BOBATH
APPROACH
Asst. Prof. Çiçek
Günday
There are a number of neurological approaches used
in the management of the patient following a
neurological deficit.
The Bobath Treatment Approach is one of the most
commonly used of these approaches
The contemporary Bobath Concept is a problem-solving
approach to the assessment and treatment of individuals
with disturbances of function, movement and postural
control due to a lesion of the central nervous system, and
can be applied to individuals of all ages.
It is not exclusive but could be applied to all patients with a
disorder of motor control, regardless of how severe their
cognitive or physical deficits might be.
Bobath is based around the brains ability to adapt to change and
reorganise and recover after neurological damage.
The Bobath approach rests on a number of principles that include:
• Encouragement of normal movement patterns
• Focusing on quality of movement
• Normalisation of tone to facilitate active movement
• Positioning and posture in lying, sitting and standing
• Discouragement of compensatory movements
• Discouragement of muscle strength training
• Promotion of maximum functional recovery to improve quality
of independence
The Founders of the Bobath Concept
Karel Bobath was born in Berlin, Germany in
1906, and trained there as a medical doctor,
graduating in 1936.
Berta Bobath was also born in Berlin, in 1907. Her
early training was as a remedial gymnast, where
she developed her understanding of normal
movement, exercise and relaxation
Note: Remedial gymnastics uses movement as the basic means for the purpose of
prevention and correction.
They both fled Berlin in 1938 just before the Second World
War. They married in 1941.
In London Berta Bobath trained as a physiotherapist,
graduating from the Chartered Society of Physiotherapy in
1950.
Karel Bobath started his career working in psychiatrist and
later more specifically with children with cerebral palsy.
In 1943 Berta Bobath was asked to treat a famous portrait painter, who had
suffered a stroke and was unhappy with conventional treatment. She focused her
treatment on the affected side, basing her interventions on her knowledge of
human movement and relaxation. She observed that with specific handling, tone
was changeable and that there was potential for the recovery of movement and
functional use of the affected side. Berta Bobath continued to explore and
further develop these early observations and techniques into principles of
treatment.
Working in partnership with Berta Bobath, Karel Bobath studied and applied the
available neurophysiology at that time, to provide a rational explanation for the
clinical success.
Together they created the Bobath Concept.
The Bobath Concept continued to develop throughout Bobaths’ lifetime.
In 1984 the Bobaths founded the International Bobath Instructors
Training Association (IBITA).
Berta Bobath stated that each therapist works differently according to
their experiences and personality, but all can build treatment upon the
same Concept.
Dr Bobath stated ‘the Bobath Concept is unfinished, we hope it will
continue to grow and develop in years to come’
The Development
of the Concept
✓ She focused her treatment on the affected side,
✓ The interventions based on her knowledge of human
movement and relaxation.
• Conventional
Treatment By applying a
First neurophys-
• Based on iological
orthopedic description
approach, the
1943 aspects,
massage,
1948 of the 1950 concept
Bobath officially took
active and approach its place in
passive physiotherapy
movement
✓ With specific handling, tone was changeable.
✓ There was potential for the recovery of movement and functional use of
the affected side
Development of Approach
1960 1990
1960 1978 1980 1990
● Interaction ● Facilitation ● Increasing ● TIPs (Tone
between the ● Less hands-on efficiency in daily Influencing Patterns)
patient and than before life ● Preparing the tone
● Functionality for movements
therapist ● Importance of ● Movement,
● Positioning
● Key points interaction ● Using the positioning and
● RIPs adaptive devices sensory stimulus
● Static postures instead of inhibition
● Analizing the
● Motivation,
results of the
repetition and motor
treatment learning
At the beginning, concept was
based on Hierarchical Model of
Motor Control. Now, it is
based on systems approach.
According to the Hierarchical
Model, movement is controlled
by a system consisting of 3 levels
with a rigid top down
organization. Higher centers
control lower centers. Damage
to the central nervous system
results to distruption of the
normal coordinated function of
these levels.
Movement was thought to be elicited through the stimulation of reflexes in
the spinal cord, with the primitive reflex patterning seen at birth refined
during maturation, through inhibition from higher centers. Lesions to the
pyramidal tract were found to produce a loss of inhibitory control.
Inhibition was therefore seen by Berta Bobath as important in adapting
motor behaviour, and her early clinical interventions demonstrated that it
was possible to influence tone through afferent input.
This led to the development of ‘reflex inhibiting postures’ and later the less
static ‘reflex inhibiting patterns’, which used rotational movement
components to fractionate the stereotypical patterns.
What are the Tone Influencing Patterns (TIPs)?
Normal patterns of activity used to modify abnormal patterns of
posture and movement. TIPs are utilized via key points.
What are the Key Points of Control?
Parts of the body where the therapist can most effectively
control and change patterns of posture and movement in other
body parts.
• Proximal: Shoulder/Scapula – Pelvis/Hip
• Distal: Jaw, wrist, ankle
• Head
• Abnormal coordination of movement patterns
combined with abnormal tonus
Main
• Strength and activity of individual muscles were
Problem of secondary importance
Bobath, 1990
• RIPs were discarded with the patient taking
an active role in their treatment.
