CEBU DOCTORS’ UNIVERSITY BASIS

COLLEGE OF REHABILITATIVE SCIENCES

DEPARTMENT OF PHYSICAL THERAPY The neurophysiological basis or fundamental
principles for this approach are the following:
PT 202
THE BOBATH APPROACH 1. Law of Memory
Prepared by: Daniel Dominick G. Te, PTRP − Any initial movement or activity is first
developed into a RUT or TRACE in the
HISTORY brain which when repeated becomes a
CHAIN and once developed becomes a
BOND or ENGRAM.
Karel Bobath, a British neurologist and Berta
Bobath, a physiotherapist, began to develop 2. Law of Shunting/Shunting Rule of Magnus
their treatment approach in the 1940s. − Magnus states that “at any moment
during movement, the CNS mirrors the
Neurodevelopmental Technique (NDT) state of elongation and contracture of
• Is based on the premise that the the musculature.” It means that the
presence of normal postural reflex state of the muscles, therefore,
mechanisms is fundamental to a motor determines the distribution of
skill's performance excitation and inhibitory processes
• The normal postural reflex mechanisms within the CNS and the subsequent
consist of righting and equilibrium outflow of excitation and inhibition to
reactions, reciprocal innervation, and the periphery.
coordination patterns − Greatest effect of “shunting” is
• The release of abnormal tone and tonic obtained from the proximal parts of the
reflexes seen in CP interfered with the body (spine, shoulder and pelvic
development of righting and girdles)
equilibrium reactions
3. Law of Reciprocal Innervation
Basic overview:
• It is an approach/concept, not a BASIC PREMISES
method
• It recognizes that all clients with 1. One learns sensations of movements, not
neurodisability have the potential for movement per se.
enhanced function 2. Every skilled activity takes place against a
• It recognizes the need for thorough background of basic patterns of postural
analysis of each patient's functional control, righting and other protective
skills reactions.
• Need for the person's own activity
• Based on available knowledge GOALS OF TREATMENT
evidence
• It is an important approach to the PRIMARY GOAL: Directed toward retraining
rehabilitation of patients with normal, functional patterns of movement.
neurological injuries. How?
• In the US, the Bobath concept is usually 1. Change, or “normalize” the abnormal tone.
referred to as neurodevelopmental 2. Eliminate unwanted muscle activity or
treatment (NDT). inhibit primitive or abnormal reflex
• It is based on the brain's ability to patterns.
reorganize (neuroplasticity) 3. Introduce and train normal movement
• It is a multidisciplinary approach, patterns in the trunk and extremities or
involving physiotherapists, facilitate automatic reactions and
occupational therapists and speech subsequent normal movement patterns.
and language therapists.
• Applied to individuals with CNS Regardless of severity, individuals of any age
pathophysiology that have dysfunction with damage to their CNS can be handled with
in posture and movement and this approach. This makes the approach
subsequent functional activity different from other forms of treatment, like
limitations. motor relearning or constraint-induced
movement therapy, which can only work on
high functioning individuals.

