The founders and

development of the Bobath

Concept

Karel Bobath,
Neuropsychatrist.

Berta Bobath, early training

was as a remedial gymnast,
Dr Bobath stated ‘the Bobath
Concept is unfinished, we
hope it will continue to grow
and develop in years to come’
(Scheichkorn 1992; Raine
2006).
Primitive reflex patterning
seen at birth refined during
maturation, through inhibition
from higher centres.

Lesions to the pyramidal

tract leads to loss of inhibitory
control and therefore
contralateral spastic
A neurologic insult will lead
to a release of the lower-level
centers from higher-level
center inhibitory control,
resulting in
Stereotypical postures,
Primitive movement patterns
Predominant reflex activity
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.
.
BASIC IDEA OF BOBATH APPROACH

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.
He will therefore be unable to
develop & lay down the memory of
normal sensory motor patterns.
According to Mrs Bobath, the
main problem seen in
neurological patients was
abnormal coordination of
movement patterns combined
with abnormal tonus.
 SYSTEM THEORY

The systems approach to

motor control provides the
foundation of the current
theoretical underpinning of the
Bobath Concept (Raine 2006).
 Movement Is
Produced By
Multiple Neural
Networks
“Coordination of movement is the
process of mastering the redundant
(unnecessary) degrees of freedom
of the moving organism”,

Muscles could work in synergies

to help solve this movement
problem, such as in postural control
and locomotion.
Neuroplasticity
The plasticity of a structure is its
ability to show modification or
change.

Motor learning is the permanent

change in an individual’s motor
performance brought about as a
result of practice (Wishart et al.
2000; Lehto et al. 2001).
Learning an activity is
synapse and circuit specific,
and can be modified with
synaptic transmission being
either facilitated
(strengthened) or depressed
(weakened).
‘Neurons that fire together,
wire together’ and promote
motor learning (Hebb 1949;
Johansson 2003).
There is a direct relationship
between the neural molecular
form and functional
performance (Kidd et al.
The nervous system is
continually undergoing
modification based upon its
experiences,

Achieving efficient and effective

functional goals in a variety of
There are three neuroplastic
phenomena that occur in the
nervous system following a lesion

1. Denervation supersensitivity,
2. Collateral sprouting and
3. Unmasking of silent (latent)
synapses.
Denervation supersensitivity
when a nerve supplying skeletal
muscle or smooth muscle or
gland is sectioned and undergo
degeneration, the muscles and
glands slowly become hyper
responsive to the
neurotransmitter which was
secreted from the nerve endings.
(Wainberg 1988; Schwartzkroin
Collateral sprouting appears in
cells around the lesion, where
collateral dendrites make
connections with those synapses
lost by cell necrosis (Darian-
Smith & Gilbert 1994).
Unmasking of silent
synapses occurs when
previous non-functioning
neurons are accessed to form
new connections (Nudo 1998;
Johansson 2000).
Emergent properties of each
cortical area are constantly
shaped by behavioural
demands, driven largely by
repetition and temporal
coincidence (Nudo 2007).

Bernstein (1967) describes the

importance of not just repetition,
 Bayona et al. (2005)
describe the consequence of
the motor system as ‘use it or
lose it’.

In the somatosensory
system of the brain it is
‘stimulate it or lose it’. Both are
essential considerations in the
Motor learning

Motor learning refers to the

permanent change in an individual’s
motor performance brought about as
a result of practice or intervention
(Wishart et al. 2000; Lehto et al.
2001).
Important determinants in motor
learning (Winstein 1991; Marley et al.
2001; Ezekiel et al. 2001; Lehto et al.
2001).

