When Mrs. Bobath started treating a patient with severe flexion spasm of the upper extremity, the child showed significant resistance when she passively stretched the elbow joint, the child’s whole body became stiff and the spasm increased significantly. Instead of direct passive manipulation at the elbow joint where the spasticity was strongest, Mrs. Bobath changed the treatment technique to one that was performed on the shoulder and trunk away from the elbow joint, and the spasticly flexed elbow joint miraculously extended. She later used this experience several times on children with tetraplegia and obtained the same results. Mr. Bobath later elucidated the problem from a neurophysiological point of view, which was the result of reflex inhibition. The shoulder and trunk are the key points. Therefore, the trainer must thoroughly analyze the cause of the disorder before treatment, and apply manual therapy to the key areas so that the child’s symptoms can be improved and the spasticity can be reduced. However, Bobath was inspired by the return of spasticity after a period of time. The treatment of cerebral palsy must not only use suppressive techniques, but must also suppress abnormal postures while promoting normal postural movements. Therefore, the basic techniques of Bobath therapy are centered on two major techniques: reflex inhibition and facilitation.
(1) Inhibition of abnormal movement patterns, especially reflexive inhibition or weakening of most abnormal tension postures in high tension posture patterns.
(2) Facilitation (evocation) of normal movement patterns: especially the facilitation of the corrective response and balance response where fine movements are unified. The actual treatment of cerebral palsy involves many aspects and it is impossible to deal with only one type of physiotherapy, so the BoLadh method is not called a technique. It needs to be manipulated by the therapist to obtain good results and achieve the therapeutic purpose, so it is called the Bobath method.
Bobath emphasizes that care should be taken in the actual treatment.
① Do not ask the child with cerebral palsy to do too many movements: because the movements that are easy for a normal child to make are difficult for a child with cerebral palsy to accomplish. The activity can cause an increase in abnormal postural reflexes such as involuntary movements, which can contribute to contractures and deformations. Training must be done slowly so that it can be completed naturally.
② Pay attention to inspiring automatic movements. Do not say in the training that this is not okay and that activity is not okay.
③It is not necessary to inhibit the primitive movement pattern, as long as the normal postural reflex is promoted to make it disappear.
④There is a difference between this method and orthopedic physical therapy. The key point is used to adjust, but not for the purpose of moving the key point area, but for the purpose of inducing normal movement of the whole body.
⑤In case of organic contracture, if manual technique treatment is ineffective, orthopedic surgery is still required to solve the problem.
⑥Evaluation while treating, timely correction of the treatment direction, and simultaneous evaluation during the treatment time means that it is not necessary to develop the details of the treatment plan in advance.
(7) Each patient’s situation is different and the problem is not the same, so a uniform treatment procedure and routine cannot be made.
The Bobath method has the following three main treatment techniques.
(i) Inhibition and control of key points
The Bobath method is a treatment method that has been confirmed by long-term clinical experience to inhibit abnormal postural reflexes and to naturally induce the potential functions of the child, i.e., the therapist operates certain parts of the body during training to inhibit contractures and abnormal postural reflexes and to promote normal postural reflexes. These areas are referred to as key points of control. These sites are mostly proximal to the body and move peripherally as the treatment progresses, with a consequent reduction in the number and amount of manipulation points. and gradually increasing the intentional movements of the child with cerebral palsy on his or her own. These key points are combined and applied in various positions in the supine, prone, four-crawl, and standing positions, depending on the child’s condition. There is a splitting of afferent nerves in children with cerebral palsy. While a normal nerve stimulus is directed into a certain neural pathway, children with cerebral palsy have a greater resistance to afferents because of the immaturity of their higher centers. They are directed into the original reflex pathway with less resistance. The input of the afferent nerve determines the output of the efferent nerve, so that when the afferent information is directed into the path of the primitive reflex, it shows abnormal movement patterns. In children with cerebral palsy who have abnormal muscle tone and sensory abnormalities, the inhibition technique is to manipulate the key points so that they have normal sensory input and the correct neural pathways for these inputs to be transmitted to obtain the correct form of movement. However, it is important to note that the application of facilitated evocation is also included in the method of inhibition.
1. Head.
(1) forward flexion: the whole body flexion mode is dominant and acts as an inhibition to the whole body extension mode, while completing the facilitated flexion posture. Head forward flexion can be performed in prone, sitting, and standing positions. However, in those with symmetrical tension neck reflexes, head forward flexion is associated with hip and lower extremity extension patterns and spinal backbends.
