Improves control of posture and selective

movements

The Bobath method was initially reserved for the treatment of children with
cerebral palsy, but was later extended to the treatment of brain injuries in
adults.

We must bear in mind that the brain is considered a plastic structure capable of
learning at all levels and, more importantly, learning to reorganize its functions.
When there is a lesion in the CNS (central nervous system),
disorders of movement, function and muscle tone appear.
Regarding the latter, we must clarify that in our muscles there is always a base
activity (basal muscle tone) that must be high enough to counteract the force of
gravity and at the same time low enough to allow movement.

Under normal conditions, movement and posture are the response to a

stimulus, which is why it is said that "we move because of what we feel." For a
perfect relationship between movement and posture, a control system is
needed that provides coordination and stability when carrying out a movement.
We are then talking about a postural control mechanism, that is, the importance
of a constant adaptation of the basal tone to the variation of a posture and, on
the other hand, of a series of normal automatic postural reactions such as
straightening reactions (produced to regain balance), balance reactions
(maintaining balance when moving) and support reactions (using our
extremities as a defense before falling).
The postural control mechanism regulates postural tone,
reciprocal innervation and coordination. As we said before, our
muscles have a base tone that allows movement. Well, not only does it allow
this, but the gradual adaptations of the tone will give rise to a precise and
selective movement; lifting a glass is not the same as lifting a table, since the
adaptation in the activity of our muscle is very different. The same occurs when
maintaining a posture, where muscle activity can vary, for example, when
pushed, requiring the patient to recover a stable position by adjusting muscle
tone. Normal reciprocal innervation, broadly speaking, can be explained as a
control of the activity of our muscles depending on whether they participate as
performers or opponents of the action (some contract and others relax, allowing
it). The important thing is to understand that while one part of our body moves,
the other remains stable. Normal movement coordination meets the need to
control the components (flexion-extension-rotations) that form movement
patterns, a control in time and space. That is, control in the development
mechanism of a movement, in which a series of muscles (forming patterns) are
responsible for producing it.
As we said before, when there is an injury to the CNS, everything
explained about normal movement is altered depending on
the degree/type of injury, as follows:
• Normal postural tone: hypotonia (flaccidity) or hypertonia (spasticity)
• Normal reciprocal innervation: abnormal
contraction• Normal coordination: static and stereotyped patterns
Spasticity is the most common alteration of muscle tone that
neurological patients present. It is characterized by presenting an increase
in the base postural tone, that is, the resistance that a muscle opposes to
movement or stretching. In this regard, we will discuss associated reactions,
understood as movements that occur unconsciously (they cannot be controlled)
due to an increase in tone (for example, when sneezing). Spasticity and
associated reactions are considered an involuntary reflex activity,
for example in a hemiplegic patient the associated reaction causes an increase
in spasticity. Let's take an example: a patient who has spasticity in the upper
limbs. When sneezing, an associated reaction will appear in said extremity (in
this case, bending the elbow and bringing the hand closer to the mouth), which
leads to an increase in the spasticity that the patient had (stretching the arm
that is bent imposes resistance to the movement). These associated reactions
appear in the form of mass and stereotyped patterns without any kind of control,
coordination or precision; that is, reflexively triggered block movements: you
want to flex your wrist and you flex shoulder-elbow-wrist (flexor pattern).
The Bobath concept is primarily aimed at “treating people
with impaired tone, movement and function due to a CNS
injury,” improving control of posture and selective movements. The treatment
aims to inhibit abnormal reflexes and re-learn normal movement through
facilitation and key control points. Regarding the latter, it is worth explaining that
key points are control points found in our body, and which can influence
postural tone. We look for its alignment with respect to the support base, that is,
the area on which we are supported. It is logical to think that depending on how
we are (standing, lying down, sitting...) these points are arranged in space in a
different way, and likewise alignment implies "posture work" in order to obtain
results in muscle tone.

For example: let's suppose that our body works like that of a puppet, where the
controls over it are established at the level of: shoulders-elbows-wrists-hips and
knees. We know that to keep the puppet stable the strings must be tight with
respect to the fixed points we mentioned. Well, when we vary its position in
space, the puppet can bend at one of its fixed points when the string is
released. We can thus understand that in our body these strings would be our
muscle chains that determine whether a segment moves or stabilizes, and also,
depending on the position of our body, the ease or complexity that our muscles
have in controlling the situation.

How can the Bobath method help?

In the Bobath concept, as with the treatment, the initial assessment is
considered of vital importance, since the treatment plan is undoubtedly
developed based on the limitations found. Carrying out a specific treatment
aimed at the individuality of each patient is essential, even more so in the field
of neurology. In the assessment we must evidence: spasticity (degree and
distribution, its effect on the joints, limitation in movement...), sensory alterations
and in postural tone, balance and straightening reactions, altered movement
patterns (associated reactions)... broadly speaking, those evidences associated
with the injury and that we expect to find. We must keep in mind that each
patient is unique and, consequently, assess whether there are associated
alterations (vision, speech, etc.) that we can help with from our field of
physiotherapy.
In neurological physiotherapy, objectives must be established
in the long term, since the results depend on the time and the
type/severity of the injury presented by the patient. Obviously,
hemiplegia cannot be compared to a contracture or injury to the muscular
system, because the complexity of the loss of function affects many
mechanisms and systems in our body. Therefore, we must be aware that the
recovery process is prolonged over time and specific to each present limitation.
Below are the most frequent limitations in the clinic of a neurological patient
and, broadly speaking, our objectives and physiotherapy treatment.
• Spasticity: initially our objective is to inhibit/reduce excessive tone through
postural changes (changing the patient's position: as we mentioned before,
basing our actions on key control points), mobilization and stretching. We must
give the patient the sensation of normal position and movement, to “remind” the
nervous system of its function and thus enhance reorganization. We always
seek to provide patients with useful movements for their daily lives.
• Associated reactions: at all times we must understand that they have a close
relationship with spasticity. We must inhibit altered movement patterns, helping
the patient to control and master normal movement, facilitating voluntary and
active movements. This is undoubtedly the most difficult part of the treatment,
as the patient tends to perform the movement that is easiest for him/her.
• Balance and straightening reactions: our objective is to control the trunk
muscles as a basis for regaining balance, working those muscle groups that are
responsible for this. The main exercise is based on placing the patient in
different positions depending on the difficulty presented (sitting, standing,
standing on a mat, etc.) and applying destabilizations (small pushes) so that the
patient recovers the initial position and thus controls his or her balance position.
• Gait: we must take into account that the impact on the patient depends on the
degree of injury that exists. Thus, the disorders that become evident during
walking depend on the specific clinical case that we are treating. The main point
is to understand the biomechanical changes after the injury (for example, if we
talk about spasticity, we are then talking about difficulty in movement and
consequently, for example, bending and extending the ankle to walk will be
compromised). We will see as a general rule that patients present a decrease in
speed, an increase in the width of their steps, dependence on their hands for
support... It is worth mentioning that gait re-education is considered the final
part of the treatment, since it is logical to think that good balance and correct
motor control must be achieved beforehand.
The Bobath method is considered the most complete, global
and widely used neurological technique since the 1940s. It is
important to point out a characteristic associated with this method, which is that
it highlights the importance of treating the individual in his or her entirety,
understanding him or her as unique in the recovery process.

Pathologies that can be treated with the bobath

method

With the Bobath method we can address all those CNS

disorders that consequently reflect an alteration of normal
movement and all the elements that make up this action
(muscles, nerve pathways, brain...). The essence of this method is based on
obtaining motor responses that are as normal as possible (if movement is not
fully recovered, facilitating movements that are useful for the patient's daily life),
using the information that we provide to our patients for subsequent
memorization at the CNS level.
As we said at the beginning of the article, the brain is capable of
learning, and more importantly, reorganizing functions (that is,
if an area of the brain was in charge of a task, in the event of an injury, other
different areas are “re-educated” to perform that function, all with repetition for
memorization. For example, driving requires prior preparation, and over time the
acquisition of skills allows us to automate movements, such as shifting into
gear, which is always deliberate at first but ultimately becomes an automated
act.) Some of the most common pathologies that benefit from
this method are the following:

• Hemiplegia
• Hemiparesis
• Head
trauma• Incomplete
spinal cord injury• Ataxia
• Facial and oral
tract disorders• Multiple
sclerosis• Cerebral palsy.

Our recommendations

The most important thing at this point is to raise awareness of the need for early
treatment in this type of patient. For example, in the case of a sprain, it is
recommended to begin physical therapy from the beginning to ensure mobility
and strength. We must understand that if we postpone treatment while the rest
period lasts, recovery will be hampered by the time of inactivity, during which
mobility and muscle strength will be limited.

Undoubtedly, the prognosis (evolution of a process) is largely

determined by the type of injury, location and extension, the capacity
of the nervous system to reorganize itself, the motivation and attitude of the
patient... but the early initiation of physiotherapy treatment also has
a lot to say. It stands to reason that the sooner we address the problem and
know the symptoms, the sooner we will be able to apply effective treatment and
prevent the situation from getting worse.
Neurological injuries also represent a specific problem for the patient's health
and a 360º change in his or her life and that of his or her family. In fact, an
essential pillar in the recovery process is the collaboration of
the family, actively involving themselves in the treatment and helping the
patient in their daily life.

It is therefore our duty as physiotherapists to provide the family with information

and skills in managing this situation, such as mobilising the patient at home,
transfers to change position, postural changes, joint mobility... basic but
incredibly useful information, which will undoubtedly help improve the patient's
quality of life, as well as facilitate and improve the conditions for family
involvement.
PHASES OF HEMIPLEGIA:

1.COMA OR FLACCID PHASE:

- Hypotonia and abolition of all reflexes.
-Muscle flaccidity-Absent or decreased ROTS
.
-Recovery of consciousness.
(The longer this phase lasts, the worse the prognosis will be.)
The patient does not move the affected side and often does not realize
that he has an arm or leg on that side (sensitivity). He has lost his
previous movement patterns and at first even the movements on the
healthy side are inadequate to compensate for the loss of activity on the
affected side (he must use his side differently and at first he does not
know how to do this). All this leads to the denial of the affected side, so
that the patient becomes completely oriented towards the healthy side,
an effect that the treatment must correct and not reinforce.
2. ACTIVE PERIOD OF ONSET OF SPASTICITY:
-ROTS Present, more exaggerated than
normal-Inversion of superficial reflexes (Babinski +)
3.SPASTIC PHASE:
-Spastic muscle (hard, tight and resistant to elongation)-Primitive
synergistic
patterns or synkinesias.
SYNERGIES: Abnormal patterns produced by the release of primitive
reflexes not inhibited by the CNS and by the inhibition of normal ones.
These synergies are stereotyped; that is, always in the same way or All
or Nothing (or with a lot of flexion or with a lot of extension).

The lower centers begin to recover their function and reflexes appear in
a disorganized way. The tone increases progressively and spasmodicity
appears. Mobility is carried out with a large number of synkinesis
(involuntary movements associated with
the main movement). We conceptualize spasticity as an abnormal
movement compared to a stretch.

The Bobath approach is important in the rehabilitation of people with

brain or spinal cord injuries.
It is based on the brain's ability to reorganize itself; which means that
healthy parts of the brain learn under certain circumstances to
compensate for functions that were previously performed by damaged
areas of the brain. The prerequisite is good support and encouragement
applied to the patient by the FSTP.
The person affected by hemiparesis tends to neglect the paretic side
and therefore its limitations in order to compensate with the less
affected side. These movements carried out with only one side of the
body help the patient in a basic way, since the affected side does not
have the capacity to receive and work with the new information. The
brain therefore does not have the opportunity to restructure itself, and
due to asymmetrical movements there is also a risk of developing
painful spasms in the affected area. The patient denies the affected side
so that he or she becomes completely oriented towards the healthy side,
an effect that the treatment must correct and not reinforce.
The value of Bobath is to support the affected side of the body as much
as necessary to adapt its movements in accordance with the less
affected or healthy side. It balances the body in terms of functionality
and mobility. It also
tries to modify the abnormal patterns that result from the injury itself
and facilitates movement, to achieve it in the most functional way.
When
an injury occurs in the CNS there are altered sensations, which
produces an alteration of movement and this causes an abnormal tone
and all this entails:
- Alteration of the perception of the environment -
Alteration of automatic
reflex mechanisms - Alteration of posture (control of key points)
The hemiplegic patient cannot move against gravity, and when he does
so it is in an abnormal way.
There is a lesion of the upper motor neuron and the normal postural
tone is replaced by:
- Spasticity (hypertonia)
- Flaccidity (hypotonia)- Abnormal reciprocal
innervation. That is to say, excessive co-contraction (where there is
spasticity, the IR disappears) the movement is with a very high tone and
a lot of effort and we have to reduce that tone.
- Or a low contraction (there is no IR either) and the goal will be to
increase tone and stability.

BOBATH TREATMENTOriginal from the Bobath couple, 1940s. Initially,

the concept was adapted to children with cerebral palsy, and later to
people after a stroke (hemiplegic). It is currently a comprehensive
approach aimed at adults and children with neurological dysfunction,
with sensorimotor disorders of cerebrospinal origin (upper motor
neuron) in an interactive process between patient and therapist, both in
evaluation and treatment.
Empirical-theoretical basis resulting from experience, that is, there is
no scientific basis.

OBJECTIVES:

Provide all the necessary requirements for normal movement to occur -

Normal postural mechanisms.
- Normal postural tone (no spasticity or hypotonia)-Normal reciprocal
innervation (no excessive co-contraction or little co-contraction.)
The Bobath couple discovered the reflex inhibitory positions. which
cause a decrease in muscle tone (there are some responses that are
primitive and not inhibited). Brain
injury causes an increase in muscle tone.
They discovered the key control points and the therapist, acting on
them, decreases muscle tone and modifies it.
* Inhibit: high tones and abnormal
movements* Facilitate: normal movement.
Give normal sensation of movement. Normal movement can only be
achieved through normal sensation.
When working with a patient with a nervous disorder, we can only get
them to respond with normal movements when we give them normal
sensations (afferent input of any kind).

The more established the pathology is, the more inhibition we will have
to do and the more difficult it will be, which is why we must act as soon
as possible.
Physiotherapy begins as early as possible to take advantage of what is
known as: NEUROPLASTICITY OF THE CNS (the ability of neurons to
organize and reorganize themselves again at each stage of their
development to connect with other neuronal cells. They make new
synapses. The repetition of activities will cause these neuronal changes
to be established or established.
Our individual capacity or individual neural network is given by a
genetic program linked to external stimulation (sensations that we
perceive throughout our life based on abilities...)
During the course of embryonic development, 10 to 12 million neurons
are formed, which little by little connect to each other by germination of
axons and dendrites and transmit information of an excitatory or
inhibitory nature.

