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BOBATH

APPROACH
(Neurodevelopmental Technique)
Background
Developed by Berta Bobath
Physiotherapist
Gymnast
(it is where she developed her understanding of
normal movement, exercise and relaxation)
Assisted by her husband, Karl, a neurologist
Designed to restore normal movement to children with
cerebral palsy & to those with hemiplegia
focuses on regaining postural control and selective
movement control and also works to normalize muscle
tone
involves the inhibition of abnormal movement patterns

and facilitation of normal voluntary movement


Techniques may include handling; inhibition of spastic

muscles and facilitation of flaccid muscles; weight


bearing and weight shifting; integration of functional
tasks; and positioning

Treatment
based on the following premise:
Principles
normal movement patterns cannot be imposed upon abnormal
ones
The inhibition of abnormal or primitive reflexes results in a
reduction & regulation of muscle tone
The facilitation of higher reflexes in their proper developmental
sequence & corresponding progression to skilled activities are
developed once the primitive reflexes are broken
focuses on the sensation of movement
it is not movement itself but the sensation of movement, that
is learned and remembered
Goals of Bobath Approach:
Decrease the influence of spasticity & abnormal coordination
treatment should avoid movements & activities that increase
muscle tone or produce abnormal reflex patterns in the
involved side
Improve control of the involved arm, trunk & leg
treatment should be directed towards the development of (N)
patterns of posture & movement; movement patterns are not
based on the development sequence but on patterns important
for function
Theoretical basis
Hierarchical
Utilized developmental sequence
Movement was expected to spontaneously carry over into function
1. Beevors axiom
the brain knows nothing of individual muscle action but only
movement

2. Law of Memory by Twitchell (1954)


the brain cells have the ability to repeat certain patterns of movement
which become first a RUT (pathway), which when repeated several
times become a CHAIN, and when fixed or learned becomes a BOND or
ENGRAM

3. Law of Shunting ( Von Uexkuell & Magnus)


also known as reflex reversal
states that at any moment during movement or postural
change, the CNS mirror, or reflects faithfully, the state of
body musculature ( as it elongate & contract)
states that the afferent flow favors contraction of the elongated
muscles, whereas the shortened muscles are in a state of inhibition
i.e., the stimulus favor the elongated muscle groups (it is in its
excitatory phase & therefore easily stimulated; sensory impulses are
taken in like touch, ice, pressure etc.), while the contracted & actively
shortened group were in a state of central inhibition (there is no influx
Theoretical basis
it is the body musculature w/c controls (directs/ guide) the
opening & closing of synaptic connections w/in the CNS &
determines the subsequent outflow
the greatest effect of shunting (channeling) is obtained from
the proximal part of the body (spine, shoulder & pelvic girdle)
it shows that we have a means of influencing & changing motor
output from outside the brain (from proprioceptive system) by:

changing the position of body parts (beginning with proximal part)


that will lead to:

change in abnormal postural pattern to stop (inhibit) the outflow of
excitation into established shunts of spastic pattern &:

can direct patients active responses into channels of higher
integrated complex patterns of more (N) coordination

REFLEX INHIBITING POSTURES
(breaking down of existing abnormal pattern by changing postures;
used to give the CNS the sensation of (N) movt.)
Theoretical basis
4. Sherringtons Law of
Reciprocal Innervation
by Sir Charles Scott Sherrington
muscles always work in pairs, when
the agonist muscle contract, the
antagonist muscle will relax & vice
versa
When contraction of a muscle is
stimulated, there is a simultaneous
inhibition of its antagonist
It is essential for coordinated
movement
Treatment strategies
Determine missing components of alignment & movement
Intervention is broken into two phases:
1. Preparatory phase
helps increase the joint mobility and facilitates postural alignment
2. Facilitation phase
facilitation of active movement
Through sensory input and uses key points of control
Key elements include:
1. Alignment Cannot impose normal movement on malaligned joints
2. Handling Inhibition, Facilitation, Key points
3. Placing Assisting patients in achieving the appropriate position through
alignment and handling
4. Practice to increase carry over & retention; functional activities, sensory-
motor experiences
Reflex inhibiting postures are used to inhibit primitive reflexes (RIPs)
Sensory stimulation is regulated with great care
Weight bearing, placing and holding, tapping and joint compression are used to
activate normal movement and posture
Compensation (such as one-handed feeding and dressing) using the noninvolved
side is discouraged during recovery from stroke because it results in inactivity and
poor recovery on the involved (paralyzed) side.
TERMINOLOGIES
1. Reflex-Inhibiting Pattern (RIPs)
partial patterns opposite to the abnormal typical patterns of postural
tone that dominate the patient
are used to counteract the typical distribution of flexor spasticity in
the UE & trunk, & extensor spasticity in LE
old technique which incorporates passive lengthening positioning of
spastic muscles
breaking down of existing abnormal pattern by changing postures;
used to give the CNS the sensation of (N) movt.)
used to inhibit patterns of abnormal muscle tone
prevents shunting of the sensory inflow abnormal patterns and
redirect it into the (N) ones
inhibitions imposed from the outside
2. Reflex-Inhibiting Movement Patterns (RIPM)
newer technique that incorporate active movement that (B) inhibit
abnormal tone & facilitate active movement responses
3. Key Points of Control
according to Bobaths, these are parts of the body where (B) normal &
abnormal motor activity originate
usually proximal parts of the body (head, neck, shoulder girdle, pelvic
girdle, trunk)
TERMINOLOGIES
4. Handling
term used by the Bobaths to denote their manner of control of
the patient through RIPs, & their movement of him/her to
elicit righting & equilibrium responses
utilized the key points of control to make it easier to control the
quality of patients movement pattern
distal key points such as foot & head are combined with the
proximal contact to control extremity motion
shoulder, pelvis, spine & ribcage are used to control proximal
parts