(2) dorsiflexion: neck extension, then the whole body extension predominates, inhibiting the whole body flexion pattern, while completing the extension posture, extension movement promotion.
(3) gyration: it can destroy the systemic extension and flexion pattern, and can induce the internal gyration of the body axis, and the abduction, external rotation, internal retraction and internal rotation patterns of the limbs. However, in severe cases such as spasticity, strong rigidity or intermittent spasticity, the head cannot be controlled directly, and the key points of the scapular girdle and trunk as described later should be used to control the limb position of the head. Special chairs can be made to maintain a good sitting posture to keep the head position in severe cases.
2.Scapular girdle and upper limbs: keep the scapular girdle protruding to the front then the whole body flexion is dominant and can inhibit the whole body extension mode state of head over extension to the back. As long as the upper limb is extended for induction, the scapular girdle can be maintained in the forward protrusion position. If the scapular girdle is made to retract, it will make the whole body extension mode to be extension dominant, which can inhibit the whole body flexion mode caused by head forward flexion, and promote the anti-gravity extension activity, which can be operated directly. Or the upper extremity can be used to maintain the change in limb position of the scapular girdle.
Combined upper extremity and shoulder joint activities often have good results.
①Internal forearm abduction with complete internal rotation of the shoulder joint is effective in suppressing the spasticity of the tachycardia-type extensors, but if used for the spastic type, it increases the spasticity of the flexor pieces of the trunk and lower gum. In this case, if it is changed to forearm abduction and elbow extension, so that the shoulder joint is completely externally rotated, it can suppress the whole body flexion pattern and promote its extension.
②If the forearm is abducted, the elbow joint is extended and the shoulder joint is externally rotated while the upper limb is horizontally abducted, the spasticity of the flexor muscles, especially the thoracic muscle group and the flexor muscle group of the neck, is suppressed and the spontaneous extension of the fingers is promoted. It also promotes simultaneous abduction, external rotation and extension of the lower limbs.
③External rotation of the shoulder joint – lifting the upper limb can inhibit the flexor twin of contracture-type quadriplegia and diplegia and the resistance of the upper limb and scapular girdle downward, so that the spine, hip joint and lower limb become easy to move.
④External rotation of the forearm together with thumb abduction can promote the extension of the whole finger.
3, trunk: (spine): the trunk is bent forward, the whole body becomes flexed position, will inhibit the generalized extension pattern and promote flexion posture, flexion movement, the supine position of the generalized extension pattern strong muscle tension disorder hand-foot tachycardia, the use of forced flexion of the trunk is one of the common techniques for the purpose of reducing generalized over tension. It should also be noted that older children with myotonic dystonia with tardive dyskinesia often experience trunk hyperextension when they sit in a chair or wheelchair with their head and back pressed backward against the back of the chair.
The posterior flexion and extension of the trunk allows the generalized extension position to dominate and becomes an inhibitory generalized flexion pattern. Trunk kyphosis can destroy the generalized flexion and extension pattern, and promote through body axis kyphosis and limb kyphosis.
4. Lower limbs and pelvic girdle.
① Flexion of the lower limbs can promote through hip abduction, external rotation and foot joint dorsiflexion.
②Extension of the lower limb can promote abduction and dorsiflexion of the foot joint.
③Dorsiflexion of the toes (especially the 2nd, 3rd, 4th and 5th toes) inhibits the spasticity of the extensor muscles of the lower limbs and promotes dorsiflexion of the foot joint and external rotation and abduction of the lower limbs.
The operation of the pelvic belt is mainly used in the sitting and standing positions. When the pelvic belt is posteriorly tilted in the sitting position, the upper body flexion position is dominant and the lower limb extension position is dominant. In the standing position, the posterior tilt position and the generalized extension pattern are achieved. In the anteriorly inclined sitting position of the pelvic girdle, the upper body extension is dominant and the lower body flexion is dominant. In the standing position, the child has an anteriorly inclined posture and a generalized flexion pattern. In a typical scissor limb position, a child with spasticity who supports weight with the front of the foot can stand up if the pelvis is tilted back, so that the weight can be shifted backward and the hip and trunk can be facilitated to extend, and a good standing position can be accomplished. A child with spasticity who has a forward-flexed head, arched spine, flexed upper limbs, and two lower limbs fixed in the inward position with the soles of the feet not on the bed, if the pelvis can be tilted forward so that the trunk is fully extended, it can promote the forward motion of the tendon joints and normal flexion of the lower limbs, and practice to a stable sitting position. For children with tardive dyskinesia and hemiplegia, if the pelvis is tilted forward, it can overcome the compensation of over-extension and reversion of the lumbar vertebrae when walking and prevent falls, so that the lower limbs can be fully assisted. The application of different manual techniques in different limb positions can also achieve effective control, as listed below.
