PRACTICAL GUIDE TO LABORATORIES

Physiotherapy Program

TEACHER: SUBJECT: AREA: PRACTICE No.

MONICA ANAYA FROM NURSERY KINETIC MODALITIES PROFESSIONAL 3

III

THEMATIC UNIT
SPECIFIC MODALITIES OF MOTOR CONTROL INTERVENTION: BOBATH METHOD IN ADULTS.

INTRODUCTION

The Bobath concept is an effective treatment in post-stroke rehabilitation, for problem solving,
assessment and treatment of people with impaired tone, movement, function and postural control due
to CNS injury.
This concept emphasizes the integration of postural and movement control, the execution of tasks for
the realization of coordinated sequences. Seeks to use appropriate sensory information to influence
proper postural control. The integration of posture and movement are modulated by sensory stimuli and
influenced by learning and experience. One of the main factors to reduce deterioration and improve
activity levels in people with brain damage is based on the capacity of neuromuscular levels to adapt
plastically to the injury and the environment, therefore, treatment focuses on the individual's potential
to recover capacities through adaptation by means of neuronal plasticity.

AIM

Apply previously acquired theoretical knowledge to practice based on the Bobath concept in adults for
the rehabilitation of users with alterations in the neuromuscular domain.

SPECIFIC COMPETENCE

The student acquires basic skills in simulated situations in the execution of procedures and intervention
modalities in neuromuscular domain alterations, specifically the Bobath method in adults, showing
respect for the people with whom he/she interacts in the execution of the physiotherapy treatment.
MATERIALS AND EQUIPMENT

 Neurological stretcher
 Mats
 Rollers of different sizes
 Balls of different sizes
 Parallel bars
 Stairs
 Materials to work on fine motor skills
 Comfortable clothes

PROCEDURE:

After a demonstration by the teacher, proceed to:

1. Divide the group of students into subgroups per stretcher.
2. Each subgroup carries out the practice taking into account what has been presented and demonstrated
by the teacher and the help videos with the different exercises of the Bobath concept in adults. Each
subgroup is then assigned a clinical case for analysis and selection of the appropriate exercises for each
particular case.
3. Each subgroup must take into account the following:
KEY CONTROL POINTS:
 Central or Final Point
 Pelvis
 Shoulder Girdle
 Feet
 Hands
 Head
MANUAL CONTACT: The therapist's hands and body guide the patient. It should be the minimum required
by the child to act.
 ORGANIZE THE USER
 GUIDE POSITIONING OR ACTIVITY SEQUENCE (at different stages)
 PROMOTE MUSCLE EFFICIENCY
 DEVELOP OR BOOSTING BALANCE AND/OR PROTECTION
 WEIGHT TRANSFERS: They promote body awareness and learning stable positions with good
alignment.
 All of the above taking into account the task of achieving functionality, without forgetting the
motivation on the part of the user.
VERBAL COMMAND: to reinforce the learning of the new posture or movement (repetition)
SMART GOALS: Keep these goals in mind when developing a good treatment plan: specific, measurable,
achievable, realistic and time-bound.
EMPHASIS ON BRAIN NEUROPLASTICITY
INITIAL FLACID STAGE
1. POSITIONING IN BED:
to. Supine position: To prevent shoulder retraction: MS in extension, elevated (higher than body level),
forearm in supination, wrist in extension, head tilted to healthy side.
b. Lateral decubitus on the affected side: head in slight flexion, affected shoulder flexed, forearm
supinated, MI extended. Healthy half of the body: MI forward on a pillow. Avoid palmar and plantar grip.
c. Lateral decubitus on the healthy side: complete lateral decubitus, not intermediate, head in slight
flexion, trunk aligned, pillow under the trunk to stretch contralateral muscles, MS elevated to the level of
the head, on a pillow like the MI, this one is also in flexion. The foot should be supported and not
suspended in inversion.
d. Rolling: Starting with the upper body, the patient must first learn to raise the affected arm with the
healthy one (hands interlaced), elbows extended, lower limbs in the midline. Train by starting the
movement with the lower limbs to one side and the other. The turn to the healthy side should be initiated
with the lower limbs and trunk, which facilitates the turn of the pelvis and lower limbs.
and. Transition to sitting: Begin by rolling with your hands clasped, towards the affected side, facilitating
the movement from the head while pushing with the affected MS. The affected MI is assisted in sliding to
the edge of the bed, and is finally facilitated from the head.
F. Sitting: head and trunk aligned, symmetrical weight relief on pelvis. MS affected in extension, hands
clasped together resting in front on midline. Avoid external rotation of the affected MI.
g. Transition to biped: FT standing in front of the patient, holding him by both hands in front, knees well
aligned, feet parallel and at right angles to the knees. Prevent the patient from lifting the affected foot off
the floor and provide anterior support to the affected knee to give the sensation of weight bearing,
support on the lumbar spine by bringing the trunk forward, pressure against the patient's knees
facilitating the push of the lower limbs to reach bipedalism.
2. PREPARATION ACTIVITIES:
to. Seated and bipedal:
- Work to control the leg: the patient's lower limb is flexed, preventing it from falling into abduction and
keeping the foot in dorsiflexion and pronation. Wait until all resistance has been released and then slowly
extend the leg in stages, asking the patient not to let it fall or to push the therapist's hand. If at any point
during the exercise the therapist feels the full weight of the MI on the hand, he asks the patient to flex
again and waits until he has control of the segment again.
- Extension in preparation for weight support: FT places the foot in dorsiflexion and pronation against his
body and asks the patient to perform small isolated knee flexion-extension movements. Control knee
hyperextension from the popliteal area.

