DR.

MADHU

BOBATH APPROACH
histroy

 This approach was developed by k bobath

and b bobath in 1940s for the evaluation and
treatment of cerebral palsy and adukt
hemiplegia.
Principles

Goals
1. To retrain normal, functional patterns of movement in
adult stroke patients.
2. Therefore it is essential to normalise the abnormal tone.
3. The training of normal movement patterns includes the
activation of postural responses that must be available on
an automatic level for functioning, re education of muscles
for weight bearing and non weight bearing function.
4. Permanent reduction of abnormal tone is possible only if
involved side moves in normal patterns of coordination.
 The following principles of treatment apply to all NDT/Bobath
treatment activities :
1. Treatment should avoid movements and activities that
increase muscle tone or produce abnormal responses in the
involved side.
2. Treatment should be directed towards the development of
normal patterns of posture and movement, patterns selected
are not based on the developmental sequence but important
for function.
3. The hemiplegic side should be incorporated into all treatment
activities to reestablish symmetry and increase functional use.
4. Treatment should produce a change in the quality of
movement and functional performance of the involved side.
Evaluation and treatment
planning
 Abnormal patterns of posture and movement must be eliminated through the
treatment because they prevent the patient from regaining normal function on
his involved side. They are:
Abnormal tone :
1. Present in almost all patients with central nervous system(CNS).
2. Normal tone is necessary for the production of normal movement.
3. Muscle must high enough to allow movement against the pull of the gravity but
low enough to allow normal speed and timing of the movement.
4. Flaccid limbs feel heavy and floppy and relaxed.
5. Placing responses are not present.
6. Spasticity produces stiff limbs and spastic muscles resist movement and placing
responses may assist if the movement is in direction towards shortening of
spastic muscles.
7. Hemiplegic patients frequently have hypertonic extremities with hypotonic
trunk.
8. Movements are limited to mass patterns of flexion or extension.
9. Certain activities and positions may increase the abnormal tone (including
associated reaction)
Loss of postural control
 The stroke patient has lost control of the system of postural
adjustments that forms “ the necessary background for normal
movement and for functional skills”.
 Normal postural reactions help to control the positions of body
against gravity (includes righting reactions or equilibrium
reactions).
 Postural reactions are associated with changes preceding and
accompanying functional movement (including weight shifts).
 They occur automatically.
 Postural control is a central neuronal mechanism and is
disrupted when there is loss of motor control of involved side.
 Loss of postural control can facilitate compensatory strategies.
Abnormal co-ordination
 Abnormal coordination, resulting in inefficient, non functional
extremity such that coordination should be there between
agonist, antagonist, synergist and fixation.
 Reciprocal inhibition is essential for smooth movement.
 Skilled activities have normal sequences of muscular activity
and are not produced with conscious attention i.e., CNS has
motor programs stored in it.
 In the stroke patient, the timing, sequencing and coordination
of muscle activation are distributed.
 This leads to abnormal patterns of limb movement and
coordination (patient exhibits abnormal synergies, co-
contraction, abnormal timing needs conscious attention,
excessive effort to produce any movement on affected side).
Abnormal functional performance:
 Patients loose the ability to integrate the sides of his body to
perform functional tasks in normal ways(including gait, lifting
and carrying objects etc).
 Coordination between both sides is lost.
 Even though one side of the body is unaffected by the stroke,
the patient is unable to use his “good” side normally, because
normal movement patterns require interaction and
coordination between the two sides of the body.
 Compensatory techniques tend to increase the patient’s
orientation toward his sound side, they may increase both
postural asymmetry and neglect of the involved side.
 Compensatory techniques cannot fulfill all the functional tasks
of activities of daily living.
Assessment

 The bobath method of assessment has three basic goals:

1. To determine the presence and distribution of abnormal
tone and abnormal movement patterns that are
interfering with the production of normal movement.
2. To identify deficits in normal motor responses, including
both automatic postural responses and volitional
movement patterns in the trunk and limbs.
3. To analyse the patients ability to perform functional
movement patterns, including gross motor tasks and
specific self-care, vocational and recreational actvities.
Treatment goals

1. Appropriate way of handling techniques and

facilitation of normal movement pattern.
2. Practicing those patterns until they can be
performed independently.
Acute hemiplegia

 For the therapist, acute care is directed toward:

1. Regaining balance in patterns important for
function in sitting.
2. Incorporating the hemiplegic arm into bed
mobility and tranfers.
3. Developing strategies for self care activities
that involve the affected arm.
4. Maintaining alignment and mobility in the
upper extremities.
 Hemiplegia with spasticity
 Spasticity is a problem in this stage even though patient has more control of his trunk and limbs
than in the acute stage (flaccid stage).
 However, patients balance, posture and movements are abnormal and poor.
 Techniques used in this stage are to inhibit the flexor posturing of the arms and extensor
posturing of legs; to facilitate or re-educate the normal patterns of upper extremity movements
and lower extremity movements.
 Handling is done slowly, to give the patient time to understand what movements are being
performed and to organise his response.
 Inhibition techniques are not used in patients who do not have spasticity or associated reactions.
 Facilitation handling techniques are designed to teach the sensation of normal movement by
moving the limbs in space with proper pattern of initiation and sequencing and to stimulate
muscles directly to contract isometrically, eccentrically and isotonically.
 Hold in alignment and provide postural stability while patient practices movement.
 teach the patient ways to incorporate the normal movement patterns learned to incorporate in
functional activities and transitional movement.
 Teach patterns of compensation that do not encourage the development encourage the
development of spasticity and associated reactions.
 In acute stage, it is very essential to retrain patterns of trunk movement because they had lost
the control of the automatic postural pattern that is effective in maintaining a normal pattern of
posture and balance essential for task performance.
 Right from acute stage it is essential to incorporate the hemiplegic arm for bed mobility, tranfer
Treatment

 Treatment basically consists of inhibiting abnormal

distribution of tone and abnormal posture while stimulating
or encouraging active motion in that level from where his
motor control is poor.
 Reflex inhibiting patterns or key points of control or sensory
stimulation can be used to facilitate normal motor control.
 Bobath believes that once patient can move easily in and
out of normal basic patterns of posture and movement, he
will automatically be able to elaborate on these patterns,
top learn more skilled activities required in ADL.
 Early treatment is ideal and necessary if true gains are to be
made and to avoid fixed abnormal patterns or contractures.
1. Reflex inhibiting patterns
 Reflex inhibiting patterns(RIPs) are partial pattern opposite to the typical
abnormal patterns of postural tone that dominate the patient.
 They prevent shunting of sensory inflow in to abnormal patterns and
redirect it into normal ones.
 Inhibition of abnormal tone is always used with facilitation of the righting
and equilibrium reactions.
 RIPs tends to redistribute the tone more normally.

Key points of contact:

 They are those points of contact from where we can redistribute the tone
to facilitate normal movement.
 They will allow the patient to develop flexible control over his own
movement and postures.
 Key points are usually proximal parts of the body, from which abnormal
reflexes seem to originate.
 Full body patterns can shunt the tone into a reverse pattern.
Key points :
 Allows maintaining the RIP.
 At the same time helps to use the limb for movement pattern similar to
normal one.
 RIPs must be individualized for each patient following careful analysis of
patient’s motor problems.

Examples for RIPs :

 Head raising to hyperextension to facilitate extensor tone in rest of body
and to inhibit flexor tone.
 Internal rotation of limb inhibits extension.
 Horizontal abduction inhibits humerus flexion.
 Elevation of arms inhibits flexor tone.
 Flexion of hip and knee with abduction of hip joint inhibits extensor tone.
 Symmetrical extension of limbs inhibits flexor spasticity.
 Rotation of trunk between shoulder and pelvis inhibits both flexion and
extensor hyper tonus.
 2. Handling
 Manner of controlling patient through RIPs to elicit righting and
equilibrium responses can be called as handling.
 It helps-
 To influence postural tone.
 To regulate coordination
 To inhibit abnormal patterns
 To facilitate normal automatic response.
 At first, handle patient passively in correct patterns of posture or
movement while he is encouraged to cooperate and help as he can.
 Guidence and support by therapist is reduced once the patient is able
to take over more and more initiate to move in correct patterns.
 The patient is not allowed to exert excessive effort because tone
increases with effort and may become stunted into abnormal patterns.
 Once the normal movement patterns occurs, it is repeated to establish
new sensorimotor patterns.
3. Righting and Equilibrium
reactions
 True inhibition of primitive patterns can be gained only through
elicitation of righting and equilibrium reactions.
 Several postures and movement are used to develop dynamic
control and to mimic normal development which occur spirally.
 Righting reactions helps the patient to move from supine to
prone, on elbows, to quadruped, to kneel standing and finally to
standing.
 Key points are used while eliciting neck or body righting.
 Equilibrium reactions are elicited by displacing the patients
centre of gravity while he is in one posture and can maintain the
posture against gravity.
 Protective reactions are next level of guard to protect the
individual from falling.
4.Sensory stimulation
 Sensory stimulation is never done unless the patient is in a RIP in
order to shunt the inflow into desired channels.
 the sensory stimulations incorporated are :
1. Weight bearing: with pressure and resistance used to increase
postural tone and decrease involuntary movement also to
normalise the tone.
2. placing and holding : patient puts effort to hold the limb without
assistance once the limb is placed.
3. Tapping :
 Pressure tapping :joint compression (by weight bearing).
 Inhibitory tapping: to decrease spasticity (by percussion and
hacking on muscles antagonists to spastic).
 Alternate tapping: for balance (by pertubation).
5.Compensatory training