2. EVOLUTION1st
phase: reflex inhibitory positions of the tone (tto. Static)

2nd phase: tto. From the development of the movement in a sequential

manner (tto. Passive)

3rd phase: straightening and balancing reactions. Tto. Dynamic through

key control points4th

phase: progressive withdrawal of external help (Physio). Voluntary

control (learning)

5th phase: tto. Aimed at functional activities. Adaptation to the patient's

environment.

6th phase: changes in exploration and treatment planning. Evaluation of

movement quality (tone and postural reactions). Comparison with
normal movement.

- Therapy and exercises performed according to the personality and

experience of each therapist but based on the concept (open).
- Dynamic treatment according to changes experienced during this.
"If the patient improves we have to change something, if it remains the
same we have to change something, and if it worsens we
have to change something urgently"
- Modifications of the concept

: * Treatment of the affected

side * Treatment of the affected side and the trunk
* Treatment of the trunk and both sides of the body (more and less
affected side... treat both)

3. CONCEPTS AND DEFINITIONS

Action: consecutive and simultaneous execution of functions and

patterns of movements coordinated in space and time, in the service of
a previously determined purpose.

Support base/Support area: surface available to support weights on.

Support area is the surface on which the weights are actually placed
(contact surface).

If the support base is wide, the postural tone decreases and vice versa.
Every person needs a support base since we are subject to the influence
of gravity at all times. We all need a base of support to fight against
gravity. The lower the BDS, the higher the tone.
Humans live and move constantly between both physical forces. the
force of gravity and the base of support.
The support base: is the surface that is under the body. From a physical
point of view, it is not necessary for the body to be in contact with said
surface
. The support area: It is the surface that is in contact with the body in
interaction.

Center of gravity of the body: S2 in standing and T8 in sitting.

Bobat concept: It is based on the inhibition of abnormal reactive

activities, the facilitation of motor unit recruitment and the relearning
of normal movements through the manipulation of key points.
According to IBITA: it is an approach to problem solving, for the
exploration and treatment of people with a disorder of tone, movement
and function due to a CNS injury. The goal of treatment is the
optimization of all functional actions by improving postural control and
selective movement for facilitation.
Treatment of abnormal movements caused by a CNS lesion follows the
following steps:
- analysis of the norm.
- analysis of deviation from the norm -
 adapted application of techniques that allow learning of a normal or
standardized movement, which enable more economical movements and
storage of neuronal sets to execute movements that approximate the
patient's normal movement.
- analysis of the effect caused by the applied treatment techniques.

NORMAL MOVEMENT:
Requires adaptation of postural tone. Frequent movements are
performed with a specific postural tone and memorized in this mode.
When they are needed again, the current postural tone is first analyzed
and if this postural tone is too high or low under normal conditions, it is
usually adapted. If this adaptation is not possible due to a lesion in the
CNS, access to the memorized movement becomes almost impossible.
The required movement must be performed again, that is, voluntarily. If
the CNS is injured, movement is performed by adapting total patterns,
instead of using fine and selective movements, and this is uneconomical
and requires greater effort, which increases postural tone, which again
makes access to memorized movements difficult. (the brain finds it
difficult to remember automated movements and does not recognize
this postural tone)

A normal
movement:* Is directed towards a goal
* Is economical
* Adapted to the circumstances of the moment
* Automatic, voluntary or automated. *
Coordinated in space (the different parts of the body are coordinated to
carry out the movement) and in time (how the sequences are linked to
produce the movement)*
Is influenced by gravity.

AUTOMATIC MOVEMENTS: These are the balance reactions that serve

to maintain a posture or regain balance. They are patterns that are
genetically obtained and never had to be learned voluntarily. They are
reflex movements: For example when we get dressed and maintain the
posture to put on our socks. VOLUNTARY

MOVEMENTS: When we are learning to do something new for us the

movement is voluntary and requires a higher postural tone (for example
when we learn to drive or put on a new garment) by dint of repetition,
as we repeat patterns and remove the superfluous it becomes
automated.
AUTOMATED MOVEMENTS: Getting dressed, familiar handling of
clothes. They are voluntary movements that have been polished through
repetition. They are cheaper and are integrated into our CNS
POSTURAL CONTROL

MECHANISM:
It is the automatic and unconscious adaptation of our strength (postural
tone) to the variability of the force of gravity. This
mechanism regulates:
- Normal
postural tone - Normal reciprocal innervation (coordination that exists
between the innervation of agonists and antagonists)
- Normal coordination of movement.
They are innate automatic movement patterns (we obtain them at birth)
have 3 fundamental parts to function well:
- Normal postural tone (excitatory-I
. normal
reciprocal- Normal postural reflexes (righting reflex, r. of balance, and
a reflex of support or defense.)

Balance: relationship of partial weights of the body with respect to the

midline and the base of support. Equal distribution of weight on both
sides of the midline.

Spasticity: WHO: velocity-dependent resistance against a passive

movement.
Throw: plastic reorganization of the CNS in a situation of inhibitory
control deficits.
Wiesendanger: locomotor disorder that develops gradually as a
response to a partial or complete loss of supraspinal control over the
spinal cord. It is characterized by the modification of the activation
patterns of the motor units that react to sensory and central signals,
and cause concomitant contractions, total patterns and abnormal
patterns.
Facilitation: learning process. Giving a stimulus by the therapist to
facilitate a process or activity.
Central pattern generator GCP: Located in the medulla and in the brain
stem in congenital neuronal reticular networks, which allow repeated
motor activities to achieve a functional objective. They are automatic
movements from birth and are not conscious.

Holding: test to check postural tone. Maintaining a certain posture (the

physiotherapist places it on the patient and thus notes the adaptability
to the changing relationships of gravity. It is tested whether a limb can
be held in a position (if we release it we see if it supports weight by
itself) If so, it can be assumed that the postural control mechanism is
working.
the patient is told voluntarily to hold the arm in a certain
positionReciprocal

innervation: alternating control of agonists and antagonists,

supplemented by control of the respective synergists, to synchronize
movement in time and space. It is the mutual innervation of different
parts of the body or muscles. Consecutive control of agonists and
antagonists, completed by control of the respective synergists for
spatial and temporal coordination of movement.
It is the integrated and coordinated interaction of opposing muscular
forces. That is, agonist, antagonist and synergist muscles (the
synergists graduate their tone according to the contraction of the
agonist). This provides an adequate combination of postural stability
and selective movement. The reciprocal i. provides:
1. Gradual movement
capacity2. Adequate combination of postural stability at the proximal
level and selective movements at the distal level.
The function is to allow postural control, essential for fine movements
(skill and precision) and allows balance. It
can occur:
- Between both hemi-bodies-
Between the cranial and caudal parts of the body.
- Between proximal and distal parts of the body-I
. reciprocal intermuscular-I
. reciprocal intramuscular. Postural control

mechanism: introduced by Karel Bobat as a synonym for CNS, includes:

peripheral nerves, muscular system and receptors. The factors of the
postural control mechanism are:
1. normal
sensitivity2. normal
postural tone3. normal
reciprocal innervation4.
normal spatial and temporal coordination Automated movements:
movements that are voluntary at the beginning and which, through
repetition, have caused the formation of neuronal groups, allowing the
execution of these movements quickly and without cortical attention,
with greater economy and acceleration of movements. Cortical
initiation.
Automatic movements: mov. economical and rapid, executed by the
activation of congenital neuronal groups, which once activated can
constantly regenerate themselves. Selective
movements: activation of the corresponding agonists, antagonists and
synergists, which cause movement in one or two joints, with
simultaneous stabilization of the surrounding joints.
Neuronal set: (set) group of neurons located in the medulla, brain stem
and cerebellum that, when excited, produce the execution of selective
movements or a pattern of movements. Vital movement patterns
(breathing, swallowing, balance reactions, propulsion) are congenital.
Voluntary movements that are repeated over and over can form new
neural ensembles (movement automation).
PCC: functional point located in the center of the body, between the
xiphoid process and D7-D8. Center of gravity of the body in a sitting
position. Movement indicator. KEY

POINTS: Body control

areas where we are going to act so that normal movement occurs.
They have a large number of sensory receptors, if we work on these
points we can transmit a large amount of information to the CNS. By
having a large number of receptors, a large amount of information can
be transmitted to the CNS. This results in a more effective and faster
motor response, and postural tone can be better modified. The pelvic
key point is also the centre of gravity of the entire body (S2) and the
central key point forms the centre of gravity of the upper body (head,
shoulder girdle, arms, rib cage, abdomen). A shift of these body parts,
i.e. the centres of gravity, is registered in particular by the vestibular
system and responds by changing the postural tone (righting reactions).

These key control points have a large number of sensory receptors and
by working with them we can transmit a large amount of information to
the

SNC. We influence: Postural

tone and selective movements and automatic postural reactions.

TYPES:
* PCCentral: It is the center of gravity of the upper part of the body,
located inside the rib cage, between the sternum and D7 and D8. It is
the indicator of movement.
Primary PC: Head and neck.
Proximal PC: shoulder girdle and pelvic girdle.
PCpelvic: in the center of the pelvis. CDG of the whole body. Higher
tone.
PCdistal or secondary: Hands and feet.
The displacement is registered in the vestibular system. By
manipulating these key points we can provoke an action, a movement
without words.

POSTURAL SET-
Symmetrical or asymmetrical alignment of PC, in relation to themselves
or to the support base- Starting
positions to move on to other positions-
In healthy people they are automatic.

NORMAL MOVEMENT COORDINATION:

It is the normal spatial and temporal coordination of selective
movement components to form movement patterns. A goal-directed
function is performed using different movement patterns, made up of
several components: The components of a movement are performed
with a certain neuromuscular activity. A movement pattern may be
dominated by:

1. An increase in extension 2
. A decrease in extension 3
. An increase in flexion 4
. A decrease in flexion.
Movement patterns are made up of different components (automatic
postural reactions) which are: flexion, extension and the combination of
both which gives rotation.
The components of a movement are carried out with a certain muscular
activity. The possible neuromuscular activities are:

1- Concentric agonist activity (biceps in elbow flexion)/eccentric

antagonist activity (triceps)
2- Concentric synergist activity/eccentric synergist activity 3-
Eccentric agonist activity/concentric antagonist activity (isometrics)
4- Eccentric synergist activity/concentric synergist activity.

Movement patterns must be correctly coordinated in time so that the

function is economical, adaptable to variations, and can be performed
with a specific objective. We do not use movement patterns without an
objective. Normal movement
coordination does not only mean spatial coordination but coordination
over the normal temporal development of the different components of
the movement: TIMING (adequate temporal sequence)

Pattern: sequence of selective movements in a given alignment.

Normal: selective movements can be combined and varied at
willAbnormal
: always made up of the same components, without any modification.
They may vary from one PC to another.
The patterns are marked by key muscles:
- in the foot-
in the leg-
in the trunk-
in the arm-
in the hand and fingersUpper

extremity Lower extremityFlexor

pattern:
- Supination -
Elbow
flexion- Shoulder
abdominis- Ext. rot. shoulder-
Retraction and/or elevation of the shoulder girdle.
Extensor pattern:
- pronation-
elbow ext- shoulder
add- shoulder
int rot- shoulder
girdle in neutral positionFlexor pattern:
- dorsal fl of fingers-
dorsal fl and ankle
inversion- knee
fl- hip fl- hip
abd- hip
ext
rotExtensor pattern:
- plantar fl of fingers-
plantar fl and ankle
inversion- knee
ext- hip ext- hip
add- hip
int

rotPlacing: test to check postural tone. A part of the body is moved by

observing its ease or resistance, and then it must be automatically
maintained in a certain position. No indication is made, either verbal or
non-verbal, as is done in the holding company. (the physical therapist
moves the arm or leg from a distal key point. While moving, note
whether the pitch is low enough to allow movement or high enough to
resist it. The physiotherapist stops the movement and tests whether the
patient can hold the limb against the force of gravity.

Postural set (alignment of key points): interaction of the key points with
each other and the support area, influencing the quality of the postural
tone and, therefore, the predominance of the tone of the flexors or the
extensors. It is the position of the key points with respect to each other
and the support base in a continuous interaction. This alignment
determines the quality of the postural tone.

Key control points: areas of the body with a different density of

receptors, from which postural tone can be controlled and influenced in
a special way. They are control points of the body (key points) that have
a special influence on postural tone: (PCC, the pelvis, both shoulder
girdles, the hands, the feet, the head) Associated

reactions: (synergies)

Lance: response of the central nervous system to a stimulus that

exceeds individual inhibitory control. Reciprocal innervation is not
sufficient to control it. Associated reactions arise from spasticity. They
are always total patterns. They are important because they are an
obstacle to the patient's treatment, so they must be inhibited before
facilitating other things. Their consequences are accompanying
movements, called associated movements. They are stereotyped. In the
associated r. the tone remains high at the end of the movement. It is
difficult to inhibit the associated reactions, it takes more time and is
often done incompletely.

Lynch: muscular activities that appear after a modification of the

neuronal connections within the spinal cord. The patient learns patterns
of hypertonia, which in turn can cause other permanent changes in the
muscles, such as spasticity.
Support reactions: automatic movements of the upper limbs. and info.
which lead to relying on these. Support reaction components can be
performed voluntarily. They require less energy than straightening
procedures, which is why it is normal for them to be performed earlier.
They allow the support base to be increased, which requires less energy
expenditure. Body displacement is greater than in equilibrium
reactions. They occur automatically. Support reactions broaden the
support base and their objective is to avoid falling and are achieved
with less energy expenditure than righting reactions.
They are the last line of defense before falling. Straightening

reactions: automatic movements of the head, trunk and limbs performed

to compensate with counterweights for movements of large weights that
lead to large imbalances. They can be done voluntarily. They are
automatic. They are done only to regain balance. They are not carried
out constantly. They are dynamic reactions in which there is a
displacement of weight. These are weight shifts that occur in the
opposite direction to the PCC's displacement.
When the PCC's weight shifts away from the support base, it will cause
weight shifts in the opposite direction to compensate.