Motor
1990’s patterns
• The best inhibition was seen as the
patient’s own activity
Mayston, 1992
• The emphasis in treatment was on normalising
tone and facilitating automatic and volitional
movement through specific handling.
Treatment • Adaptable and flexible to meet the individual’s
changing needs
Schleichkorn 1992
Current Theory Underpinning
the Bobath Concept
1) Systems approach to motor control
2) Plasticity
3) Motor learning
4) Upper motor neuron syndrome
1) Systems approach to motor control
The systems theory is based on the work of Bernstein (1967).
He stated that ‘coordination of movement is the process of mastering
the redundant degrees of freedom of the moving organism’, recognising
the importance of stability and control in movement.
He described how muscles could work in synergies to help solve this
movement problem, such as in postural control and locomotion.
Shumway-Cook and Woollacott (2007) expand Bernstein’s theory to
describe the systems approach that human motor behavior is based
upon a continuous interaction between the individual, the task and the
environment.
They describe movement as resulting from a dynamic interplay between
perception, cognition and action systems, and highlight the CNS’s ability
to receive, integrate and respond to the environment to achieve a motor
goal.
Many systems and subsystems work cooperatively for the integration of
movement into function.
2) Plasticity
Neuroplasticity: The nervous system and neuromuscular system can adapt and change their
structural organisation in response to both intrinsic and extrinsic information. The manipulation
of this information can directly effect a change in the structural organisation of the nervous
system through spatial and temporal summation and the facilitation of pre- and post-synaptic
inhibition. If two or more stimuli are presented and then reinforced together, associative
learning can occur. The capacity of the nervous system to change is demonstrated in children
during the development of neural circuits, and in the adult brain, during the learning of new
skills, establishment of new memories, and by responding to injury throughout life.
Muscle Plasticity: Like neuroplasticity, the adaptability of muscle has been investigated
extensively. Virtually every structural aspect of muscle, such as its architecture, gene
expression, fibre type distribution, number and distribution of alpha motor units and motor
end plates, number of sarcomeres, myosin heavy chain profile, fibre length, mitochondrial
distribution, tendon length, capillary density and muscle mass, has the potential for change
with the appropriate stimulus.
3) Motor learning
Motor learning refers to the permanent change in an individual’s motor
performance brought about as a result of practice or intervention
Motor learning principles help identify how we can best manipulate
the individual, the task and the environment to influence long-term
neuroplastic changes to promote an individual’s motor performance.
Mulder and Hostenbach states four basic rules for motor (re-)learning in 2001:
• Input (information) sine qua non for learning
1
• Input must be variable
2
• Input must be meaningful
3
• the site of training must be related to the site of application
4 (principle of equivalent situations).
There are numerous variables that are considered to be important
determinants in motor learning which have been investigated using
healthy individuals learning novel motor skills. These include:
● Practice (amount, variability, order of repetitions);
● Part or whole task;
● Augmented feedback (frequency, timing);
● Mental practice;
● Modelling;
● Guidance;
● Attentional focus (goal attainment);
● Contextual variety.
4) Upper motor neuron syndrome
Following a brain injury an individual will often have a complex
presentation impacting not only on the neuromuscular system but also
on the musculoskeletal, sensory-perceptual and cognitive systems.
The upper motor neurone (UMN) syndrome encompasses all the
dyscontrol characteristics associated with a lesion affecting some or all of
the descending motor pathways.
The features of an UMN syndrome have been divided into two broad groups.
Negative Phenomena Increase in motor activity
(spasticity, clonus, associated
reactions)
Reduction in motor
activity (weakness, loss of
dexterity, fatigueability) Positive Phenomena
Motor learning
Active participation
Practice
Meaningful goals
Plasticity
Individual
Cognition/perception
Function Neural
action
Muscular
Task/Environment
Upper Motor
Neuron Lesion
Old Theory Current Theory
• Hierarchical brain organization • Systems model
• Static postures and positions used for • Patient is an active participant in the session
treatment (RIPs) (TIPs)
• Progressing the patient through normal • Developmental milestones serve as guidelines
development milestones but should not be strictly adhered to
• Development of control proceeds in a • Control of movement develops in proximal to
cephalocaudal direction distal or distal to proximal directions
• Work on components of motions which • Patient must work on functional tasks to learn
the patient will then apply to function the skill
• Muscle and postural tone determine the • Task, goals, experience, individual learning
quality of the patterns of posture and strategies, movement synergies energy and
movement used in functional activities interests all affect the quality of the final
action
Clinical Application of the Theory
Underpinning the Bobath Concept
1) Motor control
2) Sensory systems
3) Musculoskeletal system
4) Adjuncts to therapy
5) Function
1) Motor control
The Bobath Concept involves the whole patient, their sensory, perceptual
and adaptive behaviours as well as their motor problems, with treatment
tailored to the patient’s individual needs.
Treatment cannot be predicted, stereotyped or repetitive, as it must
continuously adapt to the individual’s changing responses.
Rehabilitation is a process of learning to regain motor control and should
not be the promotion of compensation that can occur naturally as a
result of a lesion. Therapy should aim to promote efficiency of
movement to the individual’s maximum potential rather than normal
movement.
The Bobath Concept is goal orientated and task specific.
Therapy is an interactive process between individual, task and the
environment.
Therapists need to be aware of the principles of motor learning: active
participation, opportunities for practice and meaningful goals
Treatment is aimed at preventing the establishment of spasticity and
maximising residual function
2) Sensory systems
Sensory systems provide essential information about both the
internal and external environments upon which skilled
movement is based and refined.
Ultimately, in therapy, the aim is to re-educate the patient’s
own internal referencing system to provide accurate afferent
input, giving the patient the best opportunity to be efficient,
specific and have movement choices.
At some stages of skill acquisition, somatosensory referencing
may be emphasised over verbal or visual feedback.
This change of sensory priority is essential to reduce
compensation strategies, such as visual fixation, and
challenges the patient to use more appropriate sensory
strategies for the task (postural control, balance, stereognosis).
3) Musculoskeletal system
Muscles need sufficient activity to generate force for action.
Within therapy there is an emphasis on the patient learning
to generate movements as efficiently as possible.
However, movements must be owned by the patient and be
experienced both with and ultimately without the handling of
the therapist.
4) Adjuncts to therapy
The Bobath Concept can be complemented with
other modalities and adjuncts such as structured
practice, use of orthotics and muscle
strengthening.
5) Function
Therapy is based on the assessment of the patient’s potential.
A role of the therapist is to facilitate balance and selective
movement as a basis for functional activity and successful goal
acquisition.
Goals need to be realistic according to the patient’s potential and
appropriate to the environment encountered during daily life.
It is important that patients should not be stopped from moving in
a certain way.
An Understanding
of Functional
Movement as a
Basis for Clinical
Reasoning
The normal postural control mechanism of hemiplegic
patients was impaired due to 2 main problems:
1) Abnormal postural reflex mechanism
2) Abnormal muscle tone
In other words, in hemiplegia;
• normal muscle tone was replaced by spasticity;
• correction, balance, and other protective
reactions was replaced by abnormal postural
reflex patterns.
Normal Postural Reflex Mechanism
It contains a large number of automatic motor responses that develop
in the first three months of life.
It is necessary for voluntary functional activity.
• The ability to start and complete activity against gravity
• Automatic changes in posture before performing a
dynamic movement
• These are highly dynamic postural reactions that work to
protect individuals against falling, injuries of muscles and
joints, strengthen each others.
The normal postural reflex mechanism consists mainly of
three groups of automatic reactions. These include:
1. The righting reactions, which attain and maintain the
position of head in space and its symmetrical
relationship with trunk,
2. The equilibrium reactions attain and maintain
balance during activities to prevent falling,
3. Reactions which automatically adapt muscles to
postural changes in the trunk and extremities.
Abnormal Postural Reflex Activity in Hemiplegia
1) Associated Reactions
2) Asymmetric Tonic Neck Reflex (ATNR)
3) Positive Support Reflex
1) Associated Reactions
In patients with hemiparesis reflex tensing of muscles and involuntary
limb movements are frequently observed. These responses are known
as associated reactions.
In most patients voluntary forcefull movements in other part of the body
readily elicit such reactions in the affected limb.
In the Bobath approach, combined reactions are avoided. The patient is
provided to use all parts of the body without excessive effort.
2) Release of Asymmetric Tonic Neck Reflex (ATNR)
Asymmetric tonic neck reflex is a tonic reflex that is released in the
patients without high cortical control.
The asymmetrical tonic neck reflex is activated as a result of turning the
head to one side. As the head is turned, the arm and leg on the same
side will extend, while the opposite limbs bend.
3) Positive Support Reflex
Sudden pressure on the soles of feet causes simultaneous reflex
contraction of both extensors and flexors of the limb.
Normally it plays an important role of steadying the ankle joint in
standing position but in hemiplegic patients, it is not controlled by
the higher cortical mechanism and excessive spastic response occurs.
Requirements for Movement Efficiency
In the Bobath Concept, emphasis is given to improving the
efficiency of functional movements in order to minimise
compensatory strategies.
Requirements for movement efficiency are:
✓ Balance strategies
✓ Patterns of movement
✓ Speed and accuracy
✓ Strength and endurance
BALANCE STRATEGIES
Interaction with base of support
APA’s and reactive strategies
Stability limits
POSTURAL CONTROL PATTERNS OF
SPEED AND ACCURACY • Stability/orientation MOVEMENT
● Adaptable postural • Postural alignment ● Selective movements
tone • Postural tone ● Timing and sequencing
● Appropriate to task ● Coordination
• Neuromuscular activity
● Adaptable ● Functional
stability/mobility • Antigravity activity ● Range of movement
● Components • Afferent information ● Stability/mobility
• Body schema components
STRENGTH AND ENDURANCE
● Appropriate neuromuscular recruitment
● Force tension/length tension relationships
● Overcoming loads
● Sustaining repetitive activity
Thank You!
☺