BOBATH APPROACH.pptx. ..

Bobath approach

1. BOBATH APPROACH DR. MADHU

2. histroy This approach was developed by k bobath and b bobath in 1940s for the evaluation and treatment of cerebral palsy and adukt hemiplegia .

3. Principles Goals To retrain normal, functional patterns of movement in adult stroke patients. Therefore it is essential to normalise the abnormal tone. The training of normal movement patterns includes the activation of postural responses that must be available on an automatic level for functioning, re education of muscles for weight bearing and non weight bearing function. Permanent reduction of abnormal tone is possible only if involved side moves in normal patterns of coordination.

4. The following principles of treatment apply to all NDT/ Bobath treatment activities : Treatment should avoid movements and activities that increase muscle tone or produce abnormal responses in the i nvolved side. Treatment should be directed towards the development of normal patterns of posture and movement, patterns selected are not based on the developmental sequence but important for function. The hemiplegic side should be incorporated into all treatment activities to reestablish symmetry and increase functional use. Treatment should produce a change in the quality of movement and functional performance of the involved side.

5. Evaluation and treatment planning Abnormal patterns of posture and movement must be eliminated through the treatment because they prevent the patient from regaining normal function on his involved side. They are: Abnormal tone : Present in almost all patients with central nervous system(CNS). Normal tone is necessary for the production of normal movement. Muscle must high enough to allow movement against the pull of the gravity but low enough to allow normal speed and timing of the movement. Flaccid limbs feel heavy and floppy and relaxed. Placing responses are not present. Spasticity produces stiff limbs and spastic muscles resist movement and placing responses may assist if the movement is in direction towards shortening of spastic muscles. Hemiplegic patients frequently have hypertonic extremities with hypotonic trunk. Movements are limited to mass patterns of flexion or extension. Certain activities and positions may increase the abnormal tone (including associated reaction)

6. Loss of postural control The stroke patient has lost control of the system of postural adjustments that forms “ the necessary background for normal movement and for functional skills”. Normal postural reactions help to control the positions of body against gravity (includes righting reactions or equilibrium reactions). Postural reactions are associated with changes preceding and accompanying functional movement (including weight shifts). They occur automatically. Postural control is a central neuronal mechanism and is disrupted when there is loss of motor control of involved side. Loss of postural control can facilitate compensatory strategies.

7. Abnormal co-ordination Abnormal coordination, resulting in inefficient, non functional extremity such that coordination should be there between agonist, antagonist, synergist and fixation. Reciprocal inhibition is essential for smooth movement. Skilled activities have normal sequences of muscular activity and are not produced with conscious attention i.e., CNS has motor programs stored in it. In the stroke patient, the timing, sequencing and coordination of muscle activation are distributed. This leads to abnormal patterns of limb movement and coordination (patient exhibits abnormal synergies, co-contraction, abnormal timing needs conscious attention, excessive effort to produce any movement on affected side).

8. Abnormal functional performance: Patients loose the ability to integrate the sides of his body to perform functional tasks in normal ways(including gait, lifting and carrying objects etc). Coordination between both sides is lost. Even though one side of the body is unaffected by the stroke, the patient is unable to use his “good” side normally, because normal movement patterns require interaction and coordination between the two sides of the body. Compensatory techniques tend to increase the patient’s orientation toward his sound side, they may increase both postural asymmetry and neglect of the involved side. Compensatory techniques cannot fulfill all the functional tasks of activities of daily living.

9. Assessment The bobath method of assessment has three basic goals: To determine the presence and distribution of abnormal tone and abnormal movement patterns that are interfering with the production of normal movement. To identify deficits in normal motor responses, including both automatic postural responses and volitional movement patterns in the trunk and limbs. To analyse the patients ability to perform functional movement patterns, including gross motor tasks and specific self-care, vocational and recreational actvities .

10. Treatment goals Appropriate way of handling techniques and facilitation of normal movement pattern. Practicing those patterns until they can be performed independently.

11. Acute hemiplegia For the therapist, acute care is directed toward: Regaining balance in patterns important for function in sitting. Incorporating the hemiplegic arm into bed mobility and tranfers . Developing strategies for self care activities that involve the affected arm. Maintaining alignment and mobility in the upper extremities.