5. (N) Automatic Reactions


need to be elicited because they inhibit the primitive patterns
these are the true inhibitions from higher centers
form the necessary background for (N) movement & functional
skills
these are (N) postural reaction against gravity; active before &
during performance of movement as a result of sensory
feedback in response to unexpected perturbation
are also postural sets
are elicited for each posture and movement that is being used
TERMINOLOGIES
6. Righting Reactions
evoked to assist the patient to move from supine prone prone
on elbows quadruped kneel standing standing
serve to maintain & restore (N) position of head in space (face
vertical, mouth horizontal) & its relation to trunk together with (N)
alignment of trunk & limbs necessary to get up from floor, out of
bed, sitting up, kneeling down etc.

7. Equilibrium Reactions
elicited by displacing the persons COG while he is in one of the
developmental postures and can maintain that posture against
gravity
serve to maintain & restore balance during all activities especially
when in danger of falling
involve counter movement to restore balance, tone change etc.
involve patterns of righting reaction, such as head control &
rotation of trunk & pelvis
these reactions are needed when riding on any form of transport
can be tested either by moving the body against a fixed support
(such as the ground), or by means of a moveable platform
form the first line of defense against injury
TERMINOLOGIES
8. Protective Extension or Parachute Reaction
2nd line of defense when equilibrium reaction prove to be
insufficient
the arms and hands are use to protect the face & head from
injury when falling

9. Sensory stimulation
used for hypotonic patterns and others that appear to be
weak when the abnormal tone is inhibited, or those who have
sensory disturbance
never done unless the patient is in RIP in order to shunt the
inflow into the desired channels
a. weight bearing w/ pressure & resistance
use to increase postural tone & decrease involuntary
movements
b. placing & holding
the PT moves the limbs to various pos. with help of px.;
then px.
Hold the position without help of PT
c. tapping
Treatment/ stage of recovery
1. Initial Flaccid Stage
Focus on positioning and movement in bed to
avoid typical postural patterns of hemiplegia
2. Spastic stage
Treatment is continuation of previous stage
Goal is to break down the total pattern of
spasticity by developing control of
intermediate joints
3. Relative recovery
Treatment aims at improving the quality of
gait and use of affected hand
END
NORMAL MOVEMENT
SEQUENCE & BALANCE
REACTIONS
Intro on (N) movt
Tx is a process of teaching and learning
PTs should know their subjects well
They must know what should take place (i.e.
how people move and react)
People move in basically the same pattern
i.e spontaneous w/o the need for conscious thought
Becomes automatic in adult life
Voluntary, controlled and can be inhibited
Differences in movt comes from variations of
individual and include:
Build, personality, habits, presence of stiffness or pain
Analysis of certain everyday
movement
Rolling from supine
to prone
Head Sitting leaning
Face forward to touch
Arms feet (as if picking
Legs something)
Upper
Feet
lower
head
Trunk
Analysis of certain everyday
movement
Standing from
sitting on a chair Standing up from
Feet the floor
Knee 1 ft
Back & neck Knees
Arms Weight
Head Head
Body Back
Weight is borne arms
Analysis of certain everyday
movement
Going up and down
the stairs
1 ft
Knees Walking
Weight Stride
Head Feet
Back Heel
Arms Big toes
Eyes
Balance & equilibrium
Adjustments ofreactions
our body to gravity during
everyday activities in order to maintain
balance
Normal postural reflex mechanisms
Provides background for all skilled movt
Dependent on:
1. (N) tone
-. high enough to support body against gravity (but
not too high as to impede movt)
2. Reciprocal inhibition
-. Enables us to stabilize certain parts of body while
moving the other parts selectively
Balance & equilibrium
reactions
Lying on surface Sitting on a surface that
which tilts sideways tilts sideways
Head flexion Head flexion
Trunk flexion Trunk flexion
Arms and legs Arms
Uppermost Legs
lowermost Uppermost
lowermost
Trunk rotation
Trunk rotation

Note: when everything If chair tips further to side


has moved, the person Lowermost UE
_____ Lower leg
Balance & equilibrium
reactions
Sitting being drawn
sideways by
another person Sitting with (B) legs
Lower leg flexed and turned
Free upper leg to one side
Foot of upper leg Head, trunk and
arm
Legs
Balance & equilibrium
reactions
Sitting reaching out Standing tipped
to grasp an backward
Weight
objective Feet & toes
Head Trunk
Trunk side flexion Arms
Trunk rotation Spine
Head
Arms
LE

* Standing on a tilting
surface (backward)
Balance & equilibrium
reactions
Standing tipped Standing on a
forwards tilting surface
Head
Supporting Foot
(sideways)
Toes Knee uppermost
Side over the weight Arms
bearing leg
Feet
Side opposite the weight
bearing leg
(B) arms

* Standing on a tilting
surface (forward)
Balance & equilibrium
Balancing on one
leg (the other leg
Steps to save
held by PT)
(protective steps)
Foot
Appears when we
As the weight is
react quickly and
transferred
economically to
further.
regain balance
- Forward
- Sideways Protective extension
- backward second line of defense if
all other balance &
equilibrium rxns fail