b. March without circumduction:

- Patient with MI on one side, hanging in bed (knee flexion, hip extension and abduction). Hold the foot in
dorsiflexion and help flex and extend the knee without allowing hip movement.
- Patient on the surface, flex the hip and knee of the affected MI, maintain dorsiflexion of the foot and ask
for a bridge on the affected side.
- Flex the affected MI at hip and knee from side to side in ABD and ADD , maintaining dorsiflexion. The
movement may be asked to stop at some point and the patient must control it.

c. Seated trunk balance:

- The patient tends to fall towards the affected side and does not put weight on the affected hip. Use PCC
in MS to cause head straightening to the healthy side (lengthening of the lateral trunk flexors and
elevation of the shoulder girdle.
- FT on the affected side of the patient, raise the shoulder girdle, holding it below the armpit, taking care
of abduction, external rotation, elbow and wrist extension, and finger extension. Do not allow support
with the healthy hand (place it on the MI or lift it), lean the patient towards the therapist and facilitate the
return to the midline with control.
- FT to the affected side, elevating the shoulder girdle from the armpit, promoting MS support and
weight transfer to the affected side – pressure or alternating tapping to facilitate coactivation.
- Promote support on forearm, if the patient becomes destabilized, raise the shoulder girdle and
encourage head tilt to the healthy side – pressure or alternating tapping to facilitate coactivation.
- Promote anterior weight transfer in a seated position, controlling trunk activity and hugging the patient
with the lower limbs raised. Keep your spine extended and look forward.

d. Using MS as an active support base:

- Place the patient's hand resting at a certain distance from the trunk. Hold under the armpit in scapular
elevation or keep the elbow extended. Weight transfer from the healthy side to the affected side. Keep
the MS in external rotation. Fingers and wrist in full contact with the surface. Shoulder overpressure can
be exerted if the patient controls the scapula and elbow (increases extensor activity and stability).
- In the same position, promote controlled flexion and extension movements of the elbow.
- If the flexor spasticity of the MS is very strong and does not allow support of the patient's MS, PCC is
applied by bringing the lower limbs in extension and external rotation behind the body. In this position
the patient's hand is supported (shoulders level).
- In the same position and anterior PCC, raise the lower limbs promoting weight transfer anteriorly with
correct extension of the spine.

and. Control of the arm at the shoulder: The patient achieves control of the shoulder girdle and the MS
more easily when supine than when sitting (hip flexion increases flexor spasticity). During arm flexion and
elevation work, the patient's lower limb should have some flexion with pronation and full support on the
surface. Avoid pelvic retraction. F. Mobilization of the shoulder girdle: It is performed in supine or lateral
decubitus on the healthy side. The goal is to make painless arm elevation possible. - Hold the patient's arm
with the elbow extended and externally rotated, the PT uses both hands to move the shoulder girdle up,
down and forward (not backward). Patient's head tilted to the healthy side. If the scapular retraction is
very strong, do it in a lateral decubitus position. - Raise the patient's arm above the head with the hand
held in this position, the patient is asked to roll into prone (i.e. move the body against the MS). - Gradually
with light traction, raise the MS. Stop and go back a little to where the patient is experiencing pain. At all
times, maintain the counterbalanced pattern: trunk elongation, protruded and elevated shoulder, external
rotation, supination and extension.
- In the overhead lifting position propose: elbow flexion and extension, lifting against resistance, abduction
and adduction control, lowering the MS with stops at different moments of the movement with control.

SPASTIC STAGE:
- POSITIONING IN BED: Sitting: proper alignment, uniform pelvic belt, lower limbs interlaced and
supported in front, avoiding shoulder retraction, lower limbs in neutral rotation.
- TRANSFER FROM BED TO CHAIR: Wheelchair and assistance on the affected side. Promote movement in
bed by transferring weight onto the pelvic belt and with active support from the lower limbs. FT places
MMSS below patient's shoulders with hands on scapulae, knees and feet patient/therapist matched.
Facilitate the transition by respecting the forward-up stop.
- SITTING IN A CHAIR: Feet parallel. But on a symmetrical pelvic belt or more on the affected side, hands
clasped, slight forward tilt of the trunk.

