Treatment

The Bobath approach aims to assist the child with CP to learn to move in a
more efficient and functional way, so that he may actively participate in
activities and tasks that are meaningful to him and his family/caregivers.
This requires collaborative problem-solving with the childs family/
caregivers to devise management programmes that may be carried over
into the childs home/school environment. Treatment involves many
factors including: handling of the child by the therapist/parent/caregiver;
adapting and orchestrating the environment; and involving the child in
meaningful tasks. As mentioned above, handling techniques are but one
tool of treatment that must be adapted and modified to suit the individual
needs of the child, based on the assessment/analysis data, the childs age,
abilities and disabilities, and classification. Treatment tools are used to
bring about change (Luebben et al., 1999, p. 27). Treatment does not
comprise a set of exercises, nor is it a recipe or a rigid and standardised
method of treatment (Bobath and Bobath, 1984). Bobath/NDT treatment
tools include skilled observation and analysis, problem-solving,
specialised handling techniques, the therapists conscious use of self, and
use of the non-human environment. In treatment, the therapist is
conscious of the effects of her handling on the child and the role she plays
as an agent to effect change within the therapeutic process (Luebben et
al., 1999, p. 28), e.g. how much pressure she applies through her hands;
the directional movement cues/feedback she gives the child through
handling and verbal guidance; the type of touch she uses, light or firm;
how much skin-on-skin/body-to-body contact she has with the child; the
66 Occupational Therapy in Childhood
tone of her voice; how she relates to the childs parents/caregivers; and
even the type of clothing she is wearing which may visually overstimulate
some children.
Use of the non-human environment includes the use of adaptive/therapeutic
equipment such as wedges, bolsters, plinths, benches and therapy
balls, which may be incorporated during handling to provide support,
stability and/or movement opportunities. Adaptive equipment for
positioning and daily management of the child is also vital to ensure carryover
of treatment aims, e.g. the use of a standing frame may be helpful in
ensuring that James (case example 3) is provided with adequate opportunities
for aligned weight-bearing in standing while he plays at the kitchen
table, or has a daytime snack, while his mother prepares a meal. The
standing frame would also be a useful position for James to learn to use
his pencil and to access the computer with switch input.
The physical environment in which treatment/management occurs is
an important consideration, e.g. consideration is given to the types and
range of toys and activities to which the child may be exposed at
home/school, and during treatment. The therapists skill in task analysis
and adaptation, and her ability to select, match and build-in the appropriate
objects and playful opportunities within the context of therapy is
highly desirable. Skills in identifying what is motivating and meaningful to
the child is paramount in eliciting active participation. Technology,
including low-tech and high-tech options, also plays a role in practice
depending on the childs needs, e.g. intervention for James (case example
3) at school may focus on working on sitting on his adapted school chair

during story writing, while using switch access on his computer. The
therapist handles James to facilitate his postural alignment in sitting, as
well as to help him to grade and coordinate the placement of his arm
movements during switching, working towards hands-off . The
ergonomic dynamics of the computer in relation to Jamess position and
seating system, as well as the physical aspects of the room such as lighting
and noise distraction factors, would also be considered.
Treatment should be tailored to meet each individual childs needs. It is
important to elicit the childs own, more normal activity while he is
engaged in a goal-oriented task because the best inhibition of abnormal
tone often comes from the childs own more normal activity. TIPs allow
the therapist to help the child become more active. The therapist may use
weight shift and weight bearing as techniques of treatment to counteract
hypertonus, as well as to grade the environment, activity and handling
accordingly to inhibit and/or facilitate more normal active patterns of
movement from the child. During treatment, the therapist aims to take a
less hands-on approach to allow the child to control his own activity and
The Bobath concept 67
his own postural adjustments and movement. The therapist also aims to
establish functional carry-over into daily life through collaborating with
and educating the childs parents, and/or caregivers. This may include:
discussion and teaching handling/management strategies to counteract, or
minimise, structural deformity and contracture; education related to the
childs capabilities and disabilities; and educating parents/caregivers about
how to handle the child during the day, so that it becomes a natural part of
family life not a rigid set of exercises to be carried out once a day. The
therapist combines and applies principles of the biomechanical approach
in the evaluation and prescription of positional and adaptive equipment.
In this way, carry-over into daily life contexts may also be achieved in the
absence of regular handling.

Analysis of normal/abnormal movement and

typical child development

Bobath/NDT therapists develop high-level skills and knowledge in

analysing normal movement (Mayston, 2000a). This is one of the core
platforms for basing clinical reasoning and intervention planning. The
therapists knowledge and understanding of child development, in particular
motor development, and how this is visible in functional movement
abilities and skills are vital. Development is seen as a process that results
from the multi-dimensional interaction of developmental areas, and as
such it is an adaptive process that is horizontal, sequential and upward
spiralling. Treatment plans should consider that many motor activities
develop simultaneously, and in fact they overlap (Bobath and Bobath,
1984, p. 11), and are interrelated with other aspects of development, such
as hand function, motivation and cognition. The influence of the environment
(physical, social, cultural) on development must also be acknowledged.
This has been given a much greater emphasis as person
environmentoccupation, motor control and motor learning postulates
are integrated into the concept (Bobath Centre, 1997; Mayston, 2001).
Motor development requires a sound awareness and understanding of the
components of normal movement (Bly and Whiteside, 1997) and includes
kinesiological factors, as well as the role of the therapist, the environment,
treatment tools and the adaptive equipment that the therapist may use to
facilitate active posture and movement. Fundamental to analysis and treatment
planning is: the interplay between stability and mobility to give
dynamic functional movement; the effects of the NPCM; kinesiological
considerations including range of motion, postural alignment, base of
The Bobath concept 51
support and dissociation and the development of postural control in the
three planes of space sagittal (extension and flexion against gravity),
frontal (lateral righting) and transverse (dissociation and rotation); and
sequences and variety of movement. Also fundamental is the childs sensorimotor
development, the influence of associated conditions on motor
learning, and the dynamics of the environment, functional task and the
child (Bly and Whiteside, 1997; Bobath Centre, 1997).
Bobath/NDT intervention also requires grounded understanding of
abnormal motor development (Bobath and Bobath, 1975) and current
theories of abnormal motor control and activity in order to analyse and
understand the childs condition. Knowledge of abnormal motor coordination
encompasses kinesiological components, abnormal non-neural
properties of muscles, including any structural deformity and/or soft
tissue contracture, because secondary impairments resulting from musculoskeletal
limitations/restrictions may negatively impact on the childs
potential for functional participation. Similarly, the influence that associated
problems, or perceptualcognitive and sensoryperceptual disorders,
may have on movement control must be recognised and understood,
including any potential long-term risks for learning and behaviour.