12. Hemiplegia with spasticity Spasticity is a problem in this stage even though patient has more control of his trunk and limbs than in the acute stage (flaccid stage). However, patients balance, posture and movements are abnormal and poor. Techniques used in this stage are to inhibit the flexor posturing of the arms and extensor posturing of legs; to facilitate or re-educate the normal patterns of upper extremity movements and lower extremity movements. Handling is done slowly, to give the patient time to understand what movements are being performed and to organise his response. Inhibition techniques are not used in patients who do not have spasticity or associated reactions. Facilitation handling techniques are designed to teach the sensation of normal movement by moving the limbs in space with proper pattern of initiation and sequencing and to stimulate muscles directly to contract isometrically , eccentrically and isotonically . Hold in alignment and provide postural stability while patient practices movement. teach the patient ways to incorporate the normal movement patterns learned to incorporate in functional activities and transitional movement. Teach patterns of compensation that do not encourage the development encourage the development of spasticity and associated reactions. In acute stage, it is very essential to retrain patterns of trunk movement because they had lost the control of the automatic postural pattern that is effective in maintaining a normal pattern of posture and balance essential for task performance. Right from acute stage it is essential to incorporate the hemiplegic arm for bed mobility, tranfer and movement.

13. Treatment Treatment basically consists of inhibiting abnormal distribution of tone and abnormal posture while stimulating or encouraging active motion in that level from where his motor control is poor. Reflex inhibiting patterns or key points of control or sensory stimulation can be used to facilitate normal motor control. Bobath believes that once patient can move easily in and out of normal basic patterns of posture and movement, he will automatically be able to elaborate on these patterns, top learn more skilled activities required in ADL. Early treatment is ideal and necessary if true gains are to be made and to avoid fixed abnormal patterns or contractures.

14. 1. Reflex inhibiting patterns Reflex inhibiting patterns(RIPs) are partial pattern opposite to the typical abnormal patterns of postural tone that dominate the patient. They prevent shunting of sensory inflow in to abnormal patterns and redirect it into normal ones. Inhibition of abnormal tone is always used with facilitation of the righting and equilibrium reactions. RIPs tends to redistribute the tone more normally. Key points of contact: They are those points of contact from where we can redistribute the tone to facilitate normal movement. They will allow the patient to develop flexible control over his own movement and postures. Key points are usually proximal parts of the body, from which abnormal reflexes seem to originate. Full body patterns can shunt the tone into a reverse pattern.

15. Key points : Allows maintaining the RIP. At the same time helps to use the limb for movement pattern similar to normal one. RIPs must be individualized for each patient following careful analysis of patient’s motor problems. Examples for RIPs : Head raising to hyperextension to facilitate extensor tone in rest of body and to inhibit flexor tone. Internal rotation of limb inhibits extension. Horizontal abduction inhibits humerus flexion. Elevation of arms inhibits flexor tone. Flexion of hip and knee with abduction of hip joint inhibits extensor tone. Symmetrical extension of limbs inhibits flexor spasticity. Rotation of trunk between shoulder and pelvis inhibits both flexion and extensor hyper tonus.

16. 2. Handling Manner of controlling patient through RIPs to elicit righting and equilibrium responses can be called as handling. It helps- To influence postural tone. To regulate coordination To inhibit abnormal patterns To facilitate normal automatic response. At first, handle patient passively in correct patterns of posture or movement while he is encouraged to cooperate and help as he can. Guidence and support by therapist is reduced once the patient is able to take over more and more initiate to move in correct patterns. The patient is not allowed to exert excessive effort because tone increases with effort and may become stunted into abnormal patterns. Once the normal movement patterns occurs, it is repeated to establish new sensorimotor patterns.

17. 3. Righting and Equilibrium reactions True inhibition of primitive patterns can be gained only through elicitation of righting and equilibrium reactions. Several postures and movement are used to develop dynamic control and to mimic normal development which occur spirally. Righting reactions helps the patient to move from supine to prone, on elbows, to quadruped, to kneel standing and finally to standing. Key points are used while eliciting neck or body righting. Equilibrium reactions are elicited by displacing the patients centre of gravity while he is in one posture and can maintain the posture against gravity. Protective reactions are next level of guard to protect the individual from falling.

