Bobath Concept Indications, Treatment Techniques

Bobath therapy aims to regulate muscle tone, provide postural alignment with special grip techniques and improve functions with the active participation of the individual. The facilitation of normal movement components and their special implementation according to the task, which includes strategies preserving muscles and joint uniformity, are critical elements of Bobath Concept.

Principles of Bobath Therapy

Bobath is based around the brain’s ability to adapt to change and reorganize 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
• The normalization 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 the quality of independence

Treatment Techniques of Bobath Therapy

Motor relearning programme

Sitting up over the side of the bed 

• (1) From a supine position in bed: Flexing the affected leg while therapist stabilizes the foot and leg, turn to the intact side. Therapist assists by lowering legs. Flexing head sideways while the therapist assists into sitting.
• (2) Mobility exercises perform in bed: Rolling and bridging

Balanced sitting

Sitting on a firm surface, hands in lap, feet, and knees approximately 15 cm apart, feet on the floor.

• Head and trunk movements – Turning head and trunk to look over the shoulder, returning to mid position and repeating to another side. Looking up at the ceiling and returning to upright.
• Reaching actions – Reaching forward (flexing at the hips), sideways (both sides), backward, returning to mid position. Therapists assists in shoulder forward flexion over the affected side, one hand on elbow and another hand on the wrist.

Balanced standing

Standing on a firm surface, hands over the side of the body, feet apart, while therapist stabilizes affected the side of the knee.

• Head and trunk movements: Standing with feet apart, looking up at the ceiling and returning to upright. Standing with feet apart, turn head and body and look behind, return to mid position, repeat to another side.

• Reaching actions – Reaching forward, sideways (both sides), backward, returning to mid position. Therapists assists in shoulder forward flexion over the affected side, one hand on elbow and another hand on the wrist.

Standing up and sitting down

Sitting on a firm flat surface, no arm rests, feet flat on the floor, no flexion within upper body throughout the action.

• Standing up – Start with upper body vertical, feet placed backward. Patients swing upper body forward at the hips and stand up. Therapists stabilize paretic foot and knee, one hand over the trunk and another hand over the knee, to prevent buckling.
• Sitting down – Patient flexes hip, knee and ankles to lower body mass toward the seat. While therapists assist the movement.

Upper limb function

• Reaching: Forward (flexion at the shoulder), sideways (abduction at the shoulder) and backward (extension at the shoulder). With shoulder girdle elevation, elbow extension and a varying amount of shoulder external rotation done. The opening of hand aperture between thumb and fingers, an extension of wrist, pronation, and supination.
• Grasping: Extension of the wrist and fingers. Abduction and conjunct rotation of the carpometacarpal joints of thumb and fifth finger. Closure of fingers and thumb around the object (tumbler, rolled towel).
• Holding: Flexion and extension of wrist holding object (tumbler, rolled towel).
• Manipulation and finger dexterity: Flexion and extension of fingers. Flexion and conjunct rotation of the carpometacarpal joints of thumb and fifth finger. Independent finger flexion and extension.

Bobath technique

In sitting

• Sitting on a firm flat surface, hands rest over the bed, feet flat on the floor, while therapist place one hand over elbow and other over the wrist Weight shifting to both sides done.
• Clasping both hands forward, turning to sound side. While lifting the affected leg and crossing it over the sound side.
• Clasping both hands forward, turning to the affected side. While lifting the sound leg and crossing it over the affected side.
• Sitting with crossed legs. The affected leg over the sound one. While both hand clasps and places over the knee.
• Flexion and extension of the knee. The therapist places one hand over foot another hand over the knee.

From sitting to standing

Clasping both hands forward placing affected foot parallel with sound one. The therapist places one hand over the sacrum and another hand over knee, and help them to raise up.

In standing

• Clasping both hands forward. Turning to both sides.
• Sitting and standing up.

For movements of the arm

• Elevation of arms with clasped hands.
• Moving clasped hands to face, while therapists hand prevents retraction of the shoulder.
• Moving clasped hands above head, while therapists hand prevents retraction of the shoulder.

Bilateral shoulder flexion exercises.

• Sitting push-ups to full elbow extension.

Indications of Bobath Therapy

Bobath physiotherapists encourage a person to move in the most normal and energy efficient way and prevent abnormal movement patterns in order to:

• Head Injury
• Stroke
• Spinal cord injury
• Cerebral Palsy
• Parkinson’s disease
• 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

The Bobath approach also emphasizes the importance of early rehabilitation?, consistency of practice and a stimulating environment in order to promote recovery.

• Head and trunk flexion decreases shoulder retraction, trunk, and limb extension (key points of control – head and trunk).
• Humeral external rotation and flexion to 90 degrees decrease flexion tone of the upper extremity (a key point of control – humerus).
• Thumb abduction and extension with forearm supination decreases flexion tone of the wrist and fingers (a key point of control – the thumb).
• Femoral external rotation and abduction decrease extensor/adductor tone of the lower extremity (a key point of control – hip).
• Facilitation – Components of posture and movement that are essential for successful functional task performance are facilitated through therapeutic handling and key points.

Inhibition – Components of posture and movement that are atypical and prevent the development of desired motor patterns are inhibited. While originally this term referred strictly to the reduction of tone and abnormal reflexes, in current NDT practice it refers to the reduction of any underlying impairment that interferes with functional performance. It can be used to:

• Prevent or redirect those components of a movement that is unnecessary and interfere with intentional, coordinated movement,
• Constrain the degrees of freedom, to decrease the amount of force the client uses to stabilize posture
• Balance antagonistic muscle groups
• Reduce spasticity or excessive muscle stiffness? that interferes with moving specific segments of the body.

Bobath trained Physiotherapist

• Analyses posture and movement within functional activities
• Sets meaningful goals with family
• Decides on treatment plan accordingly

Aims to

• Change atypical tone
• Mobilize tight structures
• Activate appropriate muscle groups
• Strengthen weak muscles
• Improve the quality of posture and movement with hands-on
• Take hands off to increase the child’s own activity
• Encourage a child’s problem-solving skills to improve independence
• Work within appropriate context to improve functional skills
• Some overlapping skills with occupational therapy and speech and language therapy

Bobath trained Occupational Therapist:

• Analyses posture and movement within functional activities
• Sets meaningful goals with family
• Decides on treatment plan accordingly

Aims to

• Improve the quality of posture and movement with hands-on
• Take hands off to increase the child’s own activity
• Optimize perceptual skills
• Optimize sensory processing
• Work within appropriate context to improve functional skills
• Maximize the child’s potential for independence within daily activities such as dressing, cutlery skills, writing
• Some overlapping skills with physiotherapy and speech and language therapy
• Often uses play and exploration to develop and learn many skills

Cerebral palsy can sometimes affect a child’s perceptual and sensory ability and their judgment of spaces and distances. Occupational therapy seeks to help overcome this by using carefully graded activities so that the child can move and use their eyes and hands more effectively to dress, eat, read, write and play with friends.

Bobath trained Speech & Language Therapist

• Analyses general posture and specific oral motor ability
• Sets meaningful goals with family
• Decides on treatment plan accordingly
• Improving the quality of posture and movement in order to communicate and in relation to oral motor ability and speech breathing
• Take hands off to increase the child’s own activity
• Work within appropriate context to improve functional skills with regards to eating, drinking, and communication including access to AAC
• Maximize the child’s potential for independence with daily activities
• Some overlapping skills with physiotherapy and occupational therapy

Speech and Language Therapy deals not only with communication and speech but with all aspects of the oral movement. Difficulties in coordinating the muscles necessary for speaking mean that children may also experience problems eating and drinking.

Comparisons of the Bobath concept with other approaches do not demonstrate the superiority of one approach over the other at improving upper limb impairment, activity or participation. However, study limitations relating to methodological quality, the outcome measures used and contextual factors investigated limit the ability to draw conclusions. Future research should use sensitive upper limb measures, trained Bobath therapists and homogeneous samples to identify the influence of patient factors on the response to therapy approaches.

References