BOBATHAPPROACH

Bobath Approach 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.

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The basis of the approach is to give children an experience of normal movement by enabling the child to respond actively to specialized handling.

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Three important facts: it is impossible to superimpose normal movement patterns on abnormal ones, the abnormal patterns need to be suppressed (inhibited) the importance of sensory-motor experience (we do not learn a movement but the sensation of movement) by moving the proximal part of the body it is possible to influence and to change the movements of the distal parts

Treatment is planned for each child via assessment. Some of the areas that will be assessed are:the patterns of movement the child presents with;age-appropriate movements that the child may not be achieving or may find difficult;the child's present capabilities;examination of the child's posture in different situations and positions

Principles of TreatmentNeed to change the pattern of abnormal postural tone to be able to work for enhanced functional skills. Use various types of handling to affect changes:Tone Influencing Patterns/PostureFacilitationStimulation

Principles of TreatmentSystematic Preparation for Function:Engagement with childAddress neural and non-neural componentsImprove alignment of body partsImprove muscle activityAddress sensory/perceptual needsGive experience of and practice more normal patterns of coordination in selected tasks to promote transfer of skills into daily life.

Principles of TreatmentProblem Solving ApproachUsing purposeful, play centred and goal directed activitiesCarry Over and ManagementActive participation by patient, with gradual reduction in handling or assistanceSelf correction and self initiationForward looking long term outcomeTraining/education of parents*

The Bobath ApproachThe main aim of treatment is:to encourage and increase the child's ability to move and function in as normal a way as possible. to help the child to change his abnormal postures and movements so that he or she is able to comfortably adapt to the environment and develop a better quality of functional skills.

Change is Possible: Each child's postural (muscle) tone is changeable, not only in relation to activity and moods, but also in response to being handled.

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Positioning is very important in Bobath treatment.Correct positioning helps improve movements. Experience of different positions is necessary to improve overall body control and reduce the risk of unnecessary poor posture.

Handling a child using key points on the body allows the therapist to manipulate the child to correct their movements. Help may be given with movements like chewing, handling objects, moving about, sitting or lying down.

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Handling = making a changeThrough handling techniques the PT can assess the childs potentialsCreates opportunities for the child to experiment with movement and to problem-solving for himselfMakes more normal movement possibleChanges with the response of the child

Inhibitory control: Reflex inhibiting postures (R.I.P.)- placed and held the patient in reflex inhibiting postures to break up the abnormal postural and movement patterns- no spontaneous carry over into movement and function occurred, as the child had never previously experienced the sensation of normal movements

Inhibition combined with stimulation and facilitation- after preparing and obtaining a more normal postural tone the patient needs to learn to move in many different combinations of more normal movement patterns- looked for possibilities of how to transmit to the patient in order to enable them to experience normal sensations of functional movements they had either lost or never developed

- The Bobaths realized the importance of understanding normal development in order to be able to understand abnormal development and how to treat it.- Then the Bobaths recognised the importance of postural reactions (righting and equilibrium reactions)

Dynamic treatment with control from Key Points:- key points of control(body parts, mainly proximal - head, shoulders, pelvis) from which abnormal patterns could be controlled (inhibited), and the strength and distribution of postural tone could be influenced

At the same time normal movement patterns could be facilitated or a specific technique of stimulation could be usedFrom the key point of control the therapist is able to control and guide the movement of the whole body. The child could be facilitated to react actively where not actually held or controlled*

- The treatment should not follow rigidly the developmental milestones- During the treatment it is necessary to reduce the therapists control, handing it over gradually to the child and allowing him the control of his own movements.- Much guided control and repetition of the required reactions may be necessary to assure their quality.

Normal DevelopmentCephalo-caudal , caudo-cephalad, proximo-distal, and distal-proximalDynamic stability before dynamic mobilityEnd range movement before midrange controlSymmetrically before asymmetricallyAnterior-posterior direction first then laterally, then diagonallyDynamic relationship between BOS, COG and LOG (stability, readiness to move and with weight shifting there is movement)

Physiological FlexionBody concept (body awareness, schema, image)Postural control/set (orientation)Psychological, emotional stability (security)Muscle balance of development against extensor groupBack musculature elongation

General Picture of PrematurityPoor alignment / body schema Poor stability and mobilityStructural differences: extended back, anteriorly tilted pelvis, and changing direction of muscles and jointInsecurity: crying

Flexed PostureDevelops midlineDevelops body awarenessPromotes securityMovement (purposeful)

Main Goal of Positioningencourage development of flexionavoid excessive extensionfacilitate smooth antigravity limb movementpromote symmetrical posturereduce cranio-facial flatteningprovide support, containment, securityminimizes stress, promote sleepdecrease energy expenditureprovide tactile stimulationencourage parent-infant interactionenhance midline orientation, eye, hand, motor control

Thank You.