18. 4.Sensory stimulation Sensory stimulation is never done unless the patient is in a RIP in order to shunt the inflow into desired channels. the sensory stimulations incorporated are : 1. Weight bearing: with pressure and resistance used to increase postural tone and decrease involuntary movement also to normalise the tone. 2. placing and holding : patient puts effort to hold the limb without assistance once the limb is placed. 3. Tapping : Pressure tapping :joint compression (by weight bearing). Inhibitory tapping: to decrease spasticity (by percussion and hacking on muscles antagonists to spastic). Alternate tapping: for balance (by pertubation ).

19. 5.Compensatory training Incorporating affected side decreases neglect of the arm, protects it from injury and maintains good alignment of shoulder girdle and trunk, prepares the arm for normal participation in tasks being trained.

20. Incorporating the hemiplegic arm She developed the technique of clasped hands to give the patient a consistent way to hold and move his affected arms. The patient lifts his hemiplegic arm by interlacing his fingers and holding the palms together. They help to maintain forearm in mid position and wrist in extension. Many patients may have difficulty with the task of interlacing their fingers or can not maintain the palmar contact necessary for wrist extension. Therefore a modified way of overcoming this problem is to place ulnar border of affected hand and wrist in the palm of the sound hand, with uninvolved thumb in the palmar arch and fingers clasping the dorsum of the hand, wrist and ulna.

21. 1. Bed mobility Start in supine position with both knees bent and feet on the bed. The patient is directed to locate his affected arm in the bed and clasp it. Using his sound arm, he extends his elbows and lifts his hands toward the ceiling until the shoulders are flexed to approximately 90 degrees. He is assisted to turn his head and shoulders to the involved side. Rolling is completed by turning the knees and pelvis to the same side until sidelying position is achieved. Rolling from sidelying to supine is easiest if the pelvis and knees rotate first, followed by the arms and upper body. Reaching the clasped hands forward and up can also be used in combination with bridging for use of the bedpan and in moving up or sideways on the bed.

22. 2. Tranfers For the acute patients, task of tranfer is frightening because he lacks good control of the hemiplegic side. Therapist faces the patient and therapist supports the hemiplegic arm against her body. The therapist supports the weight of the patient’s arm, to keep his trunk symmetrical and to facilitate the correct weight shift while he maintains the spinal extension to produce a good stand. Incorporating the affected arm rather than hanging by the side of the body prevents trunk asymmetry and promotes correct weight shift. As he learns to control trunk extension and shift forward over both hips to use both legs to stand, the patient can advance to practicing with clasped hand grip to control his own arm. Preventing trunk asymmetry and teaching the right postural changes with adequate instruction not to use unaffected leg and arm with out pushing will promote patient to gain a near normal way of getting up from sitting.

23. Treatment of the hemiplegic arm Scapula mobilization The technique helps to maintain scapula in humeral alignment and mobility, to maintain muscle length around the shoulder and elbow; to minimize development of spasticity and to prevent shoulder pain. It is done primarily in supine or sidelying on the uninvolved side. Therapist sits on bed on the patients affected side, facing his head. She places her outside hand on the top of the shoulder and her inside hand on the humerus , while maintaining arm in external rotation. Patients lower arm is cradled against her body. Using both hands together, the therapist moves the scapula up and down and forward and backwards . If scapula moved freely then progressively keep the patients arm in more flexion with external rotation at the shoulder and elbow extension.

24. 2. place and hold Place and hold activities are introduced following mobilization of the scapula. With practice the patient will learn to control the arm through a larger range of shoulder and elbow movement.

25. 3. Arm movements in sitting Separation of humerus from the acromium joint occurs when scapula downwardly rotates on the rib cage (due to change in angulation of the slope of glenoid fossa the humerus sli [ ps out of the joint). Flaccidity in acute stage is cause for this. Abnormal trunk postures and lateral flexion of spine encourages malpositioning of the scapula. Therapist should support the joint from underneath in the axilla , trying first to correct trunk position, lift humerus up and externally rotate it to neutral. Once glenohumeral joint has been repositioned , reeducate the arm movement. Guide the patient’s arm movement in to shoulder flexion and abduction and elbow flexion and extension. Guidance is removed once motor control is improving.