Balance reactions: Minimal automatic adaptations of muscular tension

in order to compensate, by means of the opposite force, the minimal
weight shifts that induce small imbalances. They are functional and
serve to align the posture. They can be done voluntarily. They are
performed constantly to maintain balance. They are small or minimal
changes in tone in the body's muscles, which occur to maintain balance
despite the continuous shifts in the center of gravity. Changes in the
center of gravity require continuous adaptations of the posture during
any movement, even the smallest change must be counteracted by
changes in tone throughout the body's musculature. They form our first
line of defense against injury Tone

: is formed by grouping of motor units. Each muscle has a constant

tonal base of availability or readiness, depending on its sensorimotor
purpose.
According to Bobat, the normal tone of a posture must be high enough
to counteract gravity, and at the same time low enough to allow
movement.
A low tone is necessary for the performance of selective movements but
if it is too low it causes hypotonia
. A high tone is necessary for stability (sum of many selective
movements) but if it is too high it causes hypertonia, spasticity (lesion of
the pyramidal tract) or rigidity (lesion of the extrapyramidal tract)

Treatment of the affected side Treatment. of the trunk and the affected
side Tto. of the trunk and both sides of the body (affected + and – side)
Inhibitory reflex
positions Inhibitory reflex movement patterns Patterns for normalizing
postural tone, sometimes combined with postural patterns for
lengthening hypertonic muscles.
Neurophysiology: there are symmetrical and asymmetrical tonic
reflexes in the neck. Questions: the symptoms we see are not triggered
reflexes, but what are we seeing? The symptoms we see and feel are
hypertonic muscle chains. Mechanical positioning applied consistently
to act against spastic patterns in supine, lateral and sitting positions.
Increased positioning towards normal postural patterns. Positioning of
key points (playing with their alignment to positively influence the
individual tonal situation).
Start of treatment always distal: hand/foot, elbow/knee, shoulder/hip.
Start of treatment always proximal: discovery of the trunk. Start of
treatment according to the main problem, which can be distal or
proximal
. The therapist will stand on the most affected side of the PC. The
therapist may also treat from the less affected side. The therapist will
treat the PC from the side that suits him/her best for greater influence
on the problem. It may be on the more or less affected
sideNeurophysiology: the brain does not recognize muscles, only
movement patterns. New research indicates that the brain does know
about muscles. Doubts about treatment: the influence on some muscles
also has a positive effect. Information from the CNS for the appearance
of associated reactions modifies the anatomical structure of the
muscles, losing sarcomeres. the tto. You should consider it!
Tto: facilitation of key points always in movement patterns. Facilitating
key points in movement patterns. also with the test of facilitating
selective movements. Facilitation of key points also through some
muscles with the technique of specific inhibitory/facilitative movement
of the muscles.
The influence of the base of support on postural tone had barely been
analyzed. Analysis of the influence of the size of the support base. The
importance of the influence of the size, consistency and stability of the
support base was progressively recognized and taken into account in
the treatments.
Frequent treatment with folded hands: lying supine, when standing and
sitting, when walking. The hands are folded less and less, progressively
keeping them in a normal position, for example when getting up,
leaving them hanging at the sides. Hands are only folded in specific
situations, for example in exercises that the PC must do alone at home.

4. BASICS-
 Treatment based on understanding NORMAL MOVEMENT, using all
perceptual channels to facilitate movements, and selective postures that
increase the quality of function.
- Modifies the dominant movement patterns, ensuring normal
distribution of tone and normal graduation of reciprocal innervation.
- It is a technique that inhibits tone and abnormal movement patterns,
facilitating normal movement and stimulating in cases of hypotonia or
muscle inactivity.
- Principles: inhibition, facilitation, stimulation.

- Bobath Objectives:

Provide a range of experiences through various patterns of coordinated

movements.
Improve physical condition by rebuilding motor activity and normal
postural control. Straightening reactions, balance and support reactions
are basically facilitated, always with a functional objective.
- The Bobath method is based on neuroplasticity. Ability to shape the
brain through learning. We cannot recover dead neurons, but we can
reconstruct new connection pathways, and plasticity will depend on the
quantity and quality of stimuli it receives.

Basis of treatment: knowledge of normal individual movement (postural

control and balance)
- Factors that influence normal movement: age, gender, height,
proportions, physical constitution, genetic disposition, climate and
mood.
- Posture and movement: “posture is a stopped movement, movement is
a posture plus the time factor. Posture is movement in its smallest
amplitude. “POSTURE: Amplitude of movement so small that it is not
visible. It is the expression for minimal movement. A normal posture is
never rigid and immobile. MOVEMENT: Range of movement that
becomes visible when increased. It is the expression for

maximum movement. Normal posture and movement are based on:

- response of the central postural control mechanism to a thought or

intrinsic or extrinsic sensory stimulus.

- response to obtain a purpose (directed towards an objective)

- Economic response (to achieve the desired objective with the least
possible effort), adapted (to the circumstances of the moment, e.g.
getting up from a high chair is not the same as getting down from one)
automatic, voluntary or automated (these are the balance reactions that
serve to maintain a posture or regain balance. They are patterns that
are genetically obtained and never had to be learned voluntarily. They
are reflex reflex movements. e.g. when dressing and maintaining
posture)

- Constant adaptation of postural tone (force of gravity). Postural tone

must be varied due to the force of gravity and varies constantly, just as
the base of support varies from one person to another.

- In CNS injuries, lack of inhibitory control.

- Postural control mechanism: It is the automatic and unconscious

adaptation of our strength (postural tone) to the variability of the force
of gravity. Our nervous system constantly adapts the force we exert to
our postural tone. and is regulated by:

1. Normal sensitivity: superficial (tactile); deep (proprioception).

2. Normal
postural tone3. normal
reciprocal innervation4. temporal and spatial coordination of
movement (balance)

1)
Normal sensitivityIt is essential to have correct conscious somatic
sensitivity, both at a tactile level and at a deep level.
Normal sensory perception requires the integrity of the afferent system:
a) receptors (specialized nerve endings)
b) afferent dendrites of neurons in the posterior
root gangliac) ascending tracts in the spinal cordd
) thalamus (processing and interpretation of stimuli)
e) parietal cortex (consciousness)Sensory

receptors (neural structures located at the peripheral end of sensory

nerves):- specificity (they only transmit one stimulus)
- Sensory thresholdAll
receptors (Meissner, Pacini, Merkel, Ruffini) are sensitive to any
stimulus but with a different threshold. Some react more to a stimulus
than others.

"Although the activity of a single receptor is sufficient for the

appearance of sensations, one cannot ignore the fact that normally
several receptors are activated simultaneously, and that the perceived
sensation is actually the sum of many partial qualities" (Klinke)
Sensitivity

disorders = lack of awareness of sensitive sensations. Intimate

relationship between sensitivity and movement.
Bobath “you don't learn a move, but the feeling of a move.”

Types of sensory receptors:

a) extrinsic or exteroceptors1
. ruffini corpuscles (lateral displacements of the skin. Heat)
2. Merkel cells (vertical pressure on the skin). Slow adaptation3
. Meissner corpuscles (pressure and friction velocity) Fast adaptation4
. Pacinian corpuscle (pressure and vibration variations). Fast
adaptation.
5. free nerve endings (temperature and pain)
6. krause corpuscles (cold)
b) intrinsic or proprioceptors1
. Golgi tendon organs (tension on tendon)
2. nucleic acid bag fibers and nucleic acid chain fibers of muscle
spindles (muscle elongation and speed)
3. joint mechanoreceptors (pressure and/or compression at or around
the joint level.
Vestibular receptors (position of the head relative to the body.
Linear/angular accelerations).

2) Normal

postural tone- Constant adaptation according to demand “high enough

to act against gravity and low enough to allow movement” To determine
the normal postural control mechanism, Berta Bobath developed the
PLACING and HOLDING technique. Placing / holding

-
Interpenetration of excitatory and inhibitory forces: The construction of
postural tone requires an excitatory activity from the CNS that has to
remain under inhibitory control in order to avoid an excessive response.

- decreased tone:
a) temporary summation of inhibitory
 impulses b) spatial
summation c) repeated release of inhibitory
neurotransmitters d) release of neuromodulators of the
sensory threshold - increased tone:
a) temporal summation. (Eg: maintaining an inhibitory posture for a
while)
b) spatial summation. (repeat stimuli, gentle passive movements)
c) repeated release of excitatory
neurotransmittersd) release of neuromodulators of the sensory
thresholdFACTORS

THAT INFLUENCE POSTURAL TONE:

1. support base and support

area2. alignment of key points (postural set)

3. position in relation to the force of gravity (determines which group of

muscles act as agonists, working with a higher tone, acting
concentrically against the force of gravity, or also controlling its
influence, slowing it down through eccentric contractions.)
4. speed. (the speed with which a movement is performed determines
the quality of that movement in terms of its economy)
5. idea that one has of a movement.

6. Psychic factors (the feeling of well-being or discomfort influences

both the quantity, to increase or decrease the tone, and the quality, to
determine the predominant tone in extensors and flexors)

7. pain (Even if it is only the fear of possible pain, it increases the tone
especially in muscularly active flexors)

MECHANISMS OR STAGES IN THE COURSE OF THE DISEASE:

FLACCIDITY: It occurs in the brain in the inhibitory nuclei

(corticospinal tract, reticular formation, red nucleus), from here it
passes to the medulla, where gamma fibers emerge through the
anterior horns, then it reaches the muscle spindle and therefore the
motor impulse is not sent. The muscle is flaccid.

SPASTICITY: affects the facilitating nuclei (cerebellar hemispheres,

vestibular nuclei, red nucleus), therefore there is excessive and
inappropriate muscle activation, causing voluntary action disorders,
being unable to maintain posture, balance and walking, with a
predominance of flexors in the upper limbs and extensors in the lower
limbs.

RECOVERY: is responsible for integrating the affected body parts,

through relearning by the patient (neuroplasticity).

- Grading of hypertonia (spasticity): mild, moderate and severe.

Therapeutic approach according to graduation:

a) non-pharmacological treatment (physiotherapy). Especially in mild
spasticityb) pharmacological treatment (oral or intrathecal):
benzodiazepines, bacoflen…
c) botulinum toxin: especially for severe spasticity.

Therapeutic approach according to location: Therapeutic algorithm for

spasticity. Joint physician/physiotherapist evaluation.
a) Focal spasticity / generalized spasticityLOCAL

SPASTICITY: Physiotherapy + botulinum toxin. assess pharmacological

treatment.
GENERALIZED SPASCIITICITY: Physiotherapy + oral pharmacological
treatment. Assess botulinum toxin.
If there is no response: Intrathecal

baclofen - Grading of hypotonia: mild, moderate and severe.

In early stages, flaccidity, and in cerebellar syndrome (hypotonia,
ataxia, postural and intention tremor, etc.) Grading

scheme:
SEVERE HYPOTONIA HYPERTONIA

Severely decreased postural tone. It cannot be increased with either

global or
specific stimuliSpasticity. Associated reactions exist at rest, increase
with stress, and never disappear completely. The muscles have
undergone a change in structure and there is a risk of contractures.
MODERATE Very low postural tone, which can be increased with very
specific stimuli. There is a danger that the person responds with total
patterns. Selective movements are not possible. Associated reactions
appear with the intention to move, increase during movement,
disappear slowly and for quite some time after the end of the stress,
sometimes help is required to make them disappear.
LIGHT
Low postural tone, can be increased with global and specific stimuli.
There is still a danger that the person responds with total patterns, but
with specific stimuli selective movements can be elicited. Associated
reactions appear only with stress, disappearing quickly after the end of
the stress.

3)
Normal reciprocal innervationConsecutive control of agonists and
antagonists, completed for the control of the respective synergists for
the spatial and temporal coordination of movement.
Excitation/inhibition
modulation at the CNS level. Harmonious game of selective muscular
activities.
Different forms:
- one part of the body remains stable while the other moves.
- Both parts of the body move in opposite directions (gait).
There are various aspects of reciprocal innervation: Reciprocal
innervation must be established in all parts of the body:
- Between both half-bodies (winking one eye while the other remains
open)
- Between cranial and caudal parts (when carrying the tray the head
and shoulder girdle remain stable while the legs move)
- Between distal and proximal parts (while the trunk remains stabilized
the arms move)
- Intermuscular reciprocal innervation (takes place between agonists,
antagonists and their respective synergists of the agonists and
antagonists)
- Intramuscular reciprocal innervation (proximal and distal parts of
biarticular muscles. For example, the rectus femoris muscle is a hip
flexor and knee extensor.) Recruitment

principle according to Hennemann or principle of magnitude: Initial

recruitment of small neurons and motor units that innervate tonic

muscle fibers, subsequent activation of neurons and larger motor units
that innervate phasic muscle fibers. This produces a stable posture
before initiating a movement.
The alteration of this principle can be considered as the cause of
spasticity, because the lack of stability before starting the movement
leads to the absence of selective movements, and therefore of total
patterns.

4) Normal coordination of movement.

It is the normal spatial and temporal coordination of selective

movement components to form movement patterns. A goal-directed
function is performed using different movement patterns, made up of
several components: The components of a movement are performed
with a certain neuromuscular activity. A movement pattern may be
dominated by:

1. An increase in extension 2
. A decrease in extension 3
. An increase in flexion 4
. A decrease in flexion.

Movement patterns are made up of different components (automatic

postural reactions) which are: flexion, extension and the combination of
both which gives rotation.
The components of a movement are carried out with a certain muscular
activity.
The possible neuromuscular activities are:

1- Concentric agonist activity (biceps in elbow flexion)/eccentric

antagonist activity (triceps)
2- Concentric synergist activity/eccentric synergist activity 3-
Eccentric agonist activity/concentric antagonist activity (isometrics)
4- Eccentric synergist activity/concentric synergist activity.

Movement patterns must be correctly coordinated in time so that the

function is economical, adaptable to variations, and can be performed
with a specific objective. We do not use movement patterns without a
purpose. Normal movement
coordination does not only mean spatial coordination but coordination
over the normal temporal development of the different components of
the movement: TIMING (adequate temporal sequence)
The postural control mechanism based on a postural tone and a normal
reciprocal innervation provides spatial and above all temporal
coordination (TIMING)
Each of the neuromuscular activities of each of its components
(selective movements) is grouped into movement patterns.
Normal spatial and temporal coordination of selective movement
components to form movement patterns.
Postural control mechanism, BALANCE -

Biomechanically as the center of gravity of the weights that fall within

our support base. Uniform distribution of weights around the
longitudinal axis automatically.
- Evolution from quadruped to erect position for manipulative purposes
at the upper extremity level-
The erect position:
a) reduction of the base of support and standing (bipedalism)
b) reduction of the distance of the centre of gravity from the base of
support
c) greater risk of the centre of gravity losing contact with the base of
support and the person suffering a fall.
d) Maintenance and/or recovery of balance for automatic balance
reactions (economy). When upright, the human being

is left with only his feet as a point of support, and his arms are free to
carry out manipulations. It is more difficult to maintain balance when
you have a smaller base of support. Another problem is the distance
separating these centers of gravity from the base of support.

In both maintaining and restoring balance, the CNS reacts in strict

terms of economy. Small or minimal weight shifts have small and
minimal opposite reactions as a response, THE BALANCE REACTIONS.
When standing, the support base decreases.

BALANCE

REACTIONS These are the small or minimal changes in tone that occur
continuously in human beings. The causes of these constant weight
changes are:

Faced with the constant movement of feet that we suffer when static.