SUPINE TREATMENT:
- Raise and lower the upper limbs by holding a bar, keeping the elbow extended and making controlled
stops.
- With the bar held high, move your hands along it.
SITTING: - Have the patient sit in a chair between two others, allowing him/her to support himself/herself
on the lower limbs when moving from one chair to the other, finding the center of the chair without
looking, regaining pelvic control, trunk rotation and elongation of the affected side.
- Hands clasped, lower limbs together, ask the patient to simultaneously move their legs towards the
healthy side (avoid pelvic retraction).
- Assist the patient in lifting the affected MI over the healthy one to cross the leg.
- Knee flexion with dorsiflexion.
- Pelvic elevation from a sitting cross-legged position: Facilitate pelvic elevation and trunk flexion by
tapping on obliques. Repeat bilaterally.
- Upper trunk balance reactions: raise the lower limbs together by rotating them, facilitate the balance
position in the trunk and lower limbs in a symmetrical manner. Promote support of the affected MS on the
surface.
- Trunk control: Hands clasped, in front on midline, lean forward and diagonally. - Patient holds a towel
with his/her affected hand, the FT swings it in circles, patient does not let go.
- Mirror exercise with the patient's hand and the FT's, avoid straining

SEDENT TO BIPED
- From sitting to standing, have the patient transfer the majority of their weight to the affected side,
keeping the feet parallel, or with the healthy foot in front of the affected foot before standing up, flex the
trunk, with hands clasped, facing forward, do not look down, press the knee (sensation of weight load)
avoiding hyperextension. Return with the same considerations, making stops along the way.

BIPED
- Table in front of the patient, place his hands well positioned and flat, elbows extended, shoulders
forward. You are asked to walk backwards away from the table and then forwards without changing the
position of your lower limbs.
- Weight transfers, causing flexion and extension of the uni and bipodal lower limbs.
- Slow successive steps forward and backward with the healthy MI, controlling the position of the affected
person (No hyperextension).

MARCH:
Support phase:
- FT on the affected side of the patient, shift weight towards it. Ask the healthy MI to advance onto a
small step, keeping the affected hip forward and preventing knee hyperextension.
- Ask him/her to draw large figures on the floor with the healthy foot, ensuring proper positioning of the
affected MI.
- Ask the patient to stand on the affected MI, MMSS interlaced elevated. Induce forward and backward
movements of the healthy foot without weight-bearing – allows control of the adductors and hip flexors.
- Promote step descent with the healthy MI, maintaining adequate contact of the affected person with
the ground, transferring anterior weight onto the affected MI. Swing phase:
- Patient standing with feet together, the affected hemipelvis is guided forward and down to cause knee
flexion, heel remains on the floor.
- The same previous activity but in a passing position with the healthy MI in front.
- With the patient putting weight on the healthy MI, facilitate small steps forward and backward with the
affected foot, holding the foot in dorsiflexion and instructing him not to push down.
- Lateral gait, crossing the affected MI in front of the other when taking a step. Keep the hemipelvis
forward, avoiding excessive knee extension.
Stairs:
- Elevation: FT assists in elevating the affected leg, holding the knee while the patient pushes upward with
control. Keep your weight always forward with dorsiflexion of the foot.
- Descent: Guide the pelvis forward while the foot descends, preventing the MI from going into ADD. The
therapist's hand on the knee provides support when it is the healthy MI that is descending. Kneeling: -
Patient on all fours, push forward and backward to obtain mobility and balance reactions, then raise the
healthy MS or MI to promote support in the affected person.
- Have him/her stand on his/her knees to encourage full hip extension, raising the lower limbs in external
rotation.
- Therapist on the affected side supports the MS with elbow and wrist extended, with hand resting on
the therapist's hand. Weight transfers are promoted from here.

Gait pattern:
- Use a skate or skateboard. On the affected side, with adequate support, it allows learning of the swing
phase with control of the hip flexion and extension movements, avoiding support on the forefoot. On the
healthy side it facilitates the balancing reactions of the affected MI.
- Feedback with a scale where the patient learns to apply pressure to the heel, midfoot and forefoot
while walking. - Ask the patient to repeatedly tap the forefoot on the ground before walking, this will
inhibit the exaggerated positive support response.
- Promote balance in the affected foot, maintaining the proper positioning of the hip, knee and ankle and
preventing the hemipelvis from rising (Trendelenburg sign).
- Avoid circumduction with proper management of knee flexion