At the end of the lecture, the students should be able to: Discuss the theoretical basis of the neurodevelopmental approaches Discuss the concepts and principles underlying the Bobath approach Discuss the concepts and principles underlying the Brunnstrom approach

1. Bobath & Brunnstrom
Approaches
Dr. Maheshwari Harishchandre
Assistant Professor
M.P.Th (Neurosciences)
DVVPF College of Physiotherapy,
Ahmednagar

2. Learning Objectives…
At the end of the lecture, the students
should be able to:
• Discuss the theoretical basis of the
neurodevelopmental approaches
• Discuss the concepts and principles
underlying the Bobath approach
• Discuss the concepts and principles
underlying the Brunnstrom approach

3. Sensorimotor Approaches
• Bobath approach
• Brunnstrom’s movement therapy
• Rood approach
• Proprioceptive neuromuscular
facilitation

4. Theoretical basis…
• Neurodevelopmental model
• Reflex theory
• Hierarchical theory
• Systems approach

5. Neurodevelopmental Model
• motor control and its production
refers to two systems of output: the
open loop (voluntary control ) and
the closed loop (postural control)
mechanisms

6. Open-loop system…
• commands sequences of movement
that are centrally stored in the
nervous system and that serve the
functions of mobility in the
production of isolated joint and limb
motions

7. Closed-loop system…
• Dependent upon afferent feedback
for the elicitation of its automatic
movements that serve as the
principle motility or stability of the
organism
• prerequisite for the development of
normal movement behaviors
• arise from patterns of coordination

8. Reflex Theory
• The basic unit of motor control are reflexes
– Reflexes  purposeful movement
– Damage to the CNS results to re-emergence of
and inability to control the reflexes

9. Hierarchical Theory
• Motor control is hierarchically arranged
– CNS structures involved with movement
can be grouped into HIGHER, MIDDLE,
and LOWER levels
– Higher centers regulate and control the
middle and lower centers
– Damage to the CNS results to disruption of
the normal coordinated function of these
levels

10. Systems approach
• suggests that the CNS does not operate
in a strictly descending manner
• no higher levels with which to control
the operation of the lower levels
• there is a mutable relationship between
the various levels so that each level will
alternate between command and
subordinate roles in relation to the other
levels.

11. Bobath Approach
Concepts and Principles

12. History…
• Developed by Dr. Karel Bobath, a
neuropsychiatrist, and Mrs. Berta
Bobath, a physical therapist
• 1943 – while working with children with
cerebral palsy

13. Original theoretical
framework…
• Based on the works of Jackson,
Sherrington, and Magnus
 who described nervous system as
HIERARCHICAL in nature
• Model
 Higher brain centers exerted control
over lower-level centers
 Eg. The cerebral cortex control
supercedes that of the brainstem

14. OLD THEORY NEW THEORY
Hierarchical brain organization Systems Model
Static postures and positions used
for treatment
Client is an active participant in the
session
Progressing the client through normal
developmental milestones
Developmental milestones serve as
guidelines but should not be strictly
adhered to
Development of control proceeds in a
cephalocaudal direction
Control of movement develops in
proximal to distal or distal to proximal
directions
Work on components of motions
which the child will then apply to
function
Client must work on functional tasks
to learn the skill

15. Old theory New theory
CNS viewed as the “controller”.
Automatic postural control
mechanism simplified the
responsibility of the CNS in control
of movement
The CNS determines the pattern of
neural activity based on input from
multiple intrinsic systems and extrinsic
variables that establish the context for
movement initiation and execution
“Positive signs” including spasticity
and abnormal coordination of
movement are the most important
aspects of sensorimotor
impairments
The “negative signs’, including
weakness, impaired postural control
and paucity of movement are
recognized as equally important as the
“positive signs” in limitations of function
limitations of function
Muscle and postural tone determine
the quality of the patterns of posture
and movement used in functional
activities
Task goals, experience, individual
learning strategies, movement
synergies, energy and interests all
affect the quality of the final action

16. Basic idea of Bobath Approach
• The abnormal patterns must be stopped not
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.

17. 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.