- heart rate-
breathing-
blood and lymphatic
circulation- swallowing-

eye movementsInfluence of gravity (ventrally).Ventral weights are

greater than dorsal weights. We usually fall more forward than
backward.
Increase in basal tone not visible in antigravity muscles.
It cannot be improved voluntarily. (THEY ARE AUTOMATIC
REACTIONS)

ALL OF THE ABOVE ARE BALANCE REACTIONS AND ARE

CONSTANTLY CARRIED OUT TO MAINTAIN BALANCE. AND ALL OF
THIS INVOLVES SMALL CHANGES IN THE CENTER OF GRAVITY TO
WHICH OUR BODY REACTS WITH SMALL CHANGES IN TONE OF
WHICH WE ARE ALMOST NOT AWARE. BALANCE REACTIONS ARE
SUFFICIENT TO COMPENSATE FOR SMALL MOVEMENTS
(swallowing, heartbeat, eye movement, arm movement when writing).
Minimal shifts in the center of gravity require constant adjustments in
tone.
STATIC MUSCLES
DYNAMIC MUSCLESThey constitute the majority of skeletal muscles
Much less numerousThey
ensure statics Together, the static muscles ensure movement.
They have a slow and sustained contraction
Rapid contraction Rich in connective tissue Little connective
tissue They have short muscle fibers They have long muscle fibers They
perform unconscious involuntary movements
They perform conscious voluntary movements Red color (rich in
myoglobin) Pale color
Sensory
apparatus (spindle) has a greater number of fibers in the bag (they
record constant states of distension). Flower-shaped annulospiral
sensory fibers. Sensory apparatus with a greater number of chain fibers
(they record punctual distensions). Annulospiral sensory fibers.
Tendency to: shortening, hypotonia, rigidity Tendency to: Lengthening,
hypotonia,

flaccidity Straightening reactions.

When large weight shifts occur on a support base, such as the
movement of the PCC (xiphoid process), which is also the center of
gravity of the trunk, the increase in tone is not sufficient to counteract
them, so weights must be moved in the opposite direction. This occurs
with straightening reactions as follows:

1. From the head to the trunk: (the head seeks horizontal gaze)
2. From the trunk to the base of support:
- Own to the body: The pelvis -
Foreign to the body: a seat, the floor
3. Straightening of the extremities: In the case that the feet are not
supported on the floor and there is no base of support for the hands, it
can be observed that the legs almost always move first in the opposite
direction. Then, with progressive movements of the PCC, the
counterweight arms would also move in the opposite direction, to adapt
the

PCCNOTE: straightening reactions only appear when there is no other

more economical possibility to maintain balance. Because they generate
a lot of energy expenditure.

s Righting reactions occur to regain balance.

The initiator of weight shifts from the central key point is often:
- The head, which directs the eyes to a better position for visual control
of the environment.
- The hand that wants to touch or grab something in the environment.
When the object is out of reach of an arm, it is necessary to shift the
PCC to increase the range of action of the arms.
This is valid for both lateral weight shifts, as well as forward, backward
and at all angles around the centre of the body.

In the case of large movements of the feet and of the centre of gravity of
the trunk (PCC), where the increase in tone is not sufficient, weights
must be shifted in the opposite direction to regain balance. Not very
economical. Straightening
reactions = postural
adaptationsPredictive (anticipatory postural tone)
Preactive (facilitate during movement)
Reactive (recovery of balance)Straightening

reactions can be:

a) from the head to the trunkb
) from the trunk to the base of support (body-specific – pelvis; aligns the
body – hip)
c) straightening of the extremities.
PCC displacement:
a) within the midline (anterior/posterior)
b) outside the midline (oblique) SUPPORT

REACTIONS.

Support reactions: automatic movements of the upper limbs. and info.

which lead to relying on these. Support reaction components can be
performed voluntarily. They require less energy than straightening
procedures, which is why it is normal for them to be performed earlier.
They allow the support base to be increased, which requires less energy
expenditure. Body displacement is greater than in equilibrium
reactions. They occur automatically. Support reactions broaden the
support base and their objective is to avoid falling and are achieved
with less energy expenditure than righting reactions.
They are the last line of defense before

falling. They can appear in response to large displacements of the feet,

outside of our base of support, both at the level of the upper and lower
limbs, with the aim of once again providing the centers of gravity with a
base of support.
Bobath classifies them as: “LAST LINE OF DEFENSE” before the fall.
Lower energy cost than straightening reactions.

ABSTRACTNormal
movements are based on a physiological mechanism of control of
postural tone and physiological balance reactions.
The postural control mechanism provides normal sensitivity, normal
postural tone, normal reciprocal innervation and normal temporal and
spatial coordination of movements.

5. EXPLORATION-

Continues as a fundamental part of the chosen treatment. Dynamic

process.
- Exploration even as a treatment.
- Quantitative information, but above all qualitative (description of the
movement)
B. Bobath “exploration and treatment cannot be separated”
- validated
evaluation:. Assessment of deficits.
. Disability assessment.
- IBITA-Standard
evaluation:. Exploration at participation
level. Exploration at a structural level.

A)
VALIDATED EVALUATIONEvaluation of deficits1
) consciousness deficit:
- eye
opening- motor response.
- Verbal response.
2) muscle
tone deficit - hypotonia (cerebellar lesion)
- hypertonia:
a) Spasticity: increased tone, especially at the beginning. Muscle
resistance in the form of a “razor”. Predominance in antigravity
muscles. Due to injury to the pyramidal pathway. (Ashworth scale);
0. there are no changes in the muscle response in the mov. flexion or
extension1
. slight increase in muscle response to movement (fl-ext) visible with
palpation or relaxation, or only minimal resistance at the end of the arc
of movement.
1+ slight increase in muscle resistance to movement. in flexion or
extension followed by minimal resistance throughout the rest of the arc
of movement. (less than half).
2. noticeable increase in muscle endurance throughout most of the
range of motion. articular, but the joint moves easily.
3. marked increase in muscle endurance; the mov. passive is difficult in
flexion or extension.
4. The affected parts are rigid in flexion or extension when moved
passively.
b) Rigidity: sustained contracture of flexors and extensors. It affects all
muscles equally. “Cogwheel” resistance in Parkinson’s disease. Due to
injury to the extrapyramidal
pathway c) Paratonia: constant increase in tone, with opposition in any
direction. Related to injury to the frontal lobe. Common in advanced
stages of dementia.
3) motor deficits: Voluntary
motor skills (global and analytical assessment) Involuntary
movements (syncinecia)
Alteration of reflexes:
- deep or tendon reflexes: Spinal
reflexes
Bicipital

C5-C6 Styloradial C6
Tricipital C7 Patellar
L3-L4 Adductor L2-L3-L4

Achilles S1 REM grading scale: Intensity of motor response:

No
response Slightly decreased response.
NormalMore intense
response than
normalExalted. Clonus 01

/+
2/++
3/+++
4/++++

- Superficial or cutaneous reflexes:

AbdominalUpper

T8-T10Lower
T10-T12Cremasteric:
L1-L2Plantar-

Pathological reflexes:
BabinskiGraspingpalmomental4
) Sensory and sensory

deficits- Sensory sensitivity-

Deep
sensitivity- Superficial sensitivity (Seidel dermatome map)
C-5 ClaviclesC5-C6-C7
Lateral parts of upper limbsC8-D1
Medial side of upper limbsC6

ThumbC6-C7-C8 HandC8
Ring finger and little fingerD4
Nipple levelD10 Umbilicus
levelD12 Inguinal

regionL1-L2-L3-L4 Anterior and internal surface of lower limbsL4-L5-S1

FootL4
Medial surface of
halluxS1-S2-L5 Posterior and external surface of lower limbs lowerS1
Lateral margin of foot and
little toeS2-S3-S4 Perineum 5

) cognitive deficits (mini mental test)Disability

assessment.
. Qualitative evaluation (functional
asymmetry). Quantitative assessment (Barthel, FIM, Lawton and Brody,
Katz…)

B) IBITA-STANDARD ASSESSMENT (ibita is an institution of

physiotherapists who work with bobath)
1)
Anamnesis Name
Date of birth
Date of event
Diagnosis Additional diagnoses

Medication Profession

Hobbies Social environment 2

) Level of participation (quality of movement)
What can the person do independently?
What can a person do with help?
What can't the person do?
3) level of function. Structure. What function and structure is changed,
in what way, how does
it change and disrupt the activity?
4) postural toneSevere
Reduced--- Increased +++ Compensation
oooModerate Reduced-- Increased ++ Compensation
ooleve Reduced- Increased + Compensation
o- Mirroring-
TimmingTO
EVALUATE POSTURAL TONE WE USE PLACING AND HOLDING-

Placing: move the limb from a distal key point with proximal support,
assessing resistance and the ability to maintain the limb against gravity,
following a normal movement pattern or if a total pattern appears -
associated reaction.
- Holding: if the patient is unable to perform placing automatically, he
or she is asked to do so voluntarily.
NOTE: The CNS sends information to the neuron to contract or relax. It
inhibits or excites each neuron. If we want to contract a muscle in grade
3, the CNS facilitates grade 2 and inhibits grade 4. To maintain postural
tone, the CNS needs to be active, excited with inhibitory control.
Inhibition and excitation must be in balance for movement to be normal.

More common is the appearance of

associated reactionsASSOCIATED REACTIONS:

They are responses of the central nervous system to a stimulus that

exceeds individual inhibitory control. It's pathological. This inhibitory
control can be overcome in people without CNS disorders, with
accompanying movements or associated movements, triggered by stress
in the face of a very difficult selective movement or when making a
great effort). It can
also be overcome when performing a difficult selective movement
(threading a needle) or when making a significant effort. (e.g. pushing
aside a cupboard)

To distinguish whether these accompanying movements are normal

associated movements or abnormal associated reactions, we can base
ourselves on the following criteria:

- If the person is aware or not that he or she is performing an

accompanying movement and can put it under inhibitory control
without problems, or can suppress it, these will be associated
movements. Inhibition of associated reactions is much more difficult,
takes longer and is often carried out incompletely.

- When a movement appears with a selective movement, these are

associated movements that can be selective. Associated reactions, on
the other hand, appear in patterns.

- When the postural tone returns to normal immediately after finishing a

movement, an associated movement has taken place, if it remains
slightly high at the end of the movement, it will mean an associated
reaction.
The higher the tone, the greater the inhibitory control required to be
able to carry out selective movements, even with a higher tonal level.
ASSOCIATED

REACTIONS. (synergies)

Lance: response of the central nervous system to a stimulus that

exceeds individual inhibitory control. Reciprocal innervation is not
sufficient to control it. Associated reactions arise from spasticity. They
are always total patterns. They are important because they are an
obstacle to the patient's treatment, so they must be inhibited before
facilitating other things. Their consequences are accompanying
movements, called associated movements. They are stereotyped. In the
associated r. the tone remains high at the end of the movement. It is
difficult to inhibit the associated reactions, it takes more time and is
often done incompletely.

Lynch: muscular activities that appear after a modification of the

neuronal connections within the spinal cord. The patient learns patterns
of hypertonia, which in turn can cause other permanent changes in the
muscles, such as spasticity.

ASSOCIATED MOVEMENTS:
They can be triggered by stress, by factors such as:

- Performing a difficult selective movement, such as threading a small

needle (we stick out our tongue when performing this action)

- During new voluntary selective movements or very difficult to do or

when making significant efforts: such as when pushing a cupboard
when I hold my breath and push.

For example, swinging the arms while walking.

There is the ability to modify them, while the associated reactions are
stereotyped. always the same.
The associated movements can be put under inhibitory control and the
associated R.s cannot; the control being more difficult, incomplete and
taking longer.

Associated movements:
Easy to suppress.
They are usually mov. selective.
Normalization of
toneIrradiation on
exertionAssociated reactions:
Difficult to inhibitThey
are usually movement patterns.
Residual hypertonus at the endOne
or two stereotyped patterns.

5)

sensitivityhyposensitivity hypersensitivity
pain Severe +++ +++ ¡¡¡ At
restModerate ++ ++ ¡¡ Mov. small
/light + + At the end-
tactile, which reports fine
contact- thermal, which reports heat and cold-
painful, which captures nociceptive
stimuli- position of the joints or kinesthetic-
vibratory or palesthetic.
Types of sensory receptors:
a) extrinsic or exteroceptors1
. ruffini corpuscles (lateral displacements of the skin. Heat)
2. Merkel cells (vertical pressure on the skin). Slow adaptation3
. Meissner corpuscles (pressure and friction velocity) Fast adaptation4
. Pacinian corpuscle (pressure and vibration variations). Fast
adaptation.
5. free nerve endings (temperature and pain)
6. krause corpuscles (cold)
b) intrinsic or proprioceptors1
. Golgi tendon organs (tension on tendon)
2. nucleic acid bag fibers and nucleic acid chain fibers of muscle
spindles (muscle elongation and speed)
3. joint mechanoreceptors (pressure and/or compression at or around
the joint level.
Vestibular receptors (position of the head relative to the body.
Linear/angular accelerations).

* Superficial sensitivity: Tactile, painful, thermal.

*Deep sensitivity:
- Sensitivity to pressure (baresthesia)
- Sensitivity to the appreciation of weights (barognosia) - Vibratory
sensitivity (palesthesia)
- Sense of segmental attitudes (bathyesthesia) Superficial

sensitivity.
Alternative: through the therapist's touch on any part of the body, with
greater or lesser pressure. And he asks him where he was touched and
how strong it was, compared to the other times. The classic examination
of superficial sensitivity consists of the physiotherapist touching both
halves of the face, shoulders, arms, forearms, hands, fingers, trunk,
thighs, and legs with his hands. The physiotherapist will ask each time if
the pressure has been felt and if it has been felt equally on both sides.
Deep sensitivity (Mirroring) This involves positioning the body in a
certain position on the affected side and placing the healthy side in the
same posture.
Alternative: The therapist grabs the EESS on the affected side and
places it in a certain position, and asks the PC to reproduce it with the
healthy limb to verify that it has been understood. The patient then
closes his or her eyes and the therapist modifies the position of the
shoulder, elbow, hand and finger joints. The second phase is carried out
in the same way but in the EEII. On the affected side.
Mirroring Considerations:
1. explanation of the task to be performed while sitting, and whether it
can be performed while standing2
. It begins with the upper limbs3

. It starts with the eyes open to check the compression4

. Once understood, the test is carried out with eyes closed until
completed.

5. The lower limbs are examined in the supine position6

. It is necessary to consider the difficulty of sensory recognition at the

level of the middle and ring fingers of the hands, and the 2nd and 4th
toes of the feet. (These fingers are less sensitive). Do not overestimate if
they make mistakes at these levels.