This document is developed by Daniel Dominick G. Te, PTRP for the PT students of Cebu Doctors’ University. Using this document for other
purposes, kindly seek permission at danieldominickte@[Link] .
CONCEPTS AND PRINCIPLES OF TREATMENT The Bobath approach rests on a number of
principles that include:
1. Treatment should avoid movements and • Encouragement of normal movement
activities that increase muscle tone or patterns
produce abnormal responses in the • Focusing on quality of movement
involved side. Movements the patient • Normalization of tone to facilitate active
performs with or without the physical movement
therapist’s help should not be done with • Positioning and posture in lying, sitting
undue effort. Effort leads to increased and standing
spasticity and produces widespread • Discouragement of compensatory
associated reactions. movements
• Discouragement of muscle strength
AUTOINHIBITION: training
• Process by which physical therapist • Promotion of maximum functional
inhibits unwanted spread of activity recovery to improve quality of
throughout the affected parts of the independence
body.
• Physical therapist helps patient to STAGES OF HEMIPLEGIA
use only parts of the total spastic
patterns and prevent the 1. STAGE OF FLACCIDITY (ACUTE
reassertion by handling. HEMIPLEGIA)
− Severe loss of postural control in the
2. Treatment should be directed toward the trunk and flaccid paralysis of the
development of normal patterns of posture hemiplegic arm and leg
and movement. The movement patterns
− Poor sitting balance and cannot
selected are not based on the
perform ADLs in sitting
developmental sequence but on patterns
− Bed mobility tasks and transfers need
important for function.
assistance
• This program provides a foundation − Should frequently subluxes inferiorly
that promotes the highest level of
− Treatment focused on positioning and
functional recovery based on
movement in bed to avoid the typical
relearning normal movement rather
postural patterns of hemiplegia
than on compensation.
2. STAGE OF SPASTICITY
COMPENSATORY REHABILITATION is
− Enough trunk control to sit and stand
responsible for:
without loss of balance, and walk with a
• Increase in spasticity brace or cane
• Inactivity of the involved side − Trunk is asymmetric, lateral flexion or
rotation backward in the hemiplegic
3. The hemiplegic side should be ribcage, flexor spasticity in the
incorporated into all treatment activities to hemiplegic arm
re-establish symmetry and increase − Goal of Rx: break down total patterns of
functional use. Alignment and symmetry of spasticity by developing control of
the trunk and pelvis are necessary for good individual joints
alignment and symmetry of the extremities. − UE spasticity is inhibited through
scapular mobilization and UE weight
4. Treatment should produce a change in the bearing (WB)
quality of movement and functional
performance of the involved side. 3. STAGE OF RELATIVE RECOVERY
If they never demonstrated spasticity OR
5. Adaptive equipment is used when responded to inhibition techniques:
absolutely necessary for safety, but not as − Can walk well without asymmetry of
a first resort and not as a replacement for
posture due to good control of WB and
treatment. minimal flexor posturing
− Can move hemiplegic arm with isolated
Bobath approach is based around the brains
control of shoulder and elbow to grasp
ability to adapt to change and reorganize and
objects
recover after neurological damage.

This document is developed by Daniel Dominick G. Te, PTRP for the PT students of Cebu Doctors’ University. Using this document for other
purposes, kindly seek permission at danieldominickte@[Link] .
 Problems: protective responses, and poor WB on the
− Opening of hands to initiate grasp hemiplegic hip.
− Controlling humeral and forearm
rotation for placement POSTURAL CONTROL
− Need for excessive concentration − Automatic activation of muscles to
− Slow and uncoordinated movements maintain control of the body for posture
and movement
− Rx aimed at improving the quality of gait
and the use of affected hand. 3. Loss of specific motor abilities and task-
specific behaviors such as rolling, sitting
TYPICAL PROBLEMS IN HEMIPLEGIA up, walking, dressing or bathing
independently.
1. Problems associated with CNS damage
includes abnormal tone, abnormal patterns 4. Most patients avoid WB on affected side.
of extremity movements and atypical
posture 5. FEAR
− May be the most debilitating factor for
a. Flaccid Stage many patients
− Most common at onset of CVA − Major factor affecting spasticity
− (-) placing response
6. Sensory loss
b. Mixed Tone
− Trauma to shoulder is common 7. Neglect

c. Spastic Stage OVERVIEW OF TREATMENT

− Most commonly identified
problem and the most difficult to A. HANDLING
treat following CVA − Refers to the way that the PT uses her
− (+) associated reactions: non- hands on the patient’s body to change
functional and involuntary the quality of movement patterns of the
changes in limb position and patient; should be used with verbal
muscle tone communication
− The sensory experience of normal
TYPICAL POSTURE OF ADULT PATIENT WITH movement is the basis for learning new
HEMIPLEGIA: movement patterns and assist the
• Head: lateral flexion toward the patient in suppressing unwanted
involved side with rotation away abnormal patterns
from the involved side − Done slowly
• Upper extremity − Strong and firm hand pressure: to
Scapula: depressed and retracted lengthen spastic muscles and to stop
Shoulder: adducted and IR abnormal patterns of coordination
Elbow and forearm: flexed and − Light pressure: to guide the patient in a
pronated normal movement pattern, to teach the
Wrist: flexed and ulnar deviated feeling of normal movement, and to
Fingers and thumb: flexed and elicit an active response from the
adducted patient
• Trunk: rotated back on the
hemiplegic side; lateral flexion KEY POINTS OF CONTROL
toward the involved side (Pusher’s • Are areas of the body that make it
syndrome) easier to control the quality of the
• Lower extremity patient’s movement pattern
Pelvis: post. elevation and • Most important key points are
retraction PROXIMAL segments
Knee: extended • Proximal: shoulder, pelvis, and spine or
Ankle: PF, supinated and inverted ribcage
Toes: flexed and adducted • Distal: part of a limb – elbow, hand,
knee, foot – are combined with the
2. Problems associated with deficits in control proximal contact to control extremity
of posture and movement include poor motions
trunk control, decreased balance and