(1) Prone position.
① head extension, upper limb shoulder joint external rotation position to lift the upper limb, can promote the extension of the spine and upper limb joints.
(2) head extension, forearm rotation out, elbow extension, in the shoulder joint external rotation position so that the upper limb horizontal position abduction, you can promote through the spine extension, finger extension, lower limb abduction.
(3) head extension to the side of the gyration and flexion of the face side of the lower limbs abduction, can promote the upper limbs to the upper movement.
(2) supine position: the spastic type is not heavy, the neck and scapular band receding young children, such as when the lower limbs of their outstretched booth to the abdomen bending knee, then the two hands extended to the front will be easy to close to the middle position.
(3) Sitting position.
①For children with long sitting position with extended legs, make them fully flex the trunk at the hip joint, then you can promote the extension of the spine and head lifting.
②Stabilize the scapular girdle by keeping the inwardly rotated upper limb in the inwardly rotated position, which can facilitate pulling up to the sitting position and recovering to the supine his head control.
(3) Pressing the sternum so that the thoracic spine becomes rounded back can inhibit the retraction of the head and shoulder swollen belt, so that the head and upper limbs to the front.
(4) Knee stance, standing position.
(①Forearm inversion and complete internal rotation of the shoulder joint, and then flexion of the thoracic vertebrae can inhibit the hand-foot tachycardia-type extensor twin and hyperextension of the knee joint.
②Extension of the upper limb in external rotation position, slightly to the rear when kept on the diagonal, can inhibit the twins of the trunk, tendon joints and lower limbs for the spastic type, and can promote the extension of the spine and the external rotation and external booth extension of the broken joints and lower limbs.
The above manual techniques can be used individually or in combination for spastic, rigid and intermittent degrees of muscle spasm. Generally, for severe cases, most of the operations are performed with the purpose of inhibition; for moderate cases, inhibition is combined with facilitation factors; for mild cases, inhibition manual techniques are considered on one side along with facilitation. Application of the above-mentioned proximal position control key points to start with, and gradually reduce the manipulation with passive holding as the treatment progresses, and move to the elbow, hand, finger, knee, foot joint, and distal toe areas. Care should be taken not to assist the child too much.
(ii) Facilitation
Facilitation is a technique that enables the child to acquire active, automatic responses and motor skills. Inhibition should be used to decrease spasticity before or at the same time as facilitation. During the treatment, inhibition-promotion techniques are used continuously to give the child normal muscle tone, movement patterns, corrective responses and balance responses. The aim is to induce the maximum potential ability of the child, to the extent that it does not impede its own movement, and to wait for a response after giving appropriate stimulation. If an abnormal response occurs, it should be combined with the use of control of key point maneuvers.
The following conditions are adapted to the voluntary postural response.
①Newborns or young children.
②Spastic children: mainly promote the development of motor patterns and move to normal development.
(③) Children with tardive dyskinesia and dysmetria: their muscle contractions are high and low, especially the lack of simultaneous contractions, so the correct timing of muscle contraction adjustment should be mastered, so that the whole body contraction is equally distributed.
Children with flaccid type: In order to stimulate the autonomic response, the lungs are given strong stimulation.