EXPLORATION AND DOCUMENTATION:

- START OF PHYSIOTHERAPY
TREATMENT- Detailed
prior examination- Continuous examination: Not only at the beginning
or at the end of treatment.
Berta Bobath says that exploration and treatment should not be
separated6

) main problem7

) objectives8

) PARTS OF THE EXAMINATION:

1. Actual value: These are the symptoms with which the patient begins
treatment. These are the initial symptoms. They are more or less
abnormal or varied movements (whether sensory, motor or cognitive)
2. Gauges: These are the therapist's receptors with which he quickly
and broadly perceives the patient's symptoms, such as:
-eyes, ears,
nose- Tactile and kinesthetic receptors: These are the most important
receptors. The physiotherapist touches the patient, palpates him, moves
him, applies the placing technique and thus receives essential
indications on postural tone, reciprocal innervation (contraction-
relaxation) and coordination (therapist

receptors). Eyes (observation); hearing (listening to impressions, as well

as language disorders - aphasia; or in speech - dysarthria); smell
(personal hygiene, incontinence); tactile/kinesthetic (palpation).
3. Setpoint value: It is established during normal movement. Reference
point in the exploration and at the same time the objective of the
treatment. It is the reference point to which our treatment is directed
and must be established based on the comparison with a normal
movement (our treatment objective)

Components (level of body and structural functions) of normal

movement during the course of an action (participation level).
Treatment objective.
4. Positioning link: These are the first movements that simultaneously
influence, modify, normalize and improve tone, reciprocal innervation
and coordination. These are the tools that the therapist anticipates.
They are what we use to treat you. The physiotherapist: POSITIONS,
CONTAINS, FACILITATES..... Patient

symptoms:
- Hypotonia or hypertonia-
Sensitivity
disorders- Neuropsychological
disorders- Etc.

REAL VALUE
POSITIONING
LINK

MEASUREMENTS The therapist: The therapist:

- Observes -
Listens -
Smells
- Palpates -
Positions
- Contains - Facilitates.

GUIDELINE

VALUE Comparison with

normal movement based on the therapist's knowledge and experience
.

9) TREATMENT PRINCIPLES

INHIBITION FACILITATION STIMULATION

1. START TREATMENT AS SOON AS POSSIBLE (taking advantage of

the plasticity of the CNS, through a 24-hour care plan.) Physiotherapy

is currently started as soon as possible. The reason for this early onset
is the use of what is known as CNS
Plasticity. Plasticity is the ability of each cell in the body to organize
and reorganize itself again at each stage of its development, that is, it
allows the germination of dendrites and axons, the formation of new
synapses and thus making new connections with other cells.

Plasticity in humans.

Memories, desires, values and knowledge are covered by a network of

100 billion neurons, each of which can connect with 10,000 others.

Genes are responsible for 10% of the networks in the brain, but the
remaining 90% are formatted by experience and knowledge.

These neurons talk to each other through junction points called

synapses, where an axon comes into contact with a dendrite or the body
of another neuron, causing new information networks.
Neurons after an injury have the capacity to learn and if you stimulate
them during this time they can integrate a lot of information and learn a
lot.

TYPES OF NEUROPLASTICITY: Positive

neuroplasticity (creates and expands the neuronal network) and

negative (eliminates those that are not used)

There are four types of neuroplasticity according to their effects:

1. Reactive: Resolution of short-term environmental changes 2

. Adaptive: Stable modification of a connection route that is generated

with memory and learning. Assimilation ensures that behaviors, even if
they are new, do not start from scratch (memory). Accommodation
modifies memory by incorporating new elements that are assimilated
(learning)

3. Reconstructive: Partially or totally recovers lost functions.

4.Evolutionary: Maturation process where connection patterns are

modified by the predominant environmental influence.

2. ORGANIZATION AND REORGANIZATIONORGANIZATION

: The neural network created through the connections of the millions of

neurons formed between them by the germination of dendrites and
axons. These develop synapses in their nerve endings, releasing
transmitting elements of an excitatory or inhibitory nature. The neural
network is formed by the genetic program, in addition to the new
connections created in response to the variety of functions required.
Learning.

Organization is the basis of all learning, from the moment of conception.

During embryonic development, 10 to 12 million neurons are formed,
which gradually connect to each other through the germination of axons
and dendrites. These develop synapses at their endings, which release
transmitter elements that transmit excitatory or inhibitory information
by electrochemical means. In this way, an increasingly dense neural
network is gradually formed.
First there is a genetic program that determines which cells connect to
each other. An anatomical structure is formed, which in turn determines
the function.

REORGANIZATION: Capacity of unaffected neurons and those with

intact basal metabolism to reorganize in the face of neuronal injury,
which involves a disorder or destruction of the neuronal network.
Relearning.

An adult person has built a completely individual neural network over

the course of his or her life. It is determined by your individual and
personal genetic program, especially by the individual functions you
have performed or are performing.
Immediately after a neuronal injury, which involves a disruption or
destruction of this neuronal network, a reorganization takes place. This
does not mean that new neurons can be created. Once destroyed,
neuronal cells lose their basal metabolism and their functional
metabolism (they cannot regenerate). Undamaged
cells and those that maintain basal metabolism but have lost functional
metabolism have the ability to reorganize (if the cell loses basal
metabolism it dies and no longer regenerates).

For the germination of dendrites and axons and the formation of

synapses, various conditions must be met:

1. Growth factors (GAP 43): They are present in different phases of life
in large quantities: *

First year of life

* Puberty
* Pregnancy
* Immediately after an injury 2
. Stimulus: The requested function requires a stimulus. If there is no
stimulus there is no plasticity. It may be the patient's desire to move or
it may be triggered by physiotherapy.
3. Construction material (proteins)

4. Transport system: The system that transports the protein molecule to

the end of the dendrites or axons is the axoplasmic flow that can be
observed inside axons and dendrites3

. MOVEMENTS AS A STIMULUS DIRECTED TOWARDS A GOALThe

 stimulus of the force of gravity, the demand for an increase in postural
tone, is always present.

In activities such as body care, dressing and undressing, making beds,

postures are modified and movements are performed. It is the demand,
the function performed, that determines the anatomical form that is
being reorganized and thus the formation of a new neural network. For
this reason, it is necessary to implement a 24-hour management plan
immediately after an injury.

*The function performed is what determines the anatomical form that is

being reorganized, and thus the formation of a new neural

network*This modified form leads to a modified

functionFUNCTIONFORMCONSIDERATIONS

:
-Teamwork and in the same direction-Specific
physiotherapy must begin immediately after the
injury-Treatment adapted to the patient's condition-Individual therapy
to be carried out at home. (A task must be assigned to the
patient to do at home.

4. CHOOSING A SUPPORT BASE AND AREAIf

the support base is wide, postural

tone decreasesEach person needs a support base, since we are subject
to the influence of the force of gravity at all times. We all need a
support base to fight against gravity and the smaller it is, the greater
the postural tone.
The human being lives and moves constantly between both physical
forces, the force of gravity and the support base. *Support

base: Surfaces that are under our body. Contact of the body with this
surface is not necessary.

*Support area: Contact surface of our body with a plane on which we

are allowed to support weight on it.

NOTE:
The larger the base of support and the area of support, the lower the
postural tone.The smaller the base of support and the area of support,
the greater the postural tone.
The size of the support base determines the amount of postural tone -
To

work on balance and postural tone, the requirements of the support

base used must be taken into account.

-During treatment, you do not usually work on changing areas by going

from sitting to standing or vice versa, but rather by changing the sitting
position (forward, backward, to one side, to the edge of the stretcher,
upright sitting...) Variation in the motor demand on the subject.

-Changes in the base of support and support area have to be made

through very small changes and progressively (facilitating the CNS
adaptations of postural tone)

TYPES OF SUPPORT AREAS:

-Own to the body (feet, knees, pelvis, thighs, hands, forearms) The
body's own can be stable or mobile.
-Foreign to the body (floor, stool, table, and they are stable and the
mobile ones can be a bicycle, skates, a motorcycle ...)
-
Stable-MobileContinuous
movement with our mobile surfaces and on stable or mobile support
bases away from the body (great request for balance)

We move permanently with our own mobile surfaces of the body and on
stable or mobile support bases foreign to the body. This explains the
great balance control that must be taken into account in the
treatment. )

5. ALIGNMENT OF KEY POINTS (POSTURAL SET)

The key points are the control zones of the body where we are going to
act so that normal movement occurs.

Keypoint alignment is the position of keypoints relative to each other

and the support base in a continuous interaction. This alignment
determines the quality of the postural tone. Berta Bobath called certain
control points of the body key points. A displacement of these body
parts, i.e. the centres of gravity, is registered in particular by the
vestibular system and responds by means of a change in postural tone
(righting
reactions). The PCCs have a large number of sensory receptors and can
transmit a large amount of information to the CNS) which have a
special influence on postural tone.

Position of key points between them and the base of support

(determining factor in the quality of postural tone).

Large number of receptors -------� information to the CNS/registration

of changes in position of
the centre of gravity (vestibular system).

Modulation of postural tone �------------------ Rapid and effective motor

response.

MAIN KEY CONTROL POINTS:

1. PCC (located in the centre of the body between the Xiphoid process
and D1-D8) Centre of gravity of the upper part of the body.
2.Pelvic key point(Located at the height of S2-S3)Center of gravity of
the entire body3
.Shoulder girdles.
4.Head5
.Hands and feet.

EXAMPLE: relationship of the pelvis and shoulder girdle with the

central

key pointIn order to determine the quality of postural tone and to

influence it, the relationship between the proximal key points of the
pelvis and shoulder girdle with respect to the central key point must be
observed: if both shoulder girdles are in an anterior position with
respect to the PCC, the dominant neuromuscular activity will be that of
the flexors. If both shoulder girdles are located posterior to the PCC,
the dominant neuromuscular activity will be that of the extensors
. The same occurs with the pelvis: in a posterior straightening, if the
central key point of the pelvis (S2) is anterior with respect to the PCC,
the dominant neuromuscular activity of the trunk will be the flexors.
By tilting the pelvis anteriorly, the S2 center will be posterior to the
PCC, and the dominant neuromuscular activity will be that of the
extensors.

ALIGNMENTS OF KEY POINTS IN EVERYDAY POSITIONS: SUPINE

DECUBITUS: (predominance of extensor tone, with increased pressure

on the back of the head, scapular spine, sacrum, ankles. (Risk of
pressure ulcers) VERY HIGH EXTENSION TONE.
PCC: TOWARDS THE ROOF OPCE
: DELAYED
PCP: A LITTLE TOWARDS THE

FLOOR - SUPINE DECUBITUS WITH ADDITIONAL SUPPORT ON THE

SHOULDER GIRDLE: (slight anteriorization of the shoulder girdles,
pelvis in neutral position) More homogeneous pressure distribution.
Recommended position as a resting position and as a treatment position
as it allows selective movements of the pelvis, leg, foot, shoulder girdle,
arm and hands to be worked on
)
PCC: ELEVATED PCE
: HIGHER PCP: NOT MODIFIED.
THIS CAUSES A FLEXOR PREDOMINANCE IN THE UPPER PART OF
THE BODY AND AN EXTENSION PREDOMINANCE IN THE LOWER
PART OF THE BODY - LATERAL

DECUBITUS WITH ADDITIONAL SUPPORT AT THE SCAPULAR LEVEL

(with slight anteriorization of the scapula with a cushion between the
shoulder and head and another cushion under the advanced upper arm.
In addition, there is a slight posteriorization of the pelvis with respect to
the PCC, placing a cushion under the upper leg. It allows us selective
movement)-PRONE

DECUBITUS (anteriorization of the shoulder girdles and pelvis with

respect to the PCC, with increased flexor tone, respiratory problems,
decreased perception and vigilance, cervical rotation
problems.)FLEXOR
TONE PREDOMINANCEPCC: BACKWARDSPCCE: FORWARD WITH
RESPECT TO
PCCPCP: FORWARD WITH RESPECT TO
PCC
***IT IS NOT USED MUCH IN TREATMENT, because it decreases
vigilance and perception and the visual field, poor breathing and
increases flexor tone-RELAXED
SITTING (anteriorization of key points of the shoulder and pelvic girdle,
causing a dominant flexor tone that is positive from an economic point
of view, without demanding muscular activity, although harmful at the
vertebral level. Position rarely used therapeutically.
PCC: BACKWARDS AND DOWNWARDS
PCE: ADVANCED. AND THE MMSS TENDS TO RI AND
ADDPCP: A LITTLE ADVANCED.
PREDOMINANCE OF FLEXOR TONE. LITTLE USED
THERAPEUTICALLY -

STRAIGHT SITTING (shoulder girdles slightly anterior to the PCC,

useful for performing the main tasks with the upper extremities
(manipulating objects). At the pelvic level there is a posteriorization of
the key point affecting the extensor tone, to overcome gravity. Most
commonly used starting position at a therapeutic level. To achieve this
sitting position, it must be facilitated by supporting only 1/3 of the legs
in contact with a hard plane, knees separated at hip height, feet under
the knees and flat to the ground)
PCC: BEHIND THE OTHER POINTS PCE
: A LITTLE ADVANCE WITH RESPECT TO THE
PCCPCP: A LITTLE ADVANCE WITH RESPECT TO THE PCCES
A COMBINED POSTURAL SET WITH PREDOMINANCE OF FLEXOR
AND EXTENSOR
TONE MMSS: FLEXION AND TENDS TOWARDS ROTATION MMII
: EXTENSION, ABD AND EXTERNAL

ROT - BIPEDESTATION PREVIOUS STEP (alignment of key points

similar to straight sitting. Key points of the pelvis and PCC are located
further away from the base of support, thus increasing the extensor
tone of the lower body. In the step position, with the weight on the front
leg, an increase in extensor tone appears, so it is used to inhibit the
excessively high tone of the flexors)
PCC: FIGHT AGAINST GRAVITYDPCE
: MORE ADVANCED THAN
PCCPCP: A
LITTLE DELAYED PREDOMINANCE OF EXTENSOR TONEThe
leg on which the weight is loaded (the one in front) has an increase in
extensor tone with respect to pure bipedalism, a reflex that is produced
by an increase in weight and a decrease in the base of support.

-BACK STEP STANDING: (weight on the back leg, predominance of

flexor tone to avoid extensor patterns)FLEXOR

TONE
PREDOMINANCE-Straight sitting, standing and step position are called
“combined” key point alignments, since in the upper part of the body
there is a flexor predominance and in the lower part an extensor
predominance, well balanced between them, which allows easy rotation
and selective movements.

TREATMENT

II PRINCIPLES

• Start treatment as soon as possible, taking advantage of the plasticity

of the CNS, using a 24-hour care plan.
• Organization and reorganization (Neuroplasticity)
• Movement as a goal-directed stimulus•
Choice of support base and support area.
• Alignment of key points (Postural Set)

6.

COMMUNICATIONNon-verbal communication (communication with the

hands)
The hands should not move the patient passively, but should actively
stimulate movement, with the intention of causing a reaction in the
patient, such as: *
Increasing sensitivity (sensitization)*
Reducing sensitivity (desensitizing)*
Increasing postural
tone*Decreasing postural

toneReflexogenic zones such as the palm of the hand (palmar grip)

should be avoided because they can cause the patient to go into a
defensive position (hip flexion, knee, etc.)

Insist a lot on touch on the key control points (large number of

receptors), as well as on the body’s gravity points:

 Pelvis
PCC (laterally) Olecranon (center of gravity of the upper limbs)

Above the femoral condyles (center of gravity of the lower limbs)It is
important to have these points stabilized and controlled.
BASIC RULES:

- The hands must be placed where we want a reaction to take place.