This document is developed by Daniel Dominick G. Te, PTRP for the PT students of Cebu Doctors’ University. Using this document for other
purposes, kindly seek permission at danieldominickte@[Link] .
 NORMALIZATION OF TONE/INHIBITION − Use of symmetrical, bilateral UE
TECHNIQUES may be accomplished by patterns to maintain alignment of the
using one or more of the following upper trunk and shoulder girdle and
techniques: prevent the arm from being neglected
• WB over the affected side or abnormally positioned
• Trunk rotation − Eg. clasping of hands and WB during
• Scapular protraction task performance in sitting and
• Anterior pelvic tilt standing
• Facilitation of slow, controlled
movements CLINICAL APPLICATION
• Proper positioning
• Technique to lengthen muscle and • Bobath Concept concerns sensory,
realign joints perception and adaptive behavior along
with the motor problem that involves
REFLEX-INHIBITING PATTERNS the whole patient.
− Active movements that both inhibit • It is a goal-orientated and task-specific
abnormal tone and encourage or approach, aiming to organize the
facilitate active movement responses internal (proprioceptive) and external
(exteroceptive) environment of the
For Flexor Spasticity of UE nervous system for efficient functioning
− Extension of neck and spine of the individual.
− ER of arm and shoulder • It is an interactive process between
− Extension of elbow and wrist patients and therapists.
− Forearm supination
− Thumb abduction Therapy focuses on the following:
• Neuromuscular system, spinal cord and
For Extensor Spasticity of LE higher CNS centers to change motor
− Hip abduction, extension and ER performance
− Knee extension • Neuroplasticity, an interactive nervous
− DF of ankles and toes system, and individual expression of
− Abduction of big toe movement
• Overcoming weakness of neural drive
*Also rotation of shoulder girdle against after a UMN lesion through selective
pelvis and vice-versa activation of cutaneous and muscle
receptors
FACILITATION TECHNIQUES (Sensory
Stimulation Techniques) Motor control
− Use of tactile and proprioceptive input • Therapists should have the knowledge
to increase the intensity and duration of of the principles of motor learning:
muscle contraction active participation, opportunities for
− Applied directly to muscle or via joint practice, and meaningful goals.
approximation to stimulate muscle • Bobath concept demands training in
contraction around the joint different real-life situations rather than
− Performed with the body in normal just practicing in the therapy
alignment and directed toward areas of department.
the body that are critical for a normal • Task-specific muscle activation
movement pattern patterns and sensory input enables
− Once muscle contraction is successful completion of the task in
established, return to guided different contexts and environments,
movement to use the muscle taking in to account the perceptual and
contraction in a movement pattern cognitive demands.
• Therapy addresses abnormal,
B. COMPENSATORY TRAINING stereotypical movement patterns that
− Directed toward interfere with function. It is aimed at
1. Incorporating the involved arm into preventing development of spasticity
task performance and improving residual function.
2. Teaching patterns of compensation Therapists can influence hypertonia at
that do not encourage the a non-neural level by influencing
development of spasticity and muscle length and range.
associated reactions

This document is developed by Daniel Dominick G. Te, PTRP for the PT students of Cebu Doctors’ University. Using this document for other
purposes, kindly seek permission at danieldominickte@[Link] .
Therapists work on tone to improve movement,
not to normalize tone. Tone can be reduced by:
• Mobilization of muscles and stiff joints
• Muscle stretch
• Practice of more normal movement
patterns
• Through a more efficient, less effortful
performance of functional tasks
• Weight-bearing

Benefits of Bobath approach:

• Normalize tone
• Regain motor control
• Make movements easier to achieve
that are precise and goal directed
• Improve posture
• Lengthen tight muscles to help
decrease spasticity and reduce
contractures
• Improve ability with everyday activities
• Increase independence
• Achieve maximum potential

Essentials for Treatment Effectiveness

• Therapists must be able to observe and
distinguish normal from abnormal
alignment and movement patterns
• Therapists must be able to make the
functional retraining activities
meaningful to the patient; task specific
• Therapists must be able to select the
optimal practice method, feedback,
and environment for maximum function
and independence

This document is developed by Daniel Dominick G. Te, PTRP for the PT students of Cebu Doctors’ University. Using this document for other
purposes, kindly seek permission at danieldominickte@[Link] .