1. The first stage towards achieving functional activity is to enable the child with spasticity to be less stiff and the child with athetosis to gain some control over their posture and movement.

**Posture*Facilitation: Recognised the importance of proprioceptive stimulation to build up tone in patients with low and unstable postural tone.facilitation: easiest way to do movementInhibition: breaks the pathological movements or patternsStimulation: pump up

*The Bobath approach to treatment: aims to improve posture and movement to enable more realistic functioning in daily life through specialised ways of handling, stiffness can be reduced, muscle control against gravity increased, and fluctuating muscle activity stabilised.

**More normal movements cannot be obtained if the child stays in a few positions and moves in a limited or disordered way*We do not teach movements, we make them possible.

*Depending on the severity of the condition, the child may be better able to learn how to sit up, use his/her hands, to stand up, to stand, and to walk.

***handling:Ideally the treatment will be an integral part of the daily routine for that child. For example, the way the child is picked up, carried, put down, or positioned when sitting, will enable parents/carers to enhance the child's ability and function.

**facilitation: easiest way to do movementInhibition: breaks the pathological movements or patternsStimulation: pump up

**The overall purpose of this approach is to assist the child's acquisition of normal postural control and movement patterns. The therapist facilitates these abilities in the child by skillfully "handling" the child during purposeful activities. Handling involves the provision of graded tactile, proprioceptive, and vestibular input through key points of control *These approaches may be helpful in addressing the aspects of a child's movement dysfunction related to alignment, postural stability and movement patterns.

**the Bobaths realised the importance of understanding normal development in order to be able to understand abnormal development and how to treat it.*Active adaptation of the child being held in R.I.P. resulted in a change of activity of the whole body due to thenormalisation of postural tone.***Although they occur automatically they are activemovements. All voluntary and skilled functional activitywith its complex and selective patterns of coordinationis performed on the basis of automatic postural reactions.The motor patterns of normal postural reactionsdevelop in the child gradually during the first few yearsof life*Only by feeling a near normal active movement with minimal effort can the patient learn how to perform it. The therapists task is to make this possibleThe 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. 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 are automatic reactions which serve to maintain & restore balance during all our activities, especially when we are in danger of falling.

*- Facilitation is the process of intervention, which uses the improved postural tone in a goal-directed activity. The patient is active and the therapist is guiding and controlling the activity.- Facilitation makes movement easier but in the treatment it also means making it possible and making it have to happen.- Inhibitory control is used with facilitation. It is accomplished simultaneously with the least amount of physical intrusion. As the therapist uses techniques that reduce the dysfunctional tone, the patient makes more efficient movement adaptations.

**In normal development children develop many activities simultaneously. There is a big variability and inconsistency in normal development**Normal development: a process of achieving internal control and dissociation*weight bearing side = elongated, mobile = shortened**postural control? Stability and mobility: works together in doing purposeful movement, postural control (basis for movement), righting reactions, equilibrium reactions, supporting reactions*Body image is the presentation of the body to the outside world in a - usually - typical format (i.e. two arms and two legs etc.). Body image is the way we perceive our bodies through an interaction with others and our environment. or example an anorexic may perceive their body to be larger than in fact it is; *A body schema, however, is the selfs notion of the body represented in space.*Common Signs of Body Awareness Problems All children refine their body awareness as they mature. Compared to other children his age, does your child... seem to move awkwardly or stiffly? seem to be physically weaker than other children? use too little or excessive force on things (for example, has trouble attaching clothing snaps, pop beads, and Legos, writes way too light or too dark with a pencil, breaks toys often)? push, hit, bite, or bang into other children although he isn't an aggressive child? avoid or crave jumping, crashing, pushing, pulling, bouncing, and hanging? chew on clothing or objects more than other children do? always look at what he is doing (for example, he watches his feet when walking or running)?

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