PRINCIPLES OF

BOBATH APPROACH

BY
GAJANAN BHALERAO
 What is Bobath
therapy?
Bobath therapy is an interdisciplinary
approach to the management of cerebral
palsy involving occupational therapy,
physiotherapy and speech and language
therapy. Bobath therapy is a holistic
approach pioneered by Dr and Mrs
Bobath. The basis of the approach is to
give children an experience of normal
movement by enabling the child to
respond actively to specialised handling.
 Who were the
Bobaths?
Berta Bobath was a physiotherapist, who
had initially trained in remedial
gymnastics. She understood normal
movement and posture, and together with
her husband Karel, who was a pediatric
neurologist, Berta developed an approach
to the treatment of cerebral palsy that
would encourage a child to move and
function as normally as possible, while
Karel researched the neurological
implications of the Bobath approach.
 Why is it used for
strokes?
Because Bobath therapy is a useful
treatment for neurological-based movement
disorders. Having a stroke can cause
cerebral palsy in babies and young children,
but there is a major difference between
children and adults who have had a stroke;
adults who have lost certain abilities can tap
into their previous experiences to relearn
skills, whereas young children will have no
previous experience of a normal movement
to tap into, and have to be taught.
 What effect does it
have?

Bobath therapy helps the child to

gain more control of their bodies,
to interact with their environment,
and to achieve a greater level of
independence. Bobath therapy also
aims to reduce the problems that
develop as the child gets older.
Nothing is more
powerful than a
idea
 Basic idea of Bobath approach
sensation of movement are learned, not
movement per se
Basic postural & movement patterns are learned
which are later elaborated on to become
functional skills.
Every skilled activity takes place against a
background of basic patterns of postural control,
righting, equilibrium & other protective reaction,
reach, grasp & release.
Basic idea of Bobath approach
When brain is damaged, abnormal patterns
of posture & movement develop which are
incompatible with the performance of
normal everyday activities.
The abnormal pattern develops because of
sensation is shunted into these abnormal
patterns.
 The law of shunting
A phenomenon of efferent inflow being short circuited
either temporarily ( the athetoid patient) or more
permanently ( the spastic patient) into patterns of abnormal
co ordination released from higher inhibitory control.
A patient with abnormal motor out put who moves
abnormally in response to motivation & normal sensory
inputs will still only experiences & memories the
sensation of of his abnormal movement of excessive efforts
& lack of co ordination.
He will therefore be unable to develop & lay down the
memory of normal sensory motor patterns.
What
To
do?
 Basic idea of Bobath approach
The abnormal patterns must be stopped not so much
by modifying the sensory input, but by giving back
to the patient the lost or undeveloped control over
his out put in developmental sequence.
The basic patterns of posture & movement , the
righting reaction & equilibrium responses are
elicited by providing the appropriate stimuli while
the abnormal patterns are inhibited.
In this way patient the patient is given the
opportunity to experience normal movement.
Basic idea of Bobath approach
The sensory information of correct movement is
absolutely necessary for the development of improved
motor control.
Treatment therefore, concentrate on handling the patient
in such a way as to inhibit abnormal distribution of
tone & abnormal postures while stimulating or
encouraging the next level of motor control.
The abnormal postures & tone are controlled at key
point (proximal body parts, I.e. head neck trunk, &
sometimes distal parts I.e. thumb & fingers), using reflex
inhibiting movement or patterns called as RIPs.
 Basic idea of Bobath approach
If the patient lack s tone, sensory stimulation or
tapping is used while the RIPs is applied so the is
sensory inflow will not shunt into abnormal
patterns.
Bobath believes that once the patient can move
in & out of normal basic patterns of posture &
movement he will automatically be able to
elaborate on these patterns to learn the more
skilled activities required in daily living.
Todays success &
today's defeat
are just another
step in the long
journey of your
life
 INTRODUCTION
Bobath treatment has undergone many changes
from the time of its inception, but the underlying
concept has not changed.the main problem of
patient with upper motor neuron lesion is that of
abnormal co ordination of movement patterns
combined with abnormal postural tonus.
Problems of the strength & activity of individual
muscles and muscle group is secondary to that of
the co ordination of their action.
 INTRODUCTION
Muscles are tools of nervous system and , therefore,
the activity of individual muscles & muscle group is
secondary to that of their coordination in patterns of
activity.
Thus, the assessment & treatment of patients motor
patterns is the only way of leading directly to
functional use.
In the hemiplegic patient, muscles are not paralyzed
& deficit of muscular activity can be remedied by
their action in more normal functional patterns.
 INTRODUCTION
This is still is a concept of treatment.
What has changed is that we have found new techniques.
We have discarded all static ways of treatment like
reflex inhibiting postures, but have introduced a strong
emphasis on movement & on functional activity.
From beginning the concept has been, & still is, a
holistic approach, dealing with pattern of coordination &
not with problems of muscle function.
It involves the whole patient, his sensory, perceptual &
adaptive behavior, as well as his motor problems.
Nature of handicap of patient
with brain lesions
Neurophysiological considerations.
The physical handicap resulting from a lesion of
the upper motor neuron is seen in terms of an
interference of normal postural control.
We are dealing with abnormal coordination of
motor patterns.
If we speaks of patterns of coordination, we
mean the pattern of normal& abnormal postural
control against gravity.
Neurophysiological considerations.