These include:
● Practice
● Part Or Whole Task;
● Augmented Feedback
● Mental Practice;
● Modelling;
● Guidance;
 The Bobath Concept is goal
orientated and task specific, and
seeks to alter and construct both
the internal (proprioceptive) and
external (exteroceptive)
environment in which the nervous
system and therefore the individual
can function efficiently and
effectively (Raine 2007).
 Therapy is an interactive
process between individual,
task and the environment
(Shumway-Cook &
Woollacott 2007).
 Bobath Therapy addresses
abnormal, inefficient
stereotypical movement
patterns that interfere with
function
 UNDERSTANDING OF
FUNCTIONAL MOVEMENT
Five aspects to produce efficient
functional movement (Mayston
1999)

1. Motor
2. Sensory
3. Cognitive
4. Perceptual
5. Biomechanical
•Medial
descending
system

•Lateral
descending
system
 Evaluation In The Context
Of The International
Classification
Of Function, Disability And
Health
 Three Domain – ICF
model
Social
Body
Individual Functions
structure and
(activities or (participation
function
activity or
(integrities or limitation)
participation
impairments)
restriction),

Contextual Factors – Environment And Personal

 Body Function and
Structures
(Integrities and
Impairments)
 Body Function and
Structures
Example – Case Study
 Individual Function
(Activities and
Activity Limitations)
Individual Function -
Example
Case Study
 Social Function
(Participation and
Participation Restriction)
 Social Function –
Example Case Study
 • Family, home, school,
or work setting, and
Environmental potential living
factors environments, such as
group homes or
nursing homes.

Personal • gender, age,

factors height, weight, or
educational
background
 • Lives in large
Environmental house in
factors - countryside
example • Very soft chairs in
house

• 63 year old male

• Retired factory worker
Personal • Father of twins aged 8
factors - • Lives with wife
example • Wife works away several
weeks of year
• Inactive during the day
• Reduced drive to be more
Posture And Movement

Single
Multisystem
system
factors
factors
Neuro-Developmental Treatment
problem solving and decision
making
CLINICAL
REASONING
The key questions

What can the

‘What can the patient do with
patient do a little help
now?’ from the
therapist?
Outcome Measures
 The use of formal,
validated, and reliable
outcome measures to
document change in
neurological rehabilitation
is necessary and also
increasingly demanded
 Outcome Measures

Self
Body Activity
Report
Domain Domain
Measures
 Canadian Occupational
Performance Measure (COPM)

The COPM, a client-centred

measure, was developed to allow
occupational therapists to
determine the effectiveness of
their work.
Goal Attainment Scaling
(GAS)
GAS can be used to
measure the results of
treatment intervention at both
the impairment and the
functional level.
 Neuro-
Developmental
Treatment Practice
Model
1. Information
2. Examination
Gathering

NDT
Practice
Model

3. Evaluation 4. Intervention
 Observation
•Posture And Movement
Including Alignment

•Symmetry/Asymmetry

•Responses To The
Environment
 Therapeutic
Muscle Handling
initiation and how long the
muscle stays in contraction.
How many muscles contract together
and the order of recruitment.
Stiffness and compliance of body
segments.
Joint stability/instability.
Reactions to graded support of a
body segment.
 Therapeutic
• Active
Handling
weight shifting initiated
by the client.
• Sensitivity and reactivity to
tactile and deep-pressure
contact.
• Respiratory pattern, timing,
and rate.
 EVALUATION PRACTICE MODEL
FOR THERAPISTS
Form 1

•Participation

•Participation Restriction

•Activity (Functional)

•Activity Limitation
Form 2 : Observations of Alignment
Choose a functional (activity or participation) skill that your
client wants to achieve during intervention

Choose the outcome according to the

functional activity
Observe the client in positions and postures
that are similar to the desired outcome

How is the client’s entire body positioned?

What is the base of support for this position

 Form 2 : Continue….

What happens to the client’s alignment when

the client is relatively still? Does the
alignment stay the same? Does it change

What happens with alignment

when the client moves?

Write two to four clinical hypotheses about why you

think the client postures or moves the body and body
segments in a particular way during the function you
chose to observe.
Form 3 : Observations of Posture
Focus your first observations of posture on the trunk and
head.

