The basic theory of the Bobath method of neurodevelopmental therapy
Bobath therapy is currently the main method for treating cerebral palsy and all limbs that are not free in the world. It is a treatment method created by British scholars KaIelBobath and BedaBobath, who have worked closely together since the 1950s. Bobath mainly adopts the method of suppressing abnormal postures and promoting normal postures to treat cerebral palsy, which has achieved remarkable treatment results and has been widely adopted in developed countries such as the United Kingdom, the United States, Japan and Germany. Bobath therapy has brought hope for the recovery of incurable cerebral palsy patients.
Bobath’s Basic View of Cerebral Palsy
Bobath believes that children with cerebral palsy are different from normal children in that they have multiple impairments in fine and random movements, and thus exhibit complex and bizarre movements and various abnormal postures. These abnormalities are not only motor dysfunctions, but also language, personality, visual, auditory, intellectual and other impairments of varying degrees, which often recur, and the presence of two or more impairments in a child with cerebral palsy is called the brain injury syndrome. In the treatment of cerebral palsy, it is also found that as motor function improves, other concomitant impairments also improve to varying degrees. Therefore, Bobadk believes that the treatment of cerebral palsy must be multifaceted and follow the laws of pediatric growth and development.
Bobath analyzed cerebral palsy from a neurodevelopmental perspective and made the following two points.
1) Cerebral palsy is due to damage to brain tissue during normal development, resulting in delayed development or cessation of motor function. It is clearly proposed that this damage is acting on immature brain tissue during central nervous development. Bobath calls this condition immaturity of motor development, as it manifests clinically with significantly delayed motor development or arrest compared to children of the same age.
2) After brain injury, the inhibitory regulation of the higher central nervous system is diminished and symptoms of abnormal postural reflexes and release of abnormal movements appear. This is an abnormal postural reflex and abnormal movement that is not present in normal pediatric motor development at any age, and Bobath calls this abnormality of motor development. This abnormal postural reflex and abnormal movement, which has been demonstrated in animal tests (Shenlngton and Mapus), is a tension reflex group, which is an ancient postural reflex in germline occurrence, and exists only in lower animals, and in normal human development can only exist briefly for a certain period of time and disappear quickly afterwards, and is abnormal if it persists, and it affects the normal posture It interferes with the emergence of normal posture.
The late maturity of motor development and the abnormality of motor development are the two basic points of Bobath’s understanding of cerebral palsy, and the hyperactive state of muscle tension in cerebral palsy patients is also within this explanation.
After brain injury, motor development develops in an abnormal direction, and the patient thus does not experience normal movement, normal posture, and normal muscle tension, but instead constantly experiences abnormal sensations, which gradually form abnormal conduction paths in the nervous system, and this abnormal posture and abnormal movement become fixed in the long term, and thus the patient’s abnormal posture and abnormal movement gradually become obvious and the symptoms gradually worsen, although cerebral palsy is defined as “cerebral palsy is non-progressive”, but this abnormal posture and abnormal movement are not interrupted and the condition is still progressive, so Bobath out that “the clinical symptoms of cerebral palsy are progressive at least until puberty.” This point is also well understood by us in clinical practice small, for a patient with cerebral palsy, if not treated in time, the symptoms will become more and more serious as the age grows, so Bobath emphasizes that a favorable time should be seized to advocate early treatment, cut off the vicious circle as early as possible, and empower the function of the central nervous system. this view of Bobattl therapy, change the neural tissue can not be regenerated, damaged The treatment of cerebral palsy with Bobath therapy is a challenge to the traditional understanding of the past and is an epoch-making initiative.