The fundamental problem

1. Abnormal patterns of coordination in
posture & movement.
2. Abnormal qualities of postural tone.
3. Reciprocal innervations.
 Abnormal qualities of postural

tone.
Sherringtone(1947) stated that normal movement need a
background of normal tonus.
Tonus & the coordination of movement are indivisible;
they depend on each other.
The abnormal types of postural tone & the stereotyped
total motor patterns we see in our patient are the result
of disinhibition, I.e. of a release of lower pattern of
activity from higher inhibitory control.
Such release does not only produce muscular signs, such
as exaggerated stretch & tendon reflexes, but abnormal
patterns of coordination.
 Abnormal qualities of postural
tone.
Inhibition is very important factor in control of posture &
movement.
With increase of inhibitory control of the maturing brain,
the organism increasingly gains more selective control of
posture against gravity.
This process fallows cephalocaudal direction.
Although the limbs & parts of body achieve a partial
independence in this way, their emancipation from the
total patterns is never complete.
The movement of a limb remains to some extent always
subordinate to the control of the whole organism.
 Abnormal qualities of postural
tone.
The action of total pattern has to be inhibited prior to
the inhibition of a localized action.
This means that normal functional & skilled activity
are largely a matter of inhibitory control.
The quality of coordination & its development in
early childhood depends, therefore, on increase of
inhibitory control & not on increase of muscle power.
Inhibition is a active at every level of the CNS.
The difference between lower & higher levels of
integrations only the matter of complexity.
 Abnormal qualities of postural
tone.
Selective movement of parts of body & limbs need
inhibition of those parts of patterns which unnecessary for
specific function.
Inhibition doesn't only make selective movement possible,
but plays a imp role in the grading of movement, I.e. it is
an important factor in reciprocal innervations. It is the
balanced activity of excitation & inhibition during a
movement which control speed, range & direction.
Inhibition on excitation & changes & moulds it for the
purpose of coordination. It modifies & control action.one
might say that inhibition is control.
 Abnormal qualities of postural
tone.
The brain damaged patient suffers from a lack of
inhibitory control over his movements.
This itself show release of tonic reflex activity,
i.e. spasticity in abnormal total patterns.
Spasticity will increases, producing deterioration
of his movements. Movements become slowed
down, laboured, or he may become too stiff to
move altogether.
Abnormal qualities of postural
tone
When observing a spastic patient
one is struck by the fact that
spasticity shows itself in definite
pattern of abnormal coordination
& that is not confined to a few
isolated muscles.
The patients posture &
movement are stereotyped &
typical, & he is more or less fixed
in few abnormal pattern of
spasticity which he cannot change
or can do so only with excessive
effort.
Abnormal qualities of postural
tone
Therefore, movements,
which need a coastally
changing background of
postural control &
adjustment, are prevented.
To think to posture as
separate from movement
is highly artificial, for
posture is in fact, in
constant flux & should be
regarded as temporarily
arrested movement.
 Reciprocal innervation
In intact organism, spinal inhibition becomes
modified by higher central nervous influences &
allows reciprocal innervation, a more adequate
response to the multitude of stimuli which enters the
central nervous system in normal condition of life.
Agonist, antagonist & synergists are pitted against
each other in finely graded way giving necessary
interplay of muscles group for fixation with mobility
& optimal mechanical conditions for muscle power.
 Reciprocal innervation
In normal circumstances all the required degrees
of reciprocal interaction in various parts of the
body and limbs necessary for postural fixation,
grading of movement & for the maintenance of
equilibrium are present.
Disturbed reciprocal innervation described above
are responsible for the way in which a patient is
fixed n few abnormal patterns, & for the
difficulty in coordinating movement & their
grading.
 Reciprocal innervation
The degrees of fixation in stereotyped postural
patterns depends on the severity of spasticity in
individuals case & are the result of the release of
abnormal postural reflexes which interact with