(1) Facilitation of the cervical turn-over response: First, use both hands to slowly lift the child’s head from above the child in the supine position, and you will feel the increased contractility of the muscles around the neck, followed by a little decrease in support. When the contractility spreads to the scapular girdle and abdomen and the child’s head is felt to be light, then the hands can be changed. Gently support the head with one hand or just the fingertips; hold the child’s face with the other hand and slowly rotate back in the direction of the left stone: care must be taken to maintain a certain height of the head to the bed during this period. If the neck is rotated, the turning movement will be induced in the order of scapular belt, upper limb, trunk, pelvic belt and lower limb. That is to say, from the supine position anyway, the promotion of the response can induce the lateral and prone position, and can also be induced from the prone position to the supine position to. However, instead of turning over by passive manipulation, the head-turning response is induced by the facilitation of the head-turning response to induce muscle contraction to achieve the neutral position. Symmetrical posture, anti-gravity stretching activities, and separate movements of the upper and lower extremities are normal child developmental coordination patterns, thus allowing the child to experience normal motor sensations. It is used clinically for spastic and intermittent spasticity without severe torsades de pointes cerebral palsy to promote lateral recumbency with both hands pointing to the median position and symmetrical posture. Children with spastic diplegia can learn to separate movements of the lower limbs (especially abduction and external rotation patterns). If the child’s jaw is supported by the other hand, the child’s head is rotated back to the left or right side, and the pelvis is rotated back when the child is supported by the forearm, which induces the flexion of one lower limb to step forward. If the spasticity of the lower limb flexors tends to increase, the child’s head is held under the two axillae to induce the gyration of the scapular girdle. This is a distal manipulation of the child with spastic diplegia to assist in the coordinated movement patterns of the lower extremities. For a prone child with upper arm support, induce upper extremity extension position support while rotating the trunk back to induce a long sitting position (leg extension sitting). Continue to rotate the head back and forth so that both arms support the weight; rotate the trunk back so that the pelvis is picked up from the bed into a four-crawl position.
From the four-crawl position, the child’s jaw and posterior head are maintained and the weight is slowly shifted to the posterior to elevate the hip and trunk into a knee-standing position with anti-gravity extension. The therapist then moves to the side of the child, holding the head with both hands, shifting the weight to the knee on one side and then rotating the head back to the opposite side, lifting the free lower extremity to the front to form a single knee position. The therapist holds the head while the child changes to a forward position, with the lower limb on the forward side supported by the sole of the foot, gradually extending the hip joint and rotating the head to induce a weight-support stance with the sole of both feet. Such a series of movements is based on the upright response of the head and promotes the induction of various limb positions. This manual technique is not limited to the head, but can also select the shoulder girdle, pelvis, upper limbs, and lower limbs, and be used in response to the child’s symptoms; in addition, the body-to-body uprighting response, head-to-body uprighting response, vagal uprighting response, upper limb extension response, and balance response can also be used to promote automatic responses using the manual technique.
(2) Stretch response of upper limb protection: The stretch response of upper limb protection appears at 5 months after the disappearance of hug reflex. The developmental response of extending the hand to the front first, to the side from 8 months, and to the rear after 10 months to protect the outstretched hand is continuously maintained throughout life.
(1) In the prone position, the child’s weight is supported by the upper limbs, and the child is picked up from below, or the scapular girdle is tugged posteriorly and slowly moved laterally as a way to induce extension of the upper limbs and to carry the weight in his or her hands.
(ii) Upper extremity weight support in the four-crawl position, and as in ①, carrying the weight in the four-crawl position with the hands.
(3) Upper limb protection extension in the sitting position. For children who are sitting, the therapist should perform a sudden push to the front and side position without prior notice, so that the child’s upper limbs are extended to turn the body right up.
(3) Facilitation of balance response: Facilitate in supine, sitting, standing and other limb positions. This can be done with the use of large balls, rollers, balance boards and other auxiliary training apparatus.
(3) Stimulation of intrinsic receptors and body surface receptors manual technique
It is used for the disorder type and tardive dyskinesia type with difficulty in controlling posture due to general hypotonia or simultaneous contraction disorder. Children with spastic cerebral palsy who have low muscle tension even though abnormal postural reflexes have been suppressed with key points, etc. It is also used to learn normal muscle contraction.
(1) “Weak muscles” that lack sensory input are used to prevent children from becoming sensory deficient.
(2) Muscles that have spasticity or intermittent twin reduction due to treatment, or are completely inhibited.
(3) Muscles that lack motor sensory experience or have motor dysfunctions.
Implementation should pay attention to.
① Aim to stimulate local response, and should avoid inducing a wide range of joint response.
②In postural low tension situation manual technique treatment, if abnormally high tension is found, it should be discontinued and used alternately with inhibitory techniques.
(③) In combination with the reflexive inhibition mode stimulation manual technique, the problem of “conversion” from abnormal reflex mode to the target system and direction. The main manual techniques are the following 4 types.