18. Adult hemiplegia..
• Treatment approach was later on expanded to
include the rehabilitation of adults with motor
problems, particularly CVA
• Main problem: the abnormal coordination of
movement patterns combined with abnormal
postural tonus (Bernstein, 1967)
• Secondary problem: muscle strength and
muscle activity

19. Bobath concept…
• Is a living concept
 It has undergone changes in its
theoretical base to accommodate
developments in the fields of
neurophysiology, biomechanics, and
typical development
• Holistic approach
 It involves the whole patient, his sensory,
perceptual and adaptive behaviour, and
motor problems

20. Traditional View
• Principles of treatment
– Normalize muscle tone
– Inhibit primitive reflexes
– Facilitate normal postural reactions
– Treatment should be developmental
• Techniques
– Handling
– Weight bearing over the affected limb
– Utilize positions that allow use of the
affected limbs

21. Reconstruction of
the
NDT approach

22. Problems in the adult patient
with stroke
• Abnormal tone
• Loss of postural control
• Abnormal coordination
• Abnormal functional performance

23. Goals…
• Decrease the influence of spasticity and
abnormal coordination
• Improve control of the involved trunk,
arm and leg
• Retain normal, functional patterns of
movement in the adult stroke patient

24. Principles of treatment:
• Treatment should avoid movements and
activities that increase muscle tone or
produce abnormal reflex patterns in the
involved side
• Treatment should be directed toward the
development of normal patterns of posture
and movement.

25. Principles of treatment
• The hemiplegic side should be
incorporated into all treatment activities
to reestablish symmetry and increased
functional use
• Treatment should produce a change in
the quality of movement and functional
performance of the involved side

26. Principles of treatment:
• Increase active use of the involved side
• Provide practice to improve motor
performance that lead to motor learning

28. Stages of hemiplegia and the
Bobath Approach
• Initial Flaccid Stage
 Tx focus on positioning and movement in
bed to avoid the typical postural patterns of
hemiplegia
• Stage of Spasticity
 tx is a continuation of the previous stage
with the goal of breaking down the total
patterns by developing control of the
intermediate joints

29. Stages of hemiplegia and the
Bobath Approach
• Stage of Relative Recovery
 tx aims at improving the quality of
gait and the use of the affected hand

30. Principles of treatment:
children with cerebral palsy
• Treat the child as a whole
• Basis for intervention is normal
movement and their interrelationships
• Treatment incorporates facilitation and
inhibition using key points of control
 abnormal tone is always inhibited
 normal responses, once elicited, are
always repeated

31. What are key points of
control (KPC)?
• Parts of the body where the therapist
can most effectively control and change
patterns of posture and movement in
other body parts
– Proximal: shoulder/scapula, pelvis/hip
– Distal: jaw, wrist, ankle,
– Head may be a proximal or distal KPC

32. KEY POINT
CKP(Central Key Point)
Ant(xiphoid process)
Post(T7,8)
PKP(Proximal Key
Point)
Head, Shoulder,
Pelvis
DKP(Distal Key Point)

33. Facilitation-Inhibition
• Facilitation
 is a mean by which movement is made
easy, made possible, and made necessary
• Inhibition
 involves decreasing the use of pathological
movements and the effects of tonal
dysfunctions on movement
• Facilitation and inhibition may be used
simultaneouly and may be applied throughout
the session

34. What is handling?
Manner of controlling the patient
through tone influencing patterns
• Normal patterns of activity used to modify
abnormal patterns of posture and movement
o Total TIPs: whole body is controlled in a
reversal of the abnormal pattern
o Partial TIPs: some body parts remain free
to move
• TIPs are utilized via KPCs

35. Positioning

36. Techniques of treatment
Initial flaccid stage: last for few day to 7 week
or may be longer.
•Problems: confused & disoriented.
•Divided into two half
•No balnace or arm support on affected side
•Fear of fall
•Abnormal attitude on affected side
•No midline orientation
Treatment: self orientation on affected side.
•Carry wt on affected side
•Bilateral functioning- interplay.

37. • Explain the fact of affected side.
• Passive movement
• Proprioceptive feedback.
• Nursing preparation-Positioning &
handling- to avoid spasticity,
contracture, shoulder pain, SHS,
retraction of affected side,
rejection
• Cooperation bet nurse & therapist:
turning pt. bed pans uses.

38. • Weight bearing exe.
• Trunk balance in sitting
• Mobilization of shoulder girdle

39. Reference
Bandong, A. (2008). Approaches to
therapeutic exercise: Concepts,
principles, and strategies. Power point
lecture presentation in PT 154.
Bobath B (1990). Adult hemiplegia:
Evaluation and treatment (3rd
ed).
Oxford, Heinemann Medical Books.
Levitt S (2004). Treatment of cerebral
palsy and motor delay (4th
ed).
Singapore, McGraw-Hill Inc.

40. THANK YOU..