 The hands, depending on the reaction to be achieved, must transmit
very specific information (e.g. stimulation or inhibition).
 Hand manipulation must not trigger pain (e.g. in hypertonia, causing
pain causes greater hypertonia and can cause spasms).
 The therapist reinforces and accompanies the movement of his hands
with his whole body (economy).

Verbal communicationThere

must be verbal communication between the physiotherapist and the

patient, which is generally established before and after treatment. (No
over-involvement, limits must be sought) Specific verbal

communication during treatment sessions (relationship between tone of

voice and muscle tone. For example, if you were comfortable during the
treatment, if it hurt a lot, if you slept well the night before. If we have a
patient with hypotonia (flaccid), we will have to encourage him with a
more energetic tone of voice and if he is hypertonic with a lower tone of
voice and the rhythm of the maneuver as well)

7. PAIN
Painful treatment should be avoided.

Presence of specific receptors (nociceptors) in all structures of the

human body except the brain.

Nociceptors = Slowly adapting alarm system.

The effect of pain on postural tone is predictable (increased tone in the

active muscles in a flexor manner - defense

mechanism)• Mechanical A nociceptors (they react preferably

to strong acute stimuli)• Polymodal A nociceptors (they also react to

thermal and chemical stimuli)
• Polymodal C nociceptors (they react to strong mechanical stimuli,
thermal stimuli and different chemical substances)*

Be careful when mobilizing because pain can cause withdrawal.

HEALTHY PAIN
Caused by the treatment of increased muscle tone, in the connective
tissue and in the skin through specific mobilization of the muscles.

It is a feeling of discomfort rather than pain.

Objective: To restore normal flexibility and elasticity of the muscles,

connective tissues and skin.

JOINT PAIN (Avoid it)Sharp and intense

pain causing an increase in muscle tone and the appearance of

associated reactions.

Pain on passive mobilization:

 Glenohumeral joint (towards elevation and external rotation, due to

hypertonia of the pectorals and latissimus dorsi) It is a vicious circle.
 Hip joint (towards the ADD with a flexion of 80-90º with inguinal pain
due to hypertonia of the adductors, causing an increase in the pressure
of the femoral head on the acetabulum) •

Be careful when mobilizing these two joints because they are very
painful. For example, moving the glenohumeral at a distance.

CONSIDERATIONS

There is no sequence of protocolized exercises for the treatment of two

similar cases, since each treatment varies according to the reaction of
the same and the evaluation obtained.
 Active participation of the patient with the therapist to learn to control
spasticity, through inhibitory control, modified and influenced by trunk
movements.
 As the tone and movements improve, the therapist disappears (it is not
a lifelong treatment, the person has to learn to be as active and
autonomous as possible)
 Slow movements, with minimal effort, since otherwise the movement
can be damaged by excitement. The quality of movement must always
be controlled by means of inhibition. No high resistance exercises.
(increased muscle tone)
- Compensatory rehabilitation is largely responsible for increased
spasticity and inactivity on the affected side. (For example,
compensating the healthy side in a hemiparesis has no benefit on the
affected side.)
- Cognitive alterations have a poor prognosis for treatment.
 Work with as many parts of the body uncovered as possible, which can
give us information both visually and tactilely.
 Set short-term goals, avoiding creating false hopes.
 Take into account the variability in the patient's general condition
from one day to the next, due to the medication administered, the
emotional state, environmental factors... that can alter
and/or modify our approach. (We do not have to work mechanically)
 People with neurological diseases = multiple symptoms =
interdisciplinary approach (speech therapist + physiotherapist +
occupational therapist. Etcc.)
- Not all neurological pathologies will respond optimally to treatment.

TO WHOM IS IT DIRECTED?

Comprehensive approach aimed at adults and children with

neurological dysfunction, with sensorimotor disorders, especially of
cerebrospinal origin (upper motor neuron) CRANIAL

INJURIES OR DISEASES (Especially of the pyramidal tract because at

this level there is hypertonia, spasticity.
DISEASE PATHOPHYSIOLOGY
DEFICITS Cerebral vascular accident (CVA) Embolism, cerebral
thrombosis, intracranial or subarachnoid hemorrhage. Pyramidal
involvement. Voluntary movement deficit contralateral to the lesion.
Depending on the injury, with associated sensory and cognitive deficits.
Sagittal functional
asymmetryMultiple sclerosisProgressive
degeneration of the myelin sheaths.
Pyramidal involvement Depending on the affected area, diplopia, atia,
spasticity, action tremor,
cognitive impairmentParkinson's Involvement of the extrapyramidal
system (here there is no spasticity but rigidity) Resting tremor, slowing
of voluntary movement, rigidity.
Brain tumor Invasion, destruction of brain tissue or secondary
intracranial hypertension Increased intracranial pressure, seizures and
endocrine disorders
Traumatic brain injury (TBI) Depending on the brain injury, possible
pyramidal and/or extrapyramidal disorders. If it is severe, there are
major alterations in muscle tone and cognitive functions.

TRAUMATIC
INJURIES DISEASE PATHOPHYSIOLOGY DEFICITS
Spinal cord injury Partial or complete injury to the spinal cord.
Paralysis and total or partial anesthesia depending on the injury.
Transverse functional asymmetry.

With a complete injury, not much treatment can be done, whereas with
an incomplete injury, the patient can benefit greatly from treatment.

SPINAL CORD
INJURYSPINAL SHOCK PHASE (Spinal cord inhibition)

-Paraplegia or flaccid tetraplegia-Abolition

of deep reflexes-Complete
anesthesia below the injury. Hyperalgesia band just above the limit of
anesthesia.
-Loss of bladder activity (urinary retention)
-Paralytic ileus (fecal retention)
-Lack of erection and ejaculation-Neurovegetative
alterations (sympathetic spinal cord from C8 to L2)
-Below L1 it does not give rise to paraplegia (cauda equina syndrome)
- Above C3-C4 there is respiratory involvement: phrenic nerve.

LATE PHASE (Medullary release) from 1 to 6 weeks.

-Spastic paraplegia or tetraplegia (more frequent in lower extremities)-

Deep muscular
hyperreflexia-Defense
reflex or spinal automatism (triple withdrawal)
-Same although the hyperalgesia
band disappears-Central or automatic bladder (no involvement of
micturition centers S2-S4)
-Spastic or flaccid bladder (involvement of micturition
centers)Continuous drop-by-drop incontinence.

• the spastic phase in the spinal cord injured patient will be

bilateralBRAIN TUMORBrain

tumors cause various syndromes. In general, the manifestations

derived from intracranial hypertension and the syndromes secondary to
tumor expansion are distinguished, the latter called focal signs, which
depend on the affected anatomical structure:

1. Cranial

hypertension syndromes:• Headaches

• Epileptic
seizures• Vomiting
• Pupil edema with visual
disturbances• Behavioral disorders (irritability, emotional lability,
failures in judgment, memory disorders, lack of initiative, indifference
to social customs.

2. Local syndromes:

These are manifestations that guide the location of the lesion. The most
common are:

 Paresias (transient and incomplete paralysis)

 Partial
motor seizures  Aphasias (problems using language)
 Apraxias (problems performing certain sequences of movements, for
example pressing a button) 
Agnosias (the person can perceive objects but not associate them with
their usual role) CRANIAL ENCEPHALIC
TRAUMA (TBI) Like any physical injury or functional deterioration of
the cranial contents secondary to a sudden exchange of mechanical
energy, caused by traffic accidents, work accidents, falls or assaults.
-Focal signs according to the injured or affected brain area.
-Pyramidal pathology with major alterations in muscle tone and
cognitive

functions*The evolution of bobath treatment depends on the person's

state of consciousness.
*We will work with mild TBI, with moderate and severe TBI hardly
anything.

CEREBRAL VASCULAR ACCIDENT (STROKE) - Cerebral vascular

disorders of ischemic or hemorrhagic cause (higher mortality), lasting

more than 24 hours (WHO 1988). Cases lasting less than 24 hours,
which are designated as transient ischemic attacks (TIA), are excluded.

Greater degree of functional recovery during the first 6 months after

the injury
. Functional affectation according to the location of the injury
. Sagittal asymmetry.

FUNCTIONAL AFFECTATION ACCORDING TO THE LOCATION OF

THE INJURY (CVA)
LOCATION OF THE INJURY CAUSES NEUROLOGICAL AFFECTATION
FUNCTIONAL AFFECTATIONCorticospinal
and corticovestibular tract below the cerebral cortex and above the
medulla Lacunar infarction of the internal capsule (lenticular branch of
the middle cerebral artery) Poor prognosis. Upper motor neuron lesion
Motor deficit contralateral to the lesion of the face, arm, trunk and leg.
It may be associated with dysarthria and ataxia (associated cerebellar
involvement).
No sensory/sensory involvement. Primary motor cortex
with involvement of the cortical representation of the face, arm and
contralateral leg. Various, cerebral infarction, tumors, trauma. Etc.
Upper motor neuron lesion Motor deficit contralateral to the lesion of
the face, arm, trunk and leg.
Cognitive damage is associated (aphasia, apraxia, ocular and visual
agnosia).
More incidence on the left hemisphere. Omulla motor
cortex above the pyramidal decussation. Infarction of the medial and
anterior cerebral artery.
Spinal cord compression Multiple
sclerosis and TBI Upper motor neuron injury Motor deficit contralateral
to the injury to the face, arm, trunk and leg.
Cortical injury may present with aphasia or hemineglect. If the injury is
spinal up to C5 there are deficits in kinesthesia and palesthesia.

FUNCTIONAL AFFECTATION ACCORDING TO THE INJURED

HEMISPHERE (AVC)Left

hemisphere: dominant hemisphere, producing right hemiplegia. From a

motor point of view, the functional prognosis is better if there is no
interference from cognitive problems that tend to be severe and
disabling. (aphasia, apraxia, agnosia)Right

hemisphere: non-dominant hemisphere, producing left hemiplegia with

a worse functional prognosis. In addition, cognitive problems with a
worse prognosis may be associated (anosognosia, hemisomatognosia)
UPPER MOTOR NEURON

INJURY LOWER
MOTOR NEURON INJURY Voluntary motor deficitNo
amyotrophyIncreased
muscle tone, spasticity (hypotonia may be observed in the initial phase
which later develops into hypertonia)
No fasciculationsDepending
on the type of stroke:
-Loss of consciousness-Sensory
/sensory deficits-Cognitive
deficits Voluntary motor

deficitAmyotrophyHyporeflexiaHypotoniaFasciculations

(Abnormal muscle contractions caused by the muscle cells

themselves)FUNCTIONAL

PROGNOSIS(STROKE)Superficial

hemiplegia. Good prognosis. In the initial phase, distal movement can be

detected at the level of the extremities (extension of the fingers of the
hand, eversion of the foot or flexion of the knee with the hip in
extension). Intermediate

hemiplegia. There is a possibility of functional recovery even if there are

synkinesis or abnormal postural patterns that develop due to spasticity
(bieps brachii, quadriceps). Deep

hemiplegia. Poor prognosis Only proximal movement is detected,

associated with very marked spasticity, which results in an abnormal
postural attitude.
Muscles with greater spasticity:
- UESS: Pectoralis major, dorsal ancho, elbow and wrist
flexors - LH: Knee extensors and plantar flexors of the

foot PARKINSON

Chronic degenerative affectation caused by neuronal death at the level

of the substantia nigra, of unknown etiology. Very varied clinical
presentation with unilateral predominance in the initial stages.
Extrapyramidal pathology. (basal ganglia) There is rigidity but no
spasticity.

PRIMARY SIGNS:-Muscle

rigidity (cogwheel-like resistance to passive mobilization)

-Bradykinesia/Akinesia (slowness in active movements, with lack of wide
ranges of movement. Invalidating sign.
 Resting tremor (distal sign) and tends to disappear with voluntary
action.
 Postural instability in flexion. Parkinsonian or festinating gait
SECONDARY SIGNS

:
 Speech and voice disorders (hoarse voice)
 Dysphagia (possible cause of death)  Cognitive
disorders  Depression

 Urinary and sexual

disorders  Sleep
disorders  Eye
disorders  Hyperhidrosis and seborrhea 
Orthostatic
hypotension  Respiratory disorders Parkinsonian syndrome

: Group of disorders in which the characteristic signs and symptoms of

parkinsonism develop, but secondarily to another neurological disease
(Alzheimer's disease) CEREBELLAL

PATHOLOGY PRIMARY SIGNS: - Action or intentional

tremor - Asynergia (they are not able to coordinate a movement) -

Speech
disorders (dysarthria) - Dysmetria -

Hypotonia - Others
: scanned word (as if the fingers were shaking) MULTIPLE

SCLEROSIS Demyelinating

disease of the CNS characterized by the appearance of inflammatory

lesions or plaques with destruction of myelin with total or relative
preservation of neurons and their extensions. Secondarily, the
phenomenon of repair or gliosis occurs, configuring the lesion or
plaque.

EVOLUTIONARY PROFILE ACCORDING TO THE CLINICAL FORM:

-Relapsing remitter (There are inflammatory outbreaks. Cortisone

treatment.
-Primary progressive (degenerative)
-Secondary progressive (Begins with flare-ups and then progresses)-
Recurrent
progressive (Progression slows and from time to time they have a flare-
up)
-Benign (People who have had a flare-up and then with treatment the
progression of the disease is prevented)

The 2 main characteristics are:

1.Temporary dissemination, of deficits and neurological signs that occur

in multiple episodes (flares) (there are moments of improvement, the
flare-up appears, then they improve and so it progresses)

2.Spatial dissemination, of lesions in different territories of the CNS,

with a great diversity of signs (symptoms and signs that exist depending
on the location of the lesion.

MULTISYMPTOMATOLOGY:

-Motor: Pyramidal involvement (hyperreflexia, partial or total paralysis,

clonus, Babinski sign)
-Ocular: Involvement of the optic nerve with loss of visual acuity.
-Sensory: Paresthesia, dysesthesia, hiccups due to anesthesia,
Lhermite's sign-Coordination
disorders: Cerebellar ataxia, trunk ataxia, sensory ataxia due to
involvement of the posterior cords of the
spinal cord-Cognitive and psychic
disorders (they appear to be fine but something is wrong with their
head)-Sphincter and sexual disorders-Fatigue
(poor prognosis because with the treatments their body temperature
rises and innervation decreases by almost 50%). Ex. after eating they
are like a rag because their temperature rises with digestion)
-Others.

For the Bobath practical exam. Keep in mind:

-Explanation of the
technique-User

position-Therapist position-Therapist/
user communication-Application of the technique.
-Coherence between the theoretical explanation and the application of
the technique.
-Attitude and interest during internships.
Karel Bobath (neuropsychiatrist) and Berta Bobath (physiotherapy therapist) were born and
met in Berlin, Germany.

They emigrated in 1939 during the Second World War to London, England, where they married
in 1941.

