Transcript PRINCIPLES OF BOBATH APPROACH

PRINCIPLES OF
BOBATH APPROACH
BY –
GAJANAN BHALERAO
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.
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.
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.
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.
“Nothing is more
powerful than a
idea”
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.
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.
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.
What
To
do?
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.
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.
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.
“Today’s success & today's defeat
are just another step in the
long journey of your life”
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.
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 patient’s
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.
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.
Nature of handicap of patient
with brain lesions
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.
Neurophysiological considerations.
The fundamental problem
1. Abnormal patterns of coordination in
posture & movement.
2. Abnormal qualities of postural tone.
3. Reciprocal innervations.
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.
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.
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.
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.
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.
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 patient’s 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.
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’.
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.
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.
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.
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 nonfunctional motor patterns
THANK
YOU
NORMAL AUTOMATIC
POSTURAL CONTROL
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.
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.
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.
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.
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’
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
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.
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.
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.
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.
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.
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’.
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’.
Normal postural control provides 3 prerequisites
fro voluntary functional activity
1. Normal postural tonus of moderate intensity.
Postural tone must be high enough to resist
gravity, but should be enough to give way to
movement.
2. Normal reciprocal interaction for:a. Synergic fixation proximally to allow for
selective mobility of more distal segment.
b. Automatic adaptation of muscles to postural
changes.m
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.
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.
ABNORMAL POSTURAL
REFLEX ACTIVITY
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.
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.
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 aftercontraction 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.
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.

1.
2.
3.
4.
5.
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.
Effect of released positive
supporting reaction
Adequate stimulus for positive supporting reaction
is twofold:
1. A proprioceptive stimulus by stretch of the
intrinsic muscles of the foot.
2. 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).
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.
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
1. The perception of superficial & deep
sensation
2. 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.
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.
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.
Application of shunting rule in
treatment
 We can at the same time direct patient’s
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.