Bobath Approach

Concepts and Principles

History…
 Developed by Dr. Karel Bobath, a
neuropsychiatrist, and Mrs. Berta Bobath, a
physical therapist
 1943 – while working with children with
cerebral palsy
 Original theoretical framework…
 Based on the works of Jackson, Sherrington,
and Magnus
 who described nervous system as

HIERARCHICAL in nature
 Model
 Higher brain centers exerted control over

lower-level centers
 Eg. The cerebral cortex control supercedes

that of the brainstem

Original theoretical framework…
 Hypothesis
 A neurologic insult will lead to a release of
the lower-level centers from higher-level
center inhibitory control, resulting in
stereotypical postures, primitive movement
patterns and predominant reflex activity
Adult hemiplegia..
 Treatment approach was later on expanded
to include the rehabilitation of adults with
motor problems, particularly CVA
 Main problem: the abnormal coordination of
movement patterns combined with abnormal
postural tonus (Bernstein, 1967)
 Secondary problem: muscle strength and
muscle activity
 Bobath concept…
 Is a living concept, it is not static
 It has undergone changes in its theoretical

base to accommodate developments in the

fields of neurophysiology, biomechanics,
and typical development
 Holistic approach
 It involves the whole patient, his sensory,

perceptual and adaptive behaviour, and

motor problems
Traditional View
 Principles of treatment
 Normalize muscle tone
 Inhibit primitive reflexes

 Facilitate normal postural reactions

 Treatment should be developmental

 Techniques
 Handling
 Weight bearing over the affected limb

 Utilize positions that allow use of the

affected limbs
 Avoidance of sensory input that affect
muscle tone
Previously…
 The control of movement was thought to be
dependent on the normal postural reflex
mechanism
 E.g. utilizing righting reactions and

equilibrium reactions in association with

normal postural tone
Reconstruction of
the
NDT approach
Premise
 Different parts of the CNS influence one
another

 Nervous system is capable of initiating,

anticipating, and controlling movements
 feedforward and feedback mechanisms

 CNS has the ability to shape and/or renew

itself in response to practiced activities:
neuroplasticity
Evidence on neuroplasticity
(Fisher, BE and Sullivan, KJ, 2001)
 Neuroplasticity can occur on the lesioned side of
the cerebral cortex following CVA when
provided appropriate practice in using involved
side
 Rehabilitation strategies should promote
recovery rather than compensation
 Techniques should incorporate the following:
 Active participation in motor skill learning

 Specific skills training and strengthening

directed to the involved limbs
 Intense, task-specific practice that optimizes
the sensorimotor experience
Basic premises…
 Sensations of movements are learned, not
movements per se
 Basic postural and movement patterns are
learned that are later elaborated on to
become functional skills
Problems in the adult patient with
stroke
 Abnormal tone
 Loss of postural control
 Abnormal coordination
 Abnormal functional performance
Goals…
 Decrease the influence of spasticity and
abnormal coordination
 Improve control of the involved trunk, arm
and leg
 Retain normal, functional patterns of
movement in the adult stroke patient
 Principles of treatment:
Adult hemiplegia
 Treatment should avoid movements and
activities that increase muscle tone or produce
abnormal reflex patterns in the involved side

 Treatment should be directed toward the

development of normal patterns of posture and
movement (movement patterns are not based on
the developmental sequence but on patterns
important for function)
Principles of treatment:
Adult hemiplegia
 The hemiplegic side should be incorporated
into all treatment activities to reestablish
symmetry and increased functional use

 Treatment should produce a change in the

quality of movement and functional
performance of the involved side
Principles of treatment:
Adult hemiplegia
 Individualize functional outcomes
 Emphasize motor control
 Increase active use of the involved side
 Provide practice to improve motor
performance that lead to motor learning
 Teach 24-hour management to increase
retention and carryover
 Use an interdisciplinary approach to
intervention
 Stages of hemiplegia and the
Bobath Approach
 Initial Flaccid Stage
 tx focus on positioning and movement in bed

to avoid the typical postural patterns of

hemiplegia

 Stage of Spasticity
 tx is a continuation of the previous stage with

the goal of breaking down the total patterns by

developing control of the intermediate joints
 Stages of hemiplegia and the
Bobath Approach
 Stage of Relative Recovery
 tx aims at improving the quality of gait

and the use of the affected hand

 Principles of treatment: children
with cerebral palsy
 Treat the child as a whole

 Basis for intervention is normal movement and

their interrelationships

 Treatment incorporates facilitation and

inhibition using key points of control
 abnormal tone is always inhibited

 normal responses, once elicited, are always

repeated
What are key points of control
(KPC)?
 Parts of the body where the therapist can most
effectively control and change patterns of
posture and movement in other body parts
 Proximal: spine, sternum, shoulder/scapula,
pelvis/hip
 Distal: jaw, elbow, wrist, knee, base of the

thumb, ankle, big toe

 Head may be a proximal or distal KPC

 use KPC that allow full pattern to be broken

during handling
 Facilitation-Inhibition
 Facilitation
 is a mean by which movement is made easy,

made possible, and made necessary

 Inhibition
 involves decreasing the use of pathological

movements and the effects of tonal

dysfunctions on movement
 Facilitation and inhibition may be used
simultaneouly and may be applied throughout
the session
 What is handling?
Manner of controlling the patient through
tone influencing patterns

• Normal patterns of activity used to modify

abnormal patterns of posture and movement
o Total TIPs: whole body is controlled in a
reversal of the abnormal pattern
o Partial TIPs: some body parts remain
free to move
• TIPs are utilized via KPCs
Law of Shunting
 “ at any moment during the movement or a
postural change, the CNS mirrors or reflects
faithfully, the state of the body musculature”
 Therefore, it is the body musculature which
guides and directs the CNS
 Thus, tone inhibiting patterns are used to give
the CNS the sensation of normal movements
Principles of treatment: children
with cerebral palsy
 Child must be active during treatment to
achieve functional goals
 Voluntary control of normal responses is

encouraged

 Treatment and evaluation are ongoing

 Treatment if functionally-oriented
Principles of treatment: children
with cerebral palsy
 NDT is appropriate for persons with
sensorimotor dysfunction regardless of
age and cognition

 Non-professionals can be an active

participant in treatment
Treatment methods…
 Modify sensory input through handling,
positioning reflex inhibiting postures and
use of key points of control
 Facilitate automatic reactions
 Normal movement patterns are integrated
into developing nervous system
 OLD THEORY
Hierarchical brain organization (Reflex
model)
Normal postural reflex mechanism as the Postural control is learned together with
basis of normal movement
Static postures and positions used for
treatment
Progressing the client through normal
developmental milestones
Development of control proceeds in a
cephalocaudal direction
Work on components of motions which
the child will then apply to function
NEW THEORY
Systems Model
the skill; feedback and feedforward
mechanisms needed for efficient
movement control
Client is an active participant in the
session
Developmental milestones serve as
guidelines but should not be strictly
adhered to
Control of movement develops in
proximal to distal or distal to proximal
directions
Client must work on functional tasks to
learn the skill
Evidence
 The Effectiveness of the Bobath
Concept in Stroke Rehabilitation
 Boudewijn, K. et al. (2009)
 Stroke. 2009;40:e89.
 16 studies involving 813 patients with stroke were included for
further analysis.
 There was no evidence of superiority of Bobath on sensorimotor
control of upper and lower limb, dexterity, mobility, activities of
daily living, health-related quality of life, and cost-effectiveness.
 Only limited evidence was found for balance control in favor of
Bobath.