In January 1048 Berta published her first article.

In his time, the deformity was treated and not the patient.

Rehabilitation was exclusively medical.

They inverted the concept of habilitation, prevention of contractures and deformities, the
teaching of functional skills and daily living.

They used furniture and adaptations.

They took the treatment to the hospital, home and then to school.

They took the process out of the doctor's hands and brought it to the group of professionals.

They saw the development of the child as an anti-gravitational organism.

Their approach was to develop antigravity skills by facilitating functional motor behaviors.

They committed suicide on January 20, 1991 in their home. Berta was 83 years old and Karel
was 85.
We regard our approach as a working hypothesis based on ideas from neurophysiology, but as
a living thing, still constantly changing in the light of accumulating experience, it is
fundamentally based and always has been based on clinical experience of treatment.

It is up to the new generations of therapists to take this living thing to new levels, in
accordance with the medical and social realities of each healthcare centre and the community
in which it is inserted.

......... Karel and Berta Bobath.

Statements

Lack of inhibition of reflex patterns that are associated with abnormal tone. Key control points
to facilitate straightening and balance reactions. Experience in treatment has shown that
righting and balance reactions are potentially present in most cases. They appear
spontaneously or can be easily activated once the tonic reflexes are inhibited. These normal
reactions are obtained as automatic responses of the infant and child to specific manipulation
techniques.

The activity of the mature CNS typically falls within enduring patterns that form over the years
of development.

The CNS of the child with CP is less competent to deal with the afferent flow

There may be no alteration of the sensory and perceptual system

The motor responses of the child consist mainly of some spinal and tonic reflexes.

One or other of the more highly integrated straightening and balancing reactions may appear.
Definition.

According to the IBITA (INTERNATIONAL BOBATH INSTRUCTORS TRAINING ASSOCIATION. An

international association for adult neurological rehabilitation)

It is a holistic approach aimed at adults and children with neurological dysfunction, in an

interactive process between patient and therapist, both in evaluation and in care and
treatment.

This treatment is based on understanding normal movement, using all perceptual channels to
facilitate movements, and selective postures that increase the quality of function.

It was created by Berta and Karel Bobath to treat patients with CNS damage. Born in the
1940s. It is a living concept that has been enriched by the appearance of new information in
the sciences of movement.

IBITA is the international organisation of trainers, teaching the Bobath Concept application to
the assessment and treatment of adults with neurological conditions.

IBITA was formed in 1984 for the specific purposes of providing a forum for the definition of
the continuing interaction and education of its current instructors and the training of future
instructors and for the formulation of Bylaws and Rules and Regulations of the organization in
relation to the teaching of the Bobath Concept throughout the world.

Today IBITA unites instructors (physiotherapists and occupational therapists) worldwide,

representing more than 240 members in 26 countries.

IBITA is an association according to article 60 et seq. from the Book of Civil Law of Switzerland.

The association is based in Sankt Gallen, Switzerland.

Important features of the method

One of the important characteristics of the method is that it aims at organizing motor
behavior: Human motor behavior is based on a continuous interaction between the individual,
his environment and the tasks to be performed.

It is a purposeful method to intervene on movement dysfunction: starting from a CNS injury,

there will undoubtedly be motor control problems, not necessarily an absence of motor
function, but basically a motor control problem. This motor control can give rise to primary
and secondary alterations that are predictable. If there are primary or secondary injuries,
whether they are predictable or not, there will undoubtedly be a movement dysfunction, the
movement will not be performed correctly, but the dysfunction will in turn lead to greater
disability. It is not being used as a synonym for dysfunction and disability. A movement
dysfunction that is intervened, treated, or controlled does not necessarily have to cause a
disability or does not have to deliberately cause an increase in that disability.

Finally, within the characteristics of the method, it refers to the intervention: the intervention
process begins with the evaluation of functional performance. And that is important, the
intervention begins at the same time that the evaluation begins…and that is up-to-date and
there could not be a more modern approach. Suddenly a new approach appears and this is
what the method has been from the beginning, but now there is a greater insistence that the
evaluation should be of functional performance.

Over time, MB was transformed and became a therapy concept. The BOBATH CONCEPT as we
have said is based on the inhibition of abnormal reactive activities, that immediately makes me
understand that as we have said until now its main focus is going to inhibit all abnormal reflex
activity that is present or that remains over time indicating immaturity or the appearance of
pathological reflex activity, and in relearning (because without a doubt it is the global concept
that speaks most about learning theories).

It is based on the inhibition of abnormal reactive activities and the relearning of normal
movements using the manipulation and facilitation of key points (keys, they are also trigger
points, but not to be confused with trigger points or tiger points (traumatology) that are
indicating contracture points or painful points).

The concept is based on the fact that a brain injury produces hyperreactivity of the reflex
systems due to loss of central inhibition. I insist that it is undoubtedly focused on CNS injuries,
especially when they are high. This central lesion causes a problem of postural tone making it
impossible to elaborate voluntary movement, and not only in execution, looking at the term
“elaboration” used, it is impossible to plan voluntary movement well because the afferents
that are being received to be able to carry out this motor program are also erroneous due to
this increased reflex activity, due to this hyperreactivity, due to this presence of especially a
high tone.
It is a method of motor re-education, it is important to know motor learning and how motor
learning is carried out. It is a motor re-education method that allows improving the proximal
distal motor function of the hemiplegic, through neuromuscular inhibition and stimulation.

Characteristics of the method

It is a global method (as opposed to analytical). From the moment you are suggesting that the
intervention should begin from the outset with the evaluation of functional performance, I
have no doubt that the entire approach will be geared towards the global and not towards the
analytical.

It is not limited to the compromised side (this is what we often forget): it recognizes that the
healthy side also presents problems for global gestures (body schema problems). You are
looking at it from a functional point of view, but is there a neurophysiological basis for this?
Because there is also information that goes both ways. The pyramidal pathway is going to carry
information to both sides, there are ipsilateral and contralateral projections, and we usually
forget that. A person who has a hemiparetic side, the person feels that the other side is
functional, we usually call it the healthy side (language used with the patient), but if we are
going to do an evaluation, which is usually not done on the healthy side, we will realize that
that apparently healthy side has also decreased its capacity.

It has evaluation guidelines for kinetic schemes of postural adaptation and balance.

And this is something we did not insist on in Kabat, but we insist on here: consider a precise
dosage, a progression of stages of re-education. We have already seen this when we do stages
of progression which are the stages of neuromotor development.

And here we vary in relation to what we had said before, it adapts to all pathologies of central
and peripheral neurological origin.

Objectives of the method

They can be summarized in two main objectives:

Breaking synkinetic patterns in order to rediscover adapted and coordinated motor activities.
It's a relearning.

Rediscover an adapted postural activity and the necessary support for voluntary movements
and statokinetic balance.
Principles of the method or concept

Work below the spasticity diffusion threshold. It is possible that I am working on one side and
the spasticity on the other side increases, but if I am working contralaterally I would still have
to work below the diffusion threshold of that spasticity, it should not provoke an abnormal
tone response nor a reflex response of the type of associated movement response or
associated reaction on the affected side.

This principle has to do with spasticity. Never fight against spasticity, relax the posture (I am
using the term that is commonly used, but within my concept it is to inhibit), and progressively
begin the inhibition, that is, look for a certain position, adapt a posture and from there
progressively perform a whole manipulation to inhibit. (It should have been clear to us when
we did it with the upper limb, we started with the scapula and continued to the hand using key
points in the shoulder girdle and key points in the distal thumb).

BOBATH CONCEPT FOUNDATIONS

Assessment/analysis of the problem.

Treatment.

Results tracking.

PROBLEM ANALYSIS

PATHOLOGICAL MOVEMENT.

COMPARISON OF THE PATIENT'S PATHOLOGICAL MOVEMENT WITH NORMAL MOVEMENT.

PRINCIPLES OF TREATMENT

Manual treatment.

Early treatment » » Neuroplasticity.

Regulation of postural tone.

Postural alignment.

Stimulate the most affected nerve pathways.

Inhibition of compensations to then facilitate normal movement.

Important patient collaboration/care.

Sensory stimulation.

Management for daily life.

NORMAL MOVEMENT

Normal movement/posture: s the response to a thought/idea or stimulus. What responds is

the normal postural control mechanism

Normal postural movement/tone

Sex

Age

Height

Proportions:

trunk length

leg length

Pelvic width

Shoulder width

Weight

Type of constitution

Individual Potural Tone

climate

Normal movement

Aimed at a goal

Economic

Adapted

Postural tone adaptation

Automatic/voluntary

Normal movement/posture

S= proprioceptive and exteroceptive afferents that serve as feed-forward.

M= motor efferences as a response to the stimulus.

S= proprioceptive and exteroceptive afferents as feedback.

Normal postural control mechanism

Normal sensitivity

Normal postural tone

Normal reciprocal innervation

Normal coordination of selective movements and movement patterns

NORMAL POSTURAL TONE

High enough to go against gravity at the same time Low enough to allow movement

Support base/support area

Position in relation to gravity

Function (stability or mobility)

Speed
Individual movement experience

Pain

Psychological factors (fear.....)

Alignment of key points (Postural Set)

KEY CONTROL POINTS

These are areas where many receptors are found:

Superficial (touch, pressure...)

Proprioceptors

They are gateways to the CNS that allow the transmission of information from the periphery to
the CNS. They are control zones in the body that influence postural tone. They are special parts
of the body where postural tone/selective movements are modified/adapted/changed more
easily and effectively.

Central key point

Pelvis

Head

Shoulder girdles

Hands

Feet

POSTURAL SET

Is the symmetrical or asymmetrical position the key points in relation to:

to themselves

to the support base

It is a starting position:
To selectively move

To change the position (postural set)

Supine position (without additional support on shoulder girdles)

Supine position (with additional support on shoulder girdles)

Lateral decubitus

Prone position

Relaxed sitting

Upright sitting

Prone standing

Bipedalism
NORMAL RECIPROCAL INNERVATION

Right hemibody. / left half of body

Proximal part / distal part

Intermuscular (agonist/antagonist)

Intramuscular (proximal part / distal part)

NORMAL SPATIAL AND TEMPORAL COORDINATION

Function

Movement patterns

Increase in extension / decrease in extension

Increased flexion / decreased flexion

Components

Extension

Flexion

Rotation

NEUROMUSCULAR ACTIVITY
EQUILIBRIUM REACTIONS

Equilibrium reactions

Straightening reactions

Supportive reactions

Equilibrium reactions

They are changes in the muscle tone of the trunk and feet that appear with every movement
of the body. They serve to maintain balance

STRAIGHTENING REACTIONS

They are reactions

From the trunk to the pelvis

From the head to the trunk

Of the extremities

They serve to restore balance

BALANCE IN BIPEDESTATION

Movable toes

Mobile/stable forefoot

Stable ankles

Mobile knees

Stable hip/pelvis

Head and arms free

Stable scapulae
Mobile glenohumerals

Mobile elbows

Stable dolls

Stable Hand Centers

Movable fingers

Supportive reactions

Support reactions of the arms and legs take place to again provide the centres of gravity with a
base of support.

MONOPODAL SUPPORT FUNCTION

Stimulation

Weight shifts

Selective spinal column displacements

Column, head and feet

Postural control of the trunk

Vestibulospinal and reticulospinal system.

Action: sacral, lower lumbar and cervical areas

Through short, deep muscles.

Importance of trunk stability

SELECTIVE MOVEMENT

Stable trunk

Retroverted pelvis

Head and cervical spine mobile and capable of maintaining extension.

PCC with selective movement:

Anteroposterior LateralRotations

Upper limb

Corticospinal and rubrospinal systems.

What we need to reach an object:

Trunk stability

Stability of scapular protraction

External rotation of humerus

Lower limb

Reticulospinal and vestibulospinal systems

Trunk and PELVIS stability

Current developments in the Bobath concept

Renew the change

Research has provided us with a lot of knowledge that has forced us to change the way we
work to be more effective. Karel Bobath said that “The Bobath Concept is not finished and we
hope that it will grow and develop in the years to come.” Since then, the theoretical
framework has evolved as well as clinical practice, however some maneuvers, postures, etc.,
continue to be used even though the technical explanation has changed, and for Bettina
"Something changes so that everything remains approximately the same."

Changes in the neurological basis

Knowledge of neurophysiology was based on the brains of animals (Sherrington (brainless

cats), Magnus, Schaltenbrandt…) but these studies cannot be transferred as such to humans.
Thus, the analysis of human cadavers remains valid for anatomy but not for physiology.
Nowadays, with the advances in technology (MRI, CT, etc.), we can study the living human
brain and renew the hypotheses formulated by Karel Bobath.
Previously, the CNS was analyzed as a reaction organ, always thinking of reflexes as a response
to a hierarchical stimulus. Thus, there was a higher center (cortex) in charge of programming
movements and delegating them to subordinate centers for execution. A median center
(midbrain) in which no influence from the periphery, by means of feedback, appeared during
the execution of the action. And a lower center (reticular formation, cerebellum, medulla,
PNS...) responsible for stereotyped and non-modifiable movements even if other
circumstances required it. So there is no interaction between the different levels. The
important changes began in the years 86, 87 with the concept of neuroplasticity. According to
Brown and Hardmann in 1987, “plasticity is the ability of cells, at each stage of their
development, to change their phenotype in response to a change in their state or
environment.” Thus, neuroplasticity is the ability of the CNS to adapt and change in response
to an internal change (an injury) or environmental demand. This environment is an important
stimulus for the CNS to change and learn (I learn with this plasticity).

But before the idea of plasticity, spasticity was viewed differently than it is today. It was
thought to be caused by “loose reflexes”: asymmetric tonic reflex, symmetric tonic reflex, and
the labyrinthine reflex. According to this, reflexes were present in children until a certain age
(reflex attitudes) but reappeared in adults after a brain injury. Today this idea has been
discarded and it is agreed that spasticity or hypertonia can be considered the result of a plastic
reorganization of spinal cord responses, with partial or total loss of control of the brain stem or
brain (Lance, 1980). Spasticity is therefore considered a process and not an immediate state
after the injury (as was previously believed), which gives us the possibility of modifying it
through therapy and thanks to plasticity.

We conclude then, on the importance of early action, and 24-hour management, to create a
demand that forces the patient to use his plasticity in his favor and not develop so much
spasticity. We say then that spasticity is a movement disorder that develops gradually as a
response to a partial or total loss of supraspinal control over the spinal cord. It will be
characterized by altered activation patterns of motor units, which react to sensory and central
signals and lead to co-contraction, mass movements and altered postural patterns.
(Wiesendanger, 1991).

Definitions of the Bobath concept

Old concept: “It is a treatment concept that is based on the inhibition of abnormal reflexes and
re-learning of normal movement through the facilitation and management of key control
points.”
Current concept: “The Bobath concept is a problem-solving approach to the recognition and
treatment of individuals with impaired tone, movement, and function due to CNS injury. The
goal of treatment is to optimize all functions by improving postural control and selective
movements through facilitation. (IBITA 1996)”.