1. Compression: Compression is applied while resisting or using weight load alone, with the purpose of automatic adjustment movement of trunk and limbs. It can be performed in various positions such as supine, prone, sitting and standing. For example, in children with lack of contraction of the muscles around the shoulder (especially the deltoid muscle) and hand dysfunction, the scapular girdle is compressed from above in the prone position so that the forearm is loaded with weight and the muscles from the scapular girdle to the upper arm are contracted simultaneously. Or today the child moves the weight to the side to increase the counter force to increase the contraction of the muscles around the shoulder joint at the same time. Another example is compression of the top of the head or scapular band downward for children sitting with extended legs to inhibit tardive dyskinesia type movements and control the head.
2.Positioning response and holding response.
(1) Position response: refers to the ability to maintain a certain limb position within a certain range. Such as the upper or lower limb passively suspended in a certain limb position, for the feedback of the normal postural response to the stimulation of the weight of the limb, the automatic muscle adjustment to postural changes. Such as in the sitting position, the upper gum horizontal position lifted, slowly reduce support or suddenly scattered, the upper limb stagnation, so that the joint part of the simultaneous increase in contraction, this stagnation is the child’s conscious to control, called hold response, for the automatic adjustment of the posture change muscle role. For example, gently support the child’s jaw in the prone position first, and then slowly reduce the support, so that the child’s own efforts to control the head, can play a therapeutic role. Also in the supine position, prone position, sitting position, standing position and other postures to do a variety of upper and lower limb position changes, the purpose is to improve the contraction of muscle groups and intrinsic receptor perception.
3, pat: stimulate the intrinsic receptors, body surface receptors to improve the muscle tension method, the limbs, trunk regular or irregular patting techniques to achieve the purpose of muscle tension, in order to obtain automatic limb position to maintain the promotion of manual techniques. It is mostly used to maintain the posture of the tardive type and the disordered type; of course, it is also used for the spastic type, which can reduce the resistance to postural changes and make the balance response situation better. Clinically, it is divided into the following 4 types according to the purpose and use.
(1) Inhibitory tapping: resistance to muscle spasm without completing the mutual inhibition effect. It is a manual technique performed on the so-called “weak muscles”. Tapping stimulates the intrinsic receptors and surface receptors and increases the muscle tone of the neck, trunk and extremities in an attempt to activate the orange resistance muscle as inhibitory tapping. For example, in the medial part of the elbow joint in flexion mode due to flexor spasm of the upper extremity, a small hammer is used to repeatedly tap and slowly pull away. There is an automatic small repetitive muscle contraction of the flexor muscle group in the elbow extension direction of tapping. During the repeated contractions, the flexor muscle groups learn to contract normally, thus reducing muscle spasm. Alternatively, to inhibit spasm of the triceps calf muscle, the child is treated by placing the child in a prone position and tapping on the bottom of the foot of the flexed knee.
(2) Compressive tapping: tapping acts simultaneously on the active, antagonist, and synergist muscles in an attempt to achieve increased postural tension. For this purpose, so that the flaccid child can maintain various postures, such as the top of the head of the sitting patient with extended legs pressed downward tapping to maintain the sitting position. Or tapping on the shoulders of a standing child to promote a symmetrical posture. It is mostly used for children with cerebral palsy who have poor fixation and difficulty in sustaining certain postural tensions of the tachycardic and dysmetabolic type.
(3) Reciprocal tapping: The above manual technique is used to keep the child in a good intermediate position, to do reciprocal tapping for children with tachycardia and dyscalculia, and to promote the balance response of children with spasticity. It can be applied in various positions such as supine and prone. For example, a child sitting with legs extended is tapped from front to back. It can increase the contraction of the abdominal muscles and the quadriceps group. Another example is low abdominal muscle tone, lumbar forward bending of the dual or hemiplegic children in order to obtain leg extension sitting position, the therapist can pat from the rear of the child, so that the tilt and then back to improve the contraction of the abdominal muscles, can promote sitting, standing balance up.
(4) Rubbing tapping: strong stimulation of specific muscles and their skin, used as part of the various techniques mentioned above. The aim is to increase the activity of the active and synergistic muscles. The method is to stretch the therapist’s fingers and rub the muscles and skin flexibly and quickly to stimulate. For example, the therapist gently supports the child’s upper extremity in a chair with one hand while the fingers of the other hand rub the forearm quickly and lift it to maintain the upper extremity position. Another example is to support the lower jaw of the child in forearm support position or prone position to assist in head control, and to lift and push the lower jaw when the lower jaw falls down when the hand is removed to promote the maintenance of the central position.