Sensory influences on motor control

The interplay of the sensory and motor systems has long been acknowledged:
we do not learn movements, but the sensation of movement (Bobath

and Bobath, 1984, p. 10); we learn as we do and we do only as well as we

have learned (Brooks, 1986); and how we move influences how we sense
and in turn how we sense influences how we move (Shumway-Cook and
Wollacott, 1995, p. 136). Understanding the sensory mechanisms related to
postural control is vital in the application of the Bobath concept (Bly, 1996).
Movement arises from the interaction of multiple processes, including
sensoryperceptual, cognitive and motor systems (Shumway-Cook and
Woollacott, 1995) and this must be understood by the Bobath/NDT therapist.
The importance of perception and processing of sensory information
cannot be emphasised enough not only for learning, but for the efficient
execution of a required task (Mayston, 2001). When this factor is missed in
clinical reasoning one has seriously to question the logic and direction of
Bobath/NDT intervention (Simmons Carlsson, 1997). Principles of neuroplasticity
underpinning skill learning (Mayston, 2001) to apply the practice
model knowledgeably with children who have CP, and/or allied neurological
conditions, must also be understood.
Berta Bobath recognised that postural control was a sensorimotor task.
She also recognised the sensory effects that hands-on therapy had on the
52 Occupational Therapy in Childhood
childs systems during handling. Abnormal patterns of movement may be
influenced, or modified by altering/modifying the sensory input to the
CNS via specialised handling techniques, which, when combined with the
active participation of the child in the context of goal-directed,
meaningful, functional activities, provides a medium to allow learning to
take place (Bobath Centre, 1997; Schoen and Anderson, 1999; Mayston,
2001). The hands-on approach allows the therapist to transmit externally
to muscles and joints, indirectly sending feedback messages to the
brain, in conjunction with those facilitated via the childs active engagement
in functional tasks. The skilled Bobath/NDT therapist handles
responsively in a silent dance that guides and mirrors the childs activity,
responding to the childs actions and responses as he or she moves and
plays, and being guided by the childs reactions to handling and the task.
Guidance primarily includes hands-on tactileproprioceptive-based
handling techniques, and also verbal, other sensory-based and environmental
cueing. Most importantly, the therapist must be sensitive to the
childs own active control withdrawing guidance as the child takes over
control and becomes active, and guiding only when necessary to teach
the child how to move as he or she is doing an activity/task. Sensory input
acts as a means of bringing about change (Bly and Whiteside, 1997;
Schoen and Anderson, 1999), and when given effectively and often
enough can expand sensory areas of the cortex, providing some support
for therapeutic intervention. Although it is recognised that sensory information
is not necessary for tasks to occur, it is important for fine-tuning
and learning motor/postural tasks (see Mayston, 2001). Careful orchestration
of functional tasks and the environment is necessary and is a complementary
tool to handling to provide the just-right challenge and input.

The role of inhibition in the control of posture and

movement
Physiological inhibition is important for the development of selective and
graded movement for function. It is active at every level of the CNS where
the balance between excitation and inhibition during movement controls
speed, range and direction, and efficiency. Inhibition modifies and
controls actions to achieve coordination (Mayston, 1992). The Bobath
concept/NDT uses handling as a tool to modify and/or influence that
which is outwardly observed as abnormal, i.e. abnormal postural tone and
abnormal patterns of posture and movement; however, handling itself
does not inhibit spasticity in the neurophysiological sense. By handling,
the therapist can enable the child to gain improved muscle length to
allow for more efficient muscle activation, so that the child may be helped to move
actively in more optimal and meaningful ways within the limits of[his or her] CNS
damage (Mayston, 2000a). This notion of activation is akey component in motor
learning, a concept that has long been recognized in the Bobath approach. Bobath
referred to this in 1965 when she stressed, in her teachings, that unless the therapist
makes the child active through her or his handling she basically will have done nothing
at all (Mayston, 2000a, citing Bobath, 1965).

Specialised techniques of handling

Handling techniques, now conceptualised as tone influencing patterns
(TIPs) (Mayston, 2000b) are only tools of practice, and form only part of
the Bobath concept. TIPs are dynamic techniques of handling, which are
guided by the childs reactions to handling and the environment. They are
aimed at influencing the childs postural tone, thus enabling the child to
achieve more normal patterns of posture and movement for functional
use (Bobath Centre, 1997). TIPs involve normal patterns of movement
used to modify abnormal patterns of movement, to reduce/prevent hypertonus,
and to prevent abnormal patterns of activity occurring when trying
to build up tone (Mayston et al., 1997). The following case example illustrates
this point.