That is to say, the Concept advocates the use of the patient's hands as little as possible but as
much as necessary, which puts it at odds with other Concepts, including “Motor Learning”.

Motor Learning or Motor Control

It is a theoretical model of how humans learn movement. It induces treatment through verbal
orders, thus ruling out neurological patients with aphasia, alterations in consciousness or those
who are severely affected.

Motor Control is a study of the characteristics and causes of movement. It has to do with the
control of posture and balance, and with the movement of the body in space (Shumway-cook,
Woolacott 1995). It is based on a different CNS model than the hierarchical one: the “Systems
Model”, which is important to know since one of the influences on the way we try to recover
our patients is the theoretical model we have of how the CNS works (according to Held, 1993).

Specifically, the Systems Theory or Distributive Model of Motor Control

All systems are put into operation around a task: Musculoskeletal System, Neuromuscular
System, Cognitive System, Sensory System, Environmental System and Comparative System
(what has been sent, and what has been achieved).

They all work together, without levels (basal nuclei, cortex, thalamus...) to achieve a function.
The information would be encoded by the receptors and would be transferred to different
areas, so that the processing of this information would lead to the development of a
movement strategy whose choice would depend on the situation in which the individual found
himself. It is characterized by:

• A distribution of information to many centers.

• A flow of information between two or more neural networks/structures.

• A distribution of functions because: a center has more than one function, more centers have
the same function and more centers work as an initiative center.

• Adaptive behavior to internal/external conditions-

• Memorization of movement patterns in different centers, that is, the movement will be
stored throughout the CNS, in different centers. So after an injury, movement will not have
been lost; we will have to look at other undamaged areas.

Changes in treatment

1. Changes in treatment technique

In the past: there were inhibitory reflex postures.

Currently: we have “postural set” inhibitors of associated reactions. We don't think about
reflexes but about correcting movement patterns, so even though we sometimes use the same
postures as before, the underlying idea is different.

E.g. hands interlaced to avoid too much flexion in the fingers, to integrate the affected arm...
but not to help get up from the chair, because it leads to internal rotation of the shoulders,
increases PCC flexion and invites the lower body to act in flexion.

2. Changes in treatment technique

Formerly: Concept of following the child's neurodevelopment. 1st roll over, 2nd crawl… that is,
use the child's postures to obtain the head and trunk straightening reactions.
Currently: The child is monitored, but not only for postures, but also for movement patterns.
So, we can work on other “postural” aspects because anatomically the adult is different from
the child (longer limbs, less flexibility…) and may be impeded by age or other factors, or even
feel ridiculed in certain postures.

3. Changes in treatment technique

In the past: There was a certain sequence of activities following an order: 1° supine, 2° sitting,
3° standing with parallel feet, 4° standing in a step position, 5° walking, 6° climbing stairs.

Currently: The deficient components of the movement pattern must be identified and
practiced in different activities or postures.

4. Changes in treatment technique

In the old days: You should never touch your palms/soles of your feet, because this would start
a spastic pattern; you would avoid the stimulus to avoid the pattern.

Currently: By studying further the physiology of receptors, the entry of stimuli into the spinal
cord, and the gating system of the cortex and thalamus, we learned to give the stimulus in
such a way that the spinal cord would react appropriately. The objects we use to stimulate the
hands are: brushes, scouring pads, keys, pens, chopsticks... and to stimulate the feet: rugs,
doormats, knuckles, spikes, grass...

5. Changes in treatment technique

In the past: It was thought that the brain knew nothing about muscles but only about
movement patterns. This phrase arose from studies in neurophysiology since stimulating the
upper layers of the cortex only produced movement patterns.

Currently: With the advancement of technology, it is seen that a more precise stimulation
activates a single muscle, therefore the brain does know about muscles, however it works in
movement patterns.
6. Changes in treatment technique

In the past: Associated reactions lead to established spasticity, so a good treatment was one in
which these reactions did NOT appear. According to Bobath in 1990 and Edwards in 1996,
associated reactions are pathological movements that indicate the potential for the
development of spasticity or an increase in existing spastic synergies.

Currently: we see that the SN must be under a certain amount of stress to learn. With
associated reactions, we will consider that we are at the limit and we must remain at that level
until the patient finds the appropriate postural tone. That is, with an inhibitory control deficit,
a primary movement, which is produced with an abnormal motor unit activation pattern (lack
of prior stability of a movement) can lead to mass movements and associated reactions. So,
with better facilitation the primary movement improves and it can be observed that the
associated reactions DO NOT appear.

This is why there is clinical evidence that facilitating the control of associated reactions by the
patient leads to the recovery of sensitivity, proprioception, posture and selective movement,
and consequently functionality. (Davies 1985, Cornall 1991, Dvir and Panturin 1996)

7. Changes in treatment technique

In the old days: never touch spastic muscles.

Currently: “Specific mobilization of the inhibitory and facilitating muscles” has been developed.
Muscles in patients with hypertonia may adapt by building stronger connections between the
“cross bridges,” resulting in abnormal muscle stiffness and decreased movement.

Thus, it makes sense to mobilize the muscles to initiate another movement pattern and try to
restructure them, because according to Katz and Rymer in 1989, one cause of spastic
hypertonia is the intrinsic mechanical rigidity of the muscle.

What remains the same

Electrostimulation is not used in people with brain injuries because:

• The electrodes cannot be placed exactly on the muscle fibers that should be stimulated.

• Do not stimulate motor units in the normal sequence (tonic before phasic)

• Nor adapt the normal frequency in each movement.

• Nor activate the muscles in the normal movement pattern in their appropriate temporal-
spatial sequence.

If electrostimulation is done, the muscle changes: its threshold (which depends on the function
of the muscle), its way of contracting, its alignment, its function. However, it would be
convenient to use electrostimulation as bio-feedback: when the patient performs an activity,
he generates current and can see whether he is doing it well or not (for example, for the swing
phase in the dorsal extensors of the foot).

Efficiency of the Bobath Concept

There are no studies proving the effectiveness of all C. Bobath; Bettina found a possible answer
in reading the Alchemist:

“I don't know why these things have to be transmitted by word of mouth”, “…they have to be
transmitted like this because they would be made of Pure Life (movement is life and life is
movement), and this type of life can hardly be captured in paintings or words.” “There is only
one way to learn,” replied the Alchemist, “and that is through action.” (Paulo Coelho, The
Alchemist 1988)

However, there are studies that have led to the Concept being included in the so-called
“Evidence-based therapies”, in which it would be used…
a) Forced use:

Term developed by psychologist Taboo in the USA, based on putting a glove or bandage on the
unaffected hand to force the patient to use his or her affected hand for 6-8 hours a day.
(Results in patients with more than 15° of active dorsal flexion) This idea exists in the Bobath
Concept through: the organization of the room to stress that side, using interlaced hands…

b) Repetitive training:

Studies by Hummelsheim et all, (Germany) showed that if the same movement is repeated
many times, the patient learns it better. So the Bobaths (building on Magnus's rule of
deviation) developed the idea of 24-hour driving.

c) Treadmill training:

In studies by Dietz et all, (Germany, Switzerland) with patients with incomplete spinal cord
injuries, it was found that if the patient was “hung” in a harness (thus removing 30% of his
weight) on a treadmill at 5-6 km/h, it helped him to recover his walking. The basic idea is to
use the Locomotion Movement Pattern Generators, an idea that is achieved in the Bobath
Concept by “removing” some weight from the patient's thorax, through specific facilitation
during walking.

d) Mental training:

Studies by Miltner (Germany) with patients with hemiparesis showed that if a mirror is placed
between both arms and the patient is asked to make movements with his or her unaffected
hand, imagining that the movement he or she sees is that of his or her more affected hand, the
potential for activity in the areas of the affected cortex of the hand increases (verified by MRI).
This study has led to the conclusion in C. Bobath that “You don't learn a movement but the
feeling of a movement” by Berta Bobath in 1978.

Conclusion
We Bobath therapists are practicing an ancient treatment concept, that is, based on 60 years
of experience and at the same time current, based on contemporary studies. This does NOT
rule out the fact that we have to make an effort to do our own studies, designed by us.

This is difficult, but:

“…When you want something, the entire Universe conspires to help that person achieve their
dream.”

A holistic approach aimed at adults and children with neurological

dysfunction, in an interactive process between patient and therapist,
both in evaluation and treatment.

Treatment is based on understanding normal movement, using all

perceptual channels to facilitate movements, and selective postures
that increase the quality of function.

Modifies dominant movement patterns, ensures normal distribution of

tone and normal graduation of reciprocal innervation

This is a technique that inhibits tone and abnormal movement

patterns, facilitating normal movement and stimulating in cases of
hypotonia or muscular inactivity.”

BEGINNING

INHIBITION

FACILITATION

STIMULATION

INHIBITION

Inhibit pathological coordination patterns controlled by tonic activity

(Tonic Reflexes) by controlling key control points.
 INHIBITION CONTROL

The infinite number of possible responses must be inhibited. It is an

active process.

The patient is only freed from his primitive reflex modalities if he

manages to develop his inhibitory processes.

FACILITATION

Facilitate normal coordination patterns controlled by righting and

balance reactions.

Facilitating movement through the different key control points (distal

and proximal).

TAPPING

Activates weak muscle groups in the trunk and limbs.

Increases muscle tone.

Inhibitory.

Pressure.

Alternating.

Scanning.

SWEEPING TAPPING

It is performed with a precise stroke of the therapist's extended fingers

along the length of the muscle or a number of muscles working in the
same direction.

Stability and fixation of the trunk, shoulder girdle and hips when sitting,
kneeling and standing, raising extended arms.

ALTERNATING TAPPING
It is performed with the therapist's fingers extended on different
muscles to control balance reactions and head control.

TAPPING PRESSURE
Activates the simultaneous contraction of the Agonist and Antagonist
muscles.

It is used in spastic patients who are hypotonic with controlled

spasticity.

INHIBITORY TAPPING
PIR with elongation of hypertonic muscle groups and shortening of
weak inactive muscles.

It is performed in favor of the functional pattern

WEIGHT LOSSES

Automatic adaptation movements of the trunk and limbs.

Weight transfers in wide ranges, diagonally forward and backward.

It is combined with pressure and resistance.

Pleasing

The body is placed in different potions and is asked to control a wide

variety of patterns without help.

It is an automatic adaptation of the agonist and antagonist muscles in a

balance.

CHARACTERISTICS

See the child as a whole.

Active treatment.
Modify Muscle Tone.

Inhibit. Facilitate, Stimulate.

CHARACTERISTICS

Organize on the midline.

Provide the possibility of sensory motor experience.

Repetition of normal patterns.

CHARACTERISTICS

Inhibits pathological patterns from Proximal to Distal.

Work on body symmetry.

Stimulate superficial and deep sensitivity

KEY CONTROL POINTS

These are points from which spasticity is reduced and simultaneously

more normal postural reactions and movements are facilitated.

KEY CONTROL POINTS

UPCOMING.

DISTAL

KEY CONTROL POINTS

DISTAL
Elbow
Doll

Hand

Knees

Ankle Foot

REFLEX INHIBITION

HEAD
Head extension (with extension
of the shoulder girdle)
a) Raising the head in a prone,
sitting or erect position:
facilitates extension of the rest
of the body.
REFLEX INHIBITION

HEAD
Head flexion with shoulder girdle flexion: Inhibits extensor spasticity or
extensor spasms, facilitates sitting position or turning to one side

Arms and Shoulder Girdle

A- Internal rotation of the shoulders with pronation of the elbows:

inhibits extensor spasms (may be useful in athetoids), in spastics the
flexor spasticity will increase in the head, trunk and hips as well as in
Ms.Is.

Arms and Shoulder Girdle

External rotation with supination and extension of elbows: inhibits

flexion and increases extension of the rest of the body

Arms and Shoulder Girdle

B-Horizontal abduction of arms in external rotation with supination and

extended elbows: inhibits flexor spasticity especially in the pectorals
and neck flexors, facilitates spontaneous opening of hands and fingers

Arms and Shoulder Girdle

C- Arm elevation in external rotation: inhibits flexor spasticity,

downward pressure on the shoulder girdle and arms helps extend the
spine, hips and legs in spastic quadriparesis and diparesis

Arms and Shoulder Girdle

D- Extension diagonally backwards: just as horizontal abduction

inhibits flexor spasticity, it facilitates the opening of the hand and
fingers

Arms and Shoulder Girdle

E- Abduction of the thumb with the arm in supination: facilitates the

opening of all the fingers (the wrist should be extended)

PELVIS AND MSIs

a) Flexion of the legs: Facilitates abduction and external rotation, as

well as dorsal flexion of the ankles.

b) External rotation in extension: facilitates abduction and dorsal

flexion of the ankles

PELVIS AND MSIs

c) Flexion of the toes: (3 and 4 toes): inhibits extensor spasticity of the
leg and facilitates dorsiflexion of the ankles; in a bipedal position it is
difficult to achieve extension of the knees and hips.

PELVIS AND MsIs in D. Prone

A) Head extended, arms extended above the head, spine extended,

facilitates extension of the hips and legs.

PELVIS AND MsIs in D. Prone

B) Head elevated with arms extended and abducted horizontally,

facilitates extension of the spine, opening of the fingers and abduction
of the legs.

PELVIS AND MsIs in D. Prone

C) Head turned to one side facilitates flexion-abduction of the leg on

that side and upward movement of the arm. (Amphibian reaction).

SUPINE POSITION
In young children with extensor spasticity of the neck and shoulders,
flexion of the legs in abduction on the abdomen facilitates bringing the
hands together on the midline.

HALF KNEELING
A child's pelvis rotated posteriorly on the side of the non-weight-
bearing leg stabilizes the pelvis and prevents adduction and flexion of
the front leg as well as flexion of the weight-bearing leg.

SITTING
Pushing against the sternum and thus flexing the thoracic spine inhibits
retraction of the shoulders and neck, brings the head forward for
control and causes the arms to stretch forward.
DISSOCIATION

They are posture corrective movements that facilitate the elimination of

spasticity in the trunk, and the spastic reflexes of the limbs in relation
to each other, basically the lower limb in relation to the upper limb.

ATTACHMENTS FOR TREATMENT

1. Mattress

2. Roller.

3. Ball.

4.Vestibulator (used for balance training).

5. Stool. (Used for weight transfer.

6. Standing frame.

7. Swing table.

ROLE OF THE FAMILY

Family support is very important, but basically, that of the parents.

This is why parents have to worry about making this treatment a basic
activity in their child's life.

This is why the full cooperation of parents and other family members is
required.

ROLE OF THE FAMILY

For this work, all persons who cooperate in the management and
treatment of the child must know some fundamental issues such as:
Understanding the child's deficiencies and disorders, the skills to
perform the exercises on their own, which requires the advice of the
physiotherapist.