Neurophysiological significance of Bobath therapy
The first is the gradual establishment of a highly complex and complete normal postural reflex function. The first is the gradual establishment of a highly complex and complete normal postural reflex function, which generally refers to the upright and balance reflexes that play an important role in human postural movement. Secondly, the neonatal reflexes, i.e., the primitive reflexes and primitive movements gradually disappear and are gradually suppressed. It mostly refers to the gradual inhibition and disappearance of primitive reflexes, such as the hug reflex, asymmetric tense neck reflex, and neonatal positive support reflex. The development of the above two aspects is closely related to the maturation of brain tissue. With the maturation of brain tissue, the cerebral cortex learns and experiences repeatedly from various external stimuli such as intrinsic receptors and visual receptors, and finally completes the motor posture, which is regulated and governed by the brain to form the normal motor posture of the casual action specification. In other words, the casual movement is produced and formed in the conduction path of motor sensation.
However, in cerebral palsy patients, because these conduction paths are impaired, normal conduction cannot take place, and stimuli from the outside world can only be transmitted in the lower centers below the site of injury, which is called a short circuit by bobath. As a result of the short circuit, the higher centers are not regulated and inhibited, resulting in the abnormal posture and abnormal movements of cerebral palsy, which is the short circuit cycle. For example, according to Bobath, in patients with severe spastic cerebral palsy, the lower gluteal joints are internally retracted and internally rotated because of the spasm of the extensor group, and the stomp joints are flexed into a pointed foot state; the flexor group spasm leads to the typical fixed postures such as flexion of the skeletal joints and flexion of the knee joints. If this fixed abnormal posture, in the lower center to form a short circuit, the normal motor posture impulses from the cerebral cortex can not be transmitted down, this is in the motor conduction path, due to the short circuit cycle, abnormal nerve conduction path fixed to form abnormal posture. Therefore, it is impossible to form a normal posture with short-circuiting, and even if there are other motor postural impulses, they are restricted to circulate in the abnormal short-circuiting, making the abnormal posture even more severe.
For this reason, Bobath suggested that in order to correct this abnormal motor posture, it is necessary to close (cut off) the short-circuit cycle of this abnormal movement and to activate and open the nerve conduction pathway of normal movement, the former to inhibit the abnormal postural reflexes and the latter to promote the normal postural reflexes. In infantile cerebral palsy, as long as the short-circuit cycle of abnormal postural movements is closed, it is possible to naturally activate normal motor postures that have existed for a long time in germline development, so Bobath emphasizes early treatment of cerebral palsy. From the above point of view, when correcting abnormal posture for the above-mentioned severe spastic cerebral palsy, for spasticity of the extensor group, it is necessary to take to make the broken joint flex and knee flex; for spasticity of the flexor muscle, it is necessary to take to abduct and externally rotate the skeletal joint and dorsiflex the pedal joint, and this method is reflexive inhibition of posture. This empowerment opens up the normal motor-sensory stimulus conduction path that was already present, plays a role in promoting the passage, and cuts off the stimulus from the periphery to form a short-circuit cycle in the lower center. By this means the short circuit is closed, the normal conduction pathway to the higher centers is opened, and the motor posture of the higher centers is facilitated, which Bobadh refers to as the control short circuit. The normal reflexes that have emerged are expanded and consolidated by spatial enhancement, temporal enhancement and gradual enhancement.
Treatment steps.
1. Correctly evaluate the child’s level of neurodevelopment and development of motor ability, and identify the main abnormal postures and abnormal responses.
2.Identify the main problems
After the above evaluation, first of all, we should determine the diagnosis and find out the main problems of the child, and then list them one by one according to the main and secondary problems, and preferably draw a line diagram and make a brief description, so as to facilitate the decision of the next step of treatment and the reference of comparison for the next evaluation.
3.Determine the goal of treatment
The treatment goals are designed according to the main problems of the child and the law of child development. Generally, two goals are set: one is the short-term goal, that is, the goal that can be achieved and corrected as soon as possible after treatment, which can also be said to be the initial goal of treatment. The other is the long-term goal, which is the goal that can be achieved through a longer period of treatment, or the final or near-final goal. Both goals must be designed in accordance with the developmental pattern of the pediatric patient, taking into account the specific situation of the child, and designing a practical direction for treatment.