each other.
Treatment aims at inhibition of abnormally
release patterns of coordination & the facilitation
of the higher integrated automatic reactions of
normal postural control & of those of more
voluntary activity.
 Reciprocal innervation
Treatment helps the patient to develop & increase
his control over the disinhibited action of tonic
reflex activity by use of patterns which inhibit
spasticity.
Through inhibition his movement are channeled
into more normal patterns of function.
With the helps of therapist, the patient gains
control over the released abnormal non-functional
motor patterns
THANK
YOU
NORMAL AUTOMATIC
POSTURAL CONTROL
 NORMAL AUTOMATIC
POSTURAL CONTROL
Normal postural activity forms the
necessary background for normal
movement & for functional skills.
The basic patterns of coordination which
underly & make possible voluntary &
skilled activities are those of normal
postural reactions against gravity.
 NORMAL AUTOMATIC
POSTURAL CONTROL
This normal postural reflex mechanism consist of
a great number of dynamic postural reactions
which work together, reinforce each other &
interact for the purpose of protection against
falling & against injury to muscles & joints.
They are active during & before a movement is
performed, & they give us the ability to
counteract gravity, without fatigue, & to adjust
our posture when we are in an uncomfortable
position.
 NORMAL AUTOMATIC
POSTURAL CONTROL
They make us able to move in spite of having to
keep up against gravity, for ex walking up &
down the stairs.
They make us change our posture automatically
before we move inn order to make the intended
movement possible & easy.
Such postural adjustment called as postural sets
They are postural changes in anticipation of, as
well as accompanying any movement.
 NORMAL AUTOMATIC
POSTURAL CONTROL
They make us able to move in spite of having to
keep up against gravity, for ex walking up &
down the stairs.
They make us change our posture automatically
before we move inn order to make the intended
movement possible & easy.
Such postural adjustment called as postural sets
They are postural changes in anticipation of, as
well as accompanying any movement.
 NORMAL AUTOMATIC
POSTURAL CONTROL
Postural adjustment occur not only as a
result of sensory feedback in response to
unexpected perturbations, but also as a
result of feed forward in anticipation of
expected, self generated perturbations
 Postural reactions
They are Active movement
Although Sub cortically controlled &
Automatic
Give head & trunk control
Maintain or restore normal alignment of
body
Maintain & regain balance
 Posture
There is no dividing line between posture
& movement, but fluid transition from one
to the other.
Posture is a part of every movement, and if
a movement is arrested at any stage, it
becomes a posture.
 Postural reactions
The development of coordination in early childhood
goes step by step with the development of postural
reaction with their appearance, modifications &
disappearance when more complex & more voluntary
skilled activities are acquired.
The development of automatic postural control of
movement has been called principle mobility by
schaltenbrand (1927).
The knowledge of development of coordination is
necessary for the treatment of all patient with upper
motor neuron lesions.
 RIGHTING REACTIONS
The righting reactions are automatic reactions
which serve to maintain & restore the normal
position of head in space & its normal
relationship with the trunk, together with normal
alignment of trunk & limbs.
They develop in childhood & are well advanced
at age of 5 months of age.
Rotation around the body axis plays an important
role in these activities.
 RIGHTING REACTIONS
Gradually modifies & become integrated into
more complex activities, such as the equilibrium
reactions & voluntary movement.
There are essential in the building up of motor
patterns for adult life.
Throughout life they are necessary for getting up
from the floor, for getting out of the bed, for
sitting up, for kneeling down, etc.
 EQUILIBRIUM REACTIONS
Equilibrium reactions are automatic reactions which
serve to maintain & restore balance during all our
activities, especially when we are in danger of falling.
All equilibrium reactions reactions, tonus changes &
movement changes have to be well coordinated,
quick, adequate in range & well timed (Rademaker,
1935, Weisz1938)
Tested either by the body moving body against a
fixed support such as the ground, or by means of a
movable platform or tilting table.
 AUTOMATIC ADAPTATION OF
MUSCLES TO CHANGE OF POSTURE

