system in normal condition of
  life.
• Agonist, antagonist synergists are pitted
  against each other in finely graded way giving
  necessary interplay of muscles group for fixation
  with mobility optimal mechanical conditions for
  muscle power.

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Reciprocal innervation

• In normal circumstances all the required degrees
  of reciprocal interaction in various parts of the
  body and limbs necessary for postural fixation,
  grading of movement for the maintenance of
  equilibrium are present.
• Disturbed reciprocal innervation described above
  are responsible for the way in which a patient is
  fixed n few abnormal patterns, for the
  difficulty in coordinating movement their
  grading.

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Reciprocal innervation

• The degrees of fixation in stereotyped postural
  patterns depends on the severity of spasticity in
  individuals case are the result of the release
  of abnormal postural reflexes which interact with
  each other.
• Treatment aims at inhibition of abnormally
  release patterns of coordination the
  facilitation of the higher integrated automatic
  reactions of normal postural control of those
  of more voluntary activity.

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Reciprocal innervation

• Treatment helps the patient to develop increase
  his control over the disinhibited action of tonic
  reflex activity by use of patterns which inhibit
  spasticity.
• Through inhibition his movement are channeled
  into more normal patterns of function.
• With the helps of therapist, the patient gains
  control over the released abnormal non-functional
  motor patterns

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• THANK YOU

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NORMAL AUTOMATIC POSTURAL CONTROL
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NORMAL AUTOMATIC POSTURAL CONTROL

• Normal postural activity forms the necessary
  background for normal movement for functional
  skills.
• The basic patterns of coordination which underly
  make possible voluntary skilled activities
  are those of normal postural reactions against
  gravity.

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NORMAL AUTOMATIC POSTURAL CONTROL

• This normal postural reflex mechanism consist of
  a great number of dynamic postural reactions
  which work together, reinforce each other
  interact for the purpose of protection against
  falling against injury to muscles joints.
• They are active during before a movement is
  performed, they give us the ability to
  counteract gravity, without fatigue, to adjust
  our posture when we are in an uncomfortable
  position.

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NORMAL AUTOMATIC POSTURAL CONTROL

• They make us able to move in spite of having to
  keep up against gravity, for ex walking up down
  the stairs.
• They make us change our posture automatically
  before we move inn order to make the intended
  movement possible easy.
• Such postural adjustment called as postural
  sets
• They are postural changes in anticipation of, as
  well as accompanying any movement.

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NORMAL AUTOMATIC POSTURAL CONTROL

• They make us able to move in spite of having to
  keep up against gravity, for ex walking up down
  the stairs.
• They make us change our posture automatically
  before we move inn order to make the intended
  movement possible easy.
• Such postural adjustment called as postural
  sets
• They are postural changes in anticipation of, as
  well as accompanying any movement.

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NORMAL AUTOMATIC POSTURAL CONTROL

• Postural adjustment occur not only as a result
  of sensory feedback in response to unexpected
  perturbations, but also as a result of feed
  forward in anticipation of expected, self
  generated perturbations

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Postural reactions

• They are Active movement
• Although Sub cortically controlled Automatic
• Give head trunk control
• Maintain or restore normal alignment of body
• Maintain regain balance

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Posture

• There is no dividing line between posture
  movement, but fluid transition from one to the
  other.
• Posture is a part of every movement, and if a
  movement is arrested at any stage, it becomes a
  posture.

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Postural reactions

• The development of coordination in early
  childhood goes step by step with the development
  of postural reaction with their appearance,
  modifications disappearance when more complex
  more voluntary skilled activities are acquired.
• The development of automatic postural control of
  movement has been called principle mobility by
  schaltenbrand (1927).
• The knowledge of development of coordination is
  necessary for the treatment of all patient with
  upper motor neuron lesions.

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RIGHTING REACTIONS

• The righting reactions are automatic reactions
  which serve to maintain restore the normal
  position of head in space its normal
  relationship with the trunk, together with normal
  alignment of trunk limbs.
• They develop in childhood are well advanced at
  age of 5 months of age.
• Rotation around the body axis plays an important
  role in these activities.

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RIGHTING REACTIONS

• Gradually modifies become integrated into more
  complex activities, such as the equilibrium
  reactions voluntary movement.
• There are essential in the building up of motor
  patterns for adult life.
• Throughout life they are necessary for getting up
  from the floor, for getting out of the bed, for
  sitting up, for kneeling down, etc.

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EQUILIBRIUM REACTIONS

• Equilibrium reactions are automatic reactions
  which serve to maintain restore balance during
  all our activities, especially when we are in
  danger of falling.
• All equilibrium reactions reactions, tonus
  changes movement changes have to be well
  coordinated, quick, adequate in range well
  timed (Rademaker, 1935, Weisz1938)
• Tested either by the body moving body against a
  fixed support such as the ground, or by means of
  a movable platform or tilting table.

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AUTOMATIC ADAPTATION OF MUSCLES TO CHANGE OF
POSTURE

• These automatic reactions can be observed in
  trunk limbs, and they overlap to some extent
  with the equilibrium reactions.
• In a normal person, the central postural control
  mechanism governs the weight of a limb during
  movement both into against gravity.
• This mechanism may be called postural adaptation
  to gravity.

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AUTOMATIC ADAPTATION OF MUSCLES TO CHANGE OF
POSTURE

• A normal person is active when being moved
  against gravity.
• Relaxation, unless full support is given, is a
  voluntary learned ability.
• Normal person controls every stage of movement
  actively automatically.
• We cal this manoeuvre placing.