Short-term daily goals can be designed one stage at a time, and generally need to wait until this stage is completed before designing to proceed to a second goal, sometimes more than one, but this is not absolute. Because one kind of development often breeds another kind of development, children do not have to wait until they are completely seated before they start to crawl, sometimes they do it at the same time, and the ultimate goal is to complete the final long-term goal.
4.Design of treatment plan
The ultimate purpose of evaluation is to treat, in order to design the best treatment plan for the early recovery of the child. The design of the treatment plan should be based on the goal of treatment and the problems of the child. The Bobath treatment method is mainly for the rehabilitation of movement disorders, and it is necessary to identify the main problems, analyze the causes of the problems, design the methods of correction, and design what should be inhibited and what should be promoted according to the Bobath viewpoint. It is not necessary to mechanically make the child reach this stage before starting the next stage of training, but it can be done differently. The child will be able to achieve recovery through a well-organized and rational approach.
Bobath treatment method and stages
Bobath analyzes internal palsy from the perspective of neurophysiology, and proposes that cerebral palsy is the immaturity and abnormality of motor development, and the treatment must also follow these two perspectives, inhibiting abnormal postural movements and promoting normal postural movements. In order to inhibit abnormal posture and suppress abnormal postural reflexes, we adopt the reflexive inhibition posture; in order to promote normal postural reflexes, we induce normal movements while doing key point conditioning; in order to stimulate superficial receptors and intrinsic receptors and increase the muscle tone of specific muscle groups, we adopt the method of gentle percussion called percussion method. The above three methods are the basic theory and basic methods of Bobath therapy. However, in the actual treatment, because the disorders of children with cerebral palsy are multifaceted, they cannot be completely cured by physiotherapy alone, and it is necessary to carry out a comprehensive treatment in many aspects. Bobath therapy is a physiological treatment that requires the therapist (trainer) to be skilled and experienced, to have his or her own feelings and experiences during the treatment, and to induce normal responses in the child as the treatment progresses, and to continuously summarize and explore the best treatment method. Therefore, it can be said that there is no fixed treatment standard for Bobath therapy, but there are many different treatment techniques. The complex problems of individual children with cerebral palsy should be treated differently and the corresponding treatment methods should be adopted separately. The trainer should try to get close to the child before the treatment and become a good friend of the child quickly, and getting good cooperation from the child is the key to the treatment. During the training, words of encouragement can be used to increase the child’s interest in the training. The length of training time should be determined by the child’s response and tolerance, usually 40-50 minutes each time, or a little longer if the child tolerates it, and at least twice a day. During training, we should always observe the child’s response and pay attention to whether normal postural movements occur. The intensity, size and direction of the stimulus should be adjusted according to the child’s response. The treatment is conducted in a one-on-one manner between the trainer and the child, and records are kept after the training.
The overall goal of Bobath therapy is to suppress abnormal posture, promote the upright and balance reflexes, form the most important automatic reflexes in life, promote normal coordination of the muscular system, keep the coordination of the action and antagonistic muscles, so that the child can continuously gain normal sensory-motor experience, and gradually acquire the most basic motor functions in life, such as turning over, crawling, sitting alone and standing.
Bobath treatment can be carried out in three broad phases as follows.
Phase I: To restore or approach normal muscle tone, inhibition of abnormal tense postural reflexes, such as asymmetrical tense neck reflex and tense vagal reflex, may be used. Gradually, normal muscle tone is obtained.
Phase 2: Promote the development of upright reflex and balance reflex, mostly unconsciously, in various postures and in the state of imbalance. For example, if you stop suddenly when riding in a car, unconsciously take a step forward to maintain balance, or you can push the child forward, backward, left, or right at the point to make him or her take the first step in the case of loss of balance. Promoting the balancing action, which is an unconscious automatic reflex, is one of the most important functions in life.
Stage 3: Moving to the casual movement stage, the treatment does not pose a good movement for the child, but through the designed scene, the child is guided to appear in a normal movement posture, experience the feeling of normal movement, so that the spasm is reduced, and gradually induce spontaneous casual movements, in the order of turning over, four crawling, sitting, standing, etc.