These automatic reactions can be observed in

trunk & limbs, and they overlap to some extent
with the equilibrium reactions.
In a normal person, the central postural control
mechanism governs the weight of a limb during
movement both into & against gravity.
This mechanism may be called postural
adaptation to gravity.
 AUTOMATIC ADAPTATION OF
MUSCLES TO CHANGE OF POSTURE

A normal person is active when being

moved against gravity.
Relaxation, unless full support is given, is
a voluntary learned ability.
Normal person controls every stage of
movement actively & automatically.
We cal this manoeuvre placing.
 Normal postural control provides 3 prerequisites
fro voluntary functional activity

1. Normal postural tonus of moderate intensity.

Postural tone must be high enough to resist
gravity, but should be enough to give way to
movement.
2. Normal reciprocal interaction for:-
a. Synergic fixation proximally to allow for
selective mobility of more distal segment.
b. Automatic adaptation of muscles to postural
changes.m
 Normal postural control provides 3 prerequisites
fro voluntary functional activity

c. Graded control of agonist & antagonist

integrate with that of synergists for the
timing & direction of movement.
3. The automatic movement patterns of the
righting & equilibrium reactions which are
the background against which voluntary
functional activity takes place.
Disturbance of Normal postural control

The effect of UMN lesion is described as

Disturbance of Normal postural control mechanism.
Interference with normal motor ability is caused by
pathological deviation from the fundamental
prerequisites motioned above.
Instead of normal postural tone we find spasticity.
Instead of normal coordination of righting,
equilibrium & other protective reactions we find
few static & stereotyped postural reflex patterns.
ABNORMAL POSTURAL
REFLEX ACTIVITY
 FACTORS INTERFERING WITH
NORMAL MOVEMENT
1. Associated reactions
2. The effect of released asymmetrical tonic
neck reflex activity.
3. The effect of released positive supporting
reaction.
 ASSOCIATED REACTIONS
WALSHE (1923) described associated
reactions as tonic reflexes, i.e. postural
reactions in muscles deprived of voluntary
control.
In hemi associated reactions produces
widespread increase of spasticity
throughout the hole of the affected side.this
accentuate the hemiplegic attitude.
 ASSOCIATED REACTIONS
Higher the spasticity, more forceful & longer lasting will
be the associated reactions.
The duration of associated reactions is roughly that of
the movement or contraction evoking it, but there is in
some instances a prolonged after-contraction or tonic
prolongation of the spasm, which last for several
seconds.
More spastic the limb, longer the latency & after
contraction.
Antagonistic muscles groups, flexor & extensors, are to
be observed in simultaneous contraction.
 ASSOCIATED REACTIONS
After-contractions is due to lack of inhibition &
plays a detrimental role in the performance of
repetitive movements(i.e walking).
With increasing spasticity & co-contraction of
opposing muscle group, the movements are
slowed down, smaller in range & performed with
increasing effort.
The reinforcement & strengthening of spastic
pattern through associated reactions can lead to
contractures & deformities.
 Facts to consider to reduce detrimental effect of associated
reactions:-
1. There less spasticity & after contraction if movement are done
slowly.
2. The spread of excitation into total spastic patterns can be
counteracted by inhibiting parts of these patterns.
3. The therapist should inhibit spasticity immediately the
movement begins to deteriorate.
4. At the start of treatment, excitation & effort are kept to a
minimum, then it is gradually increased.
5. Therapist helps the patient to learn to inhibit this spasticity by
the use of selective movements.
 Effect of released positive
supporting reaction
Adequate stimulus for positive supporting reaction
is twofold:
1. A proprioceptive stimulus by stretch of the
intrinsic muscles of the foot.
2. An exteroceptive evoked by the contact of the
pads of the foot with the ground.the antagonists
don't relax, but contract, exerting a synergic
function, which result in the fixation of the
joints (co contractions).
 Effect of released positive
supporting reaction
The normal positive supporting reaction allows
for moderate degree of co contraction with
necessary mobility for balance, for movement of
the body forward over the standing foot, for
mobility of the hip & knee to the leg for the next
step, & for walking up & down the stairs.
In the spastic patient , the positive supporting
reaction is released from higher control &
combined with extensor spasticity of the leg,
becomes an exaggerated spastic response.
 Sensory & perceptual
disturbances
They are serious handicap to effective treatment &
adversely influence the chances of recovery from
functional disability.
Margeret Reinhold has stressed that;
voluntary movement is partly dependent upon
1. The perception of superficial & deep sensation
2. Motor power & coordination.
In normally functioning organism cerebral cortex acts
as a whole & we should, therefore, think of the
sensory-motor areas as one functional unit.
 Application of shunting rule in
treatment
Magnus stated that at any movement during a
movement , the central nervous system mirrors the
state of elongation & contraction of the
musculature.
It is therefore, the body musculature which
controls the opening & closing of synaptic
connections within the central nervous system &
determines the subsequent outflow.
The greatest effect of shunting is obtained from
the proximal parts of the body.
 Application of shunting rule in
treatment
In accepting the role of shunting, it is clear that
we have a means of influencing and changing
motor out put from periphery, i. e. from
proprioceptive system, beginning usually with
proximal parts of the body.
By changing the relative positions of the parts of
the body & limbs when handling a hemiplegic
patient, we can change his abnormal postural
pattern & stop (inhibit)the outflow of excitation
in to established shunts of spastic patterns.
 Application of shunting rule in
treatment
We can at the same time direct patients
active responses into the channels of higher
integrated & complex pattern of more
normal coordination.
In this way, spasticity becomes reduced by
inhibition of its patterns, while more
normal postural reactions & movement are
facilitated.