 Incorporating affected side decreases neglect

of the arm, protects it from injury and
maintains good alignment of shoulder girdle
and trunk, prepares the arm for normal
participation in tasks being trained.
Incorporating the hemiplegic arm
 She developed the technique of clasped hands to give the
patient a consistent way to hold and move his affected arms.
 The patient lifts his hemiplegic arm by interlacing his fingers
and holding the palms together.
 They help to maintain forearm in mid position and wrist in
extension.
 Many patients may have difficulty with the task of
interlacing their fingers or can not maintain the palmar
contact necessary for wrist extension.
 Therefore a modified way of overcoming this problem is to
place ulnar border of affected hand and wrist in the palm of
the sound hand, with uninvolved thumb in the palmar arch
and fingers clasping the dorsum of the hand, wrist and ulna.
1. Bed mobility
 Start in supine position with both knees bent and feet on the bed.
 The patient is directed to locate his affected arm in the bed and
clasp it.
 Using his sound arm, he extends his elbows and lifts his hands
toward the ceiling until the shoulders are flexed to approximately
90 degrees.
 He is assisted to turn his head and shoulders to the involved side.
 Rolling is completed by turning the knees and pelvis to the same
side until sidelying position is achieved.
 Rolling from sidelying to supine is easiest if the pelvis and knees
rotate first, followed by the arms and upper body.
 Reaching the clasped hands forward and up can also be used in
combination with bridging for use of the bedpan and in moving
up or sideways on the bed.
2. Tranfers
 For the acute patients, task of tranfer is frightening because he
lacks good control of the hemiplegic side.
 Therapist faces the patient and therapist supports the
hemiplegic arm against her body.
 The therapist supports the weight of the patient’s arm, to keep
his trunk symmetrical and to facilitate the correct weight shift
while he maintains the spinal extension to produce a good stand.
 Incorporating the affected arm rather than hanging by the side of
the body prevents trunk asymmetry and promotes correct
weight shift.
 As he learns to control trunk extension and shift forward over
both hips to use both legs to stand, the patient can advance to
practicing with clasped hand grip to control his own arm.
 Preventing trunk asymmetry and teaching the right postural
changes with adequate instruction not to use unaffected leg and
arm with out pushing will promote patient to gain a near normal
way of getting up from sitting.
Treatment of the hemiplegic arm
1. Scapula mobilization
 The technique helps to maintain scapula in humeral alignment and
mobility, to maintain muscle length around the shoulder and
elbow; to minimize development of spasticity and to prevent
shoulder pain.
 It is done primarily in supine or sidelying on the uninvolved side.
 Therapist sits on bed on the patients affected side, facing his head.
 She places her outside hand on the top of the shoulder and her
inside hand on the humerus, while maintaining arm in external
rotation.
 Patients lower arm is cradled against her body.
 Using both hands together, the therapist moves the scapula up
and down and forward and backwards .
 If scapula moved freely then progressively keep the patients arm in
more flexion with external rotation at the shoulder and elbow
extension.
2. place and hold
 Place and hold activities are introduced
following mobilization of the scapula.
 With practice the patient will learn to control
the arm through a larger range of shoulder
and elbow movement.
3. Arm movements in sitting
 Separation of humerus from the acromium joint occurs when
scapula downwardly rotates on the rib cage (due to change in
angulation of the slope of glenoid fossa the humerus sli[ps out of
the joint).
 Flaccidity in acute stage is cause for this.
 Abnormal trunk postures and lateral flexion of spine encourages
malpositioning of the scapula.
 Therapist should support the joint from underneath in the axilla,
trying first to correct trunk position, lift humerus up and
externally rotate it to neutral.
 Once glenohumeral joint has been repositioned , reeducate the
arm movement.
 Guide the patient’s arm movement in to shoulder flexion and
abduction and elbow flexion and extension.
 Guidance is removed once motor control is improving.