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 NEW THEORY
Hierarchical brain organization (Reflex Systems Model
model)
Normal postural reflex mechanism as the Postural control is learned together with
basis of normal movement the skill; feedback and feedforward
mechanisms needed for efficient
movement control
Static postures and positions used for Client is an active participant in the
treatment session
Progressing the client through normal Developmental milestones serve as
developmental milestones guidelines but should not be strictly
adhered to
Development of control proceeds in a Control of movement develops in
cephalocaudal direction proximal to distal or distal to proximal
directions
Work on components of motions which Client must work on functional tasks to
the child will then apply to function 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.