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Normal postural control provides 3 prerequisites
fro voluntary functional activity

• Normal postural tonus of moderate intensity.
  Postural tone must be high enough to resist
  gravity, but should be enough to give way to
  movement.
• Normal reciprocal interaction for-
• Synergic fixation proximally to allow for
  selective mobility of more distal segment.
• Automatic adaptation of muscles to postural
  changes.m

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Normal postural control provides 3 prerequisites
fro voluntary functional activity

• c. Graded control of agonist antagonist
  integrate with that of synergists for the timing
  direction of movement.
• 3. The automatic movement patterns of the
  righting equilibrium reactions which are the
  background against which voluntary functional
  activity takes place.

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Disturbance of Normal postural control

• The effect of UMN lesion is described as
  Disturbance of Normal postural control mechanism.
• Interference with normal motor ability is caused
  by pathological deviation from the fundamental
  prerequisites motioned above.
• Instead of normal postural tone we find
  spasticity.
• Instead of normal coordination of righting,
  equilibrium other protective reactions we find
  few static stereotyped postural reflex patterns.

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ABNORMAL POSTURAL REFLEX ACTIVITY
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FACTORS INTERFERING WITH NORMAL MOVEMENT

1. Associated reactions
2. The effect of released asymmetrical tonic neck
   reflex activity.
3. The effect of released positive supporting
   reaction.

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ASSOCIATED REACTIONS

• WALSHE (1923) described associated reactions as
  tonic reflexes, i.e. postural reactions in
  muscles deprived of voluntary control.
• In hemi associated reactions produces widespread
  increase of spasticity throughout the hole of the
  affected side.this accentuate the hemiplegic
  attitude.

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ASSOCIATED REACTIONS

• Higher the spasticity, more forceful longer
  lasting will be the associated reactions.
• The duration of associated reactions is roughly
  that of the movement or contraction evoking it,
  but there is in some instances a prolonged
  after-contraction or tonic prolongation of the
  spasm, which last for several seconds.
• More spastic the limb, longer the latency after
  contraction.
• Antagonistic muscles groups, flexor extensors,
  are to be observed in simultaneous contraction.

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ASSOCIATED REACTIONS

• After-contractions is due to lack of inhibition
  plays a detrimental role in the performance of
  repetitive movements(i.e walking).
• With increasing spasticity co-contraction of
  opposing muscle group, the movements are slowed
  down, smaller in range performed with
  increasing effort.
• The reinforcement strengthening of spastic
  pattern through associated reactions can lead to
  contractures deformities.

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• Facts to consider to reduce detrimental effect of
  associated reactions-
• There less spasticity after contraction if
  movement are done slowly.
• The spread of excitation into total spastic
  patterns can be counteracted by inhibiting parts
  of these patterns.
• The therapist should inhibit spasticity
  immediately the movement begins to deteriorate.
• At the start of treatment, excitation effort
  are kept to a minimum, then it is gradually
  increased.
• Therapist helps the patient to learn to inhibit
  this spasticity by the use of selective movements.

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Effect of released positive supporting reaction

• Adequate stimulus for positive supporting
  reaction is twofold
• A proprioceptive stimulus by stretch of the
  intrinsic muscles of the foot.
• An exteroceptive evoked by the contact of the
  pads of the foot with the ground.the antagonists
  don't relax, but contract, exerting a synergic
  function, which result in the fixation of the
  joints (co contractions).

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Effect of released positive supporting reaction

• The normal positive supporting reaction allows
  for moderate degree of co contraction with
  necessary mobility for balance, for movement of
  the body forward over the standing foot, for
  mobility of the hip knee to the leg for the
  next step, for walking up down the stairs.
• In the spastic patient , the positive supporting
  reaction is released from higher control
  combined with extensor spasticity of the leg,
  becomes an exaggerated spastic response.

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Sensory perceptual disturbances

• They are serious handicap to effective treatment
  adversely influence the chances of recovery
  from functional disability.
• Margeret Reinhold has stressed that
• voluntary movement is partly dependent upon
• The perception of superficial deep sensation
• Motor power coordination.
• In normally functioning organism cerebral cortex
  acts as a whole we should, therefore, think of
  the sensory-motor areas as one functional unit.

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Application of shunting rule in treatment

• Magnus stated that at any movement during a
  movement , the central nervous system mirrors the
  state of elongation contraction of the
  musculature.
• It is therefore, the body musculature which
  controls the opening closing of synaptic
  connections within the central nervous system
  determines the subsequent outflow.
• The greatest effect of shunting is obtained from
  the proximal parts of the body.

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Application of shunting rule in treatment

• In accepting the role of shunting, it is clear
  that we have a means of influencing and changing
  motor out put from periphery, i. e. from
  proprioceptive system, beginning usually with
  proximal parts of the body.
• By changing the relative positions of the parts
  of the body limbs when handling a hemiplegic
  patient, we can change his abnormal postural
  pattern stop (inhibit)the outflow of excitation
  in to established shunts of spastic patterns.

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Application of shunting rule in treatment

• We can at the same time direct patients active
  responses into the channels of higher integrated
  complex pattern of more normal coordination.
• In this way, spasticity becomes reduced by
  inhibition of its patterns, while more normal
  postural reactions movement are facilitated.