How the client controls stability of the

posture

Is stability controlled through muscle activity, skeletal

alignment, external support, or a combination of these three?

Observe how the client control the postural stability?

Whether efficient or inefficient way
Form 4 : Observations of
Movement
How does the client initiate the
movement?

What muscles contract to initiate and

control trajectory and speed of the
movement?

Is the movement successful, If not, hypothesize

why the movement is inefficient and/or ineffective.
Treatment is tailored to the
individual patient and is
response-based.
 POSTURAL SETS
Postural sets describe the
interrelationship between body
segments at a given moment.

Movement may be described as

a continuous change of postural
sets.
 Bobath therapists
analyse posture and
movement through the
alignment of key points
They are divided into three key
points of control

Proximal – shoulder girdles,

head and pelvis
Distal – hands and feet
Central - Mid-thoracic region.
Posture can be assessed in stable
and dynamic situations in order to
analyse functional activity.
There are core postural sets that
are part of functional movements,
which include
•Standing
>Bridging
•Supine >Walking
•Sitting
•side lying
ABCs Of Posture And
Movement
A •Alignment

B •Base Of Support

C •Centre Of Mass
SYMMETRY
Impaired
Somatosensory
Awareness
Visual Impairment
Vestibular Impairment
EXTREME
ASYMMETRY

RESPIRATORY AND
GASTROINTESTINAL
PROBLEMS
WEIGHT SHIFT
STANDING
POSTURAL SWAY
Patients with stroke
who put less weight
through their paretic
leg during sit to stand
had poorer mobility
scores on the
Functional
Independence
Measure (Lee et al
 An active and efficient
standing leg will produce kinetic
energy for swing

An active arm facilitates

postural activity, whereas the
use of arm support may alter or
negate postural control
depending on how it is used
 Contractual Hand
Orientation Response
(CHOR)
SITTING
 When addressing the hemiplegic
shoulder complex, the first area to
be assessed is the alignment of the
trunk.

The optimal alignment of anterior

pelvic tilt, followed by lumbar
extension and thoracic extension,
provides a biomechanical foundation
of all head, neck, and limb
How the sitting postural set
influence head/neck and
trunk?
 HANDS ON
Falla and colleagues (2007)
the activity of the deep neck
flexors and lumbar multifidus
were significantly greater
when postural correction was
facilitated by a therapist
(hands on) than through
 The session
outcome forms the
foundation from which the
session is planned,
designed, implemented,
and evaluated.
Establishing a meaningful and
achievable session outcome can
be motivating and empowering to
clients and families
 Activity Analysis
The first part of the
session plan includes
selecting an activity
that can be used as
meaningful and
motivating practice
throughout the
Activity Task session.
Sub task
analysis analysis
 Intervention session

Handling
Environmental
factors Key point of
control
 KPCs can be unilateral or
bilateral, proximal or distal,
symmetrical or asymmetrical

The therapist’s hands

should be viewed as a clinical
tool; a piece of therapeutic
equipment.
 Single System
Preparation

1. 3.
2. Musculoskeletal 4.
Regulatory
system Sensory system system (find the Neuromuscular
(visual, auditory structure system (muscle
(agitated, responsible for tone/postural
and
fearful and lack of mobility/ tone)
angry) somatosensory)
strength)
Neuromuscular system
• Spatial and temporal summation of input
• Selective recruitment of sustained postural motor
Motor unit units while activate sustained movement phasic
motor units.

Muscle • Concentric, isometric and

contraction eccentric contraction

• Reciprocal activation
Gradation • Co contraction of muscles
 Single System
Preparation…
5.
Respiratory 6. 7.
Cardiovascular Gastrointestinal 8.
system Integumentary
(respiratory system system
system (skin,
status, ribcage (cardiovascular (swallowing,
connective
mobility and fitness and GERD,
distal blood flow aspiration and tissue and
posture fascia)
influence the ) constipation)
respiration)
 Multisystem
preparation

Postural
control/postural
orientation /postural
SIMULATION
ENVIRONMENT SETUP
Tool object (real tool or
simulation tool)

Contextual environment

Client setup

Therapist position
PRE-SESSION POST-
SESSION
INTERVENTION
STRATEGIES
STRATEGY 1
The proximal
shoulder girdle
and arm
muscles are
unable to initiate
activity and/or
are profoundly
CC

MC

OC
 STRATEGY 1 in
Pediatric
Limb Control Progression
In Pediatric
Alternative
QUADRUPE Weight
D Bearing
Position
 STRATEGY 2 Demanding
Gravity
Rule no 1 • Keep limb in vertical (line with gravity)

• Slanted surface
Rule no 2
• Isometric facilitation with CC
• Once isometric contraction achieved then
Rule no 3 encourage movement in vertical line above
head for UE

• Once strength is achieved then final range of

Rule no 4 work between 70 to 110°

Rule no 5 • Use short lever movement first

 IMPAIRMENTS
Impairment Impairment Impairment
1 2 3

• Inability • Inability • Inability

to to to
initiate sustain generate
activity activity sufficient
force
in the in the productio
muscle muscle n in the
muscle
 Modulating and
Varying the Level of
 POSTURE TO
TRANSITIONS
High sitting

Higher sitting

Liftoff positions

Squatting
 Range and
Alignment pattern of Timing
mts

Postural
Speed Strength
control
Based on literature, common
constraints are

1.Starting position

2.Seat height

3.Foot position

4.Upper limb position

Phases of sit to
stand
 Flexion Extensio
Momentu
momentu Stabilization
m
m transfer n
Stage 1: Flexion
momentum

- begins with initiation of

the movement and ends
just before the buttocks lift
from the chair (seat off)
Act • In relaxed sitting, the pelvis is often in
a degree of posterior tilt and the pelvis
no 1 moves towards anterior tilt

• Trunk extensor muscles and

Act abdominal muscle co-activation are
required to produce linear extension
no 2 on a stable base

• Improvements in reaching
Act activities in sitting correlated with
increased activation of the lower
no 3 limbs
Efficiency in recruitment of trunk
activity to transfer the body weight
upwards and forwards requires a
number of factors to be considered.
These include:

● Starting Posture,
● Degree Of Support,
● Postural Alignment And Activity,
● Relative Seat Height And
 The isometric ‘rising
forces’ exerted under the
buttocks in preparation for
seat off which raise the
centre of gravity before
forward flexion begins.
Hirschfeld et al.(1999)
Stage 2: Momentum
Transfer

… begins at seat off and ends at

maximal ankle dorsiflexion
Act • requires maximum power in the
lower limbs
no 1

Act • dorsiflexors have been identified as

the first muscle group to be active in
no 2 STS drawing the tibial shank forward

Act • stability depends

coordinated activity of
upon
tibialis
no 3 anterior and soleus
It is not essential for the whole
foot to be in contact with the floor at
initiation of STS, but there must be
the potential to reach the floor
during the transfer.

The timing of this event is a key

component of propulsion gained
from the foot in STS.
Stage 3: Extension phase

….just after maximal ankle

dorsiflexion until cessation of hip
extension
 Coordinated activation of the hip, knee
and ankle extensors raises the body up
against gravity.

In posturally unstable patients may be

used various strategies to control the COM
displacement, for example:
● adopting a wide base of support;
● increasing forward flexion;
● hyperextending knees;
● exaggerating dorsiflexion;
● bracing legs back against the seat
Stage 4: Stabilisation

… from when hip extension

ceases until all movement has
stopped.
Key Observations In The
Assessment Of Movement
Dysfunction
 1.Centre Of Gravity

3.Knee
hyperextension
and hip flexion

2. Excessive
Lateral
Displacement
 5.Posterior 4.
rotation affected Flexed
side left UL

6.Reduced hip
abduction and
extension