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. “Today’s 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 patient’s 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 patient’s 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 nonfunctional 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 aftercontraction 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. 1. 2. 3. 4. 5. Facts to consider to reduce detrimental effect of associated reactions:There less spasticity & after contraction if movement are done slowly. The spread of excitation into total spastic patterns can be counteracted by inhibiting parts of these patterns. The therapist should inhibit spasticity immediately the movement begins to deteriorate. At the start of treatment, excitation & effort are kept to a minimum, then it is gradually increased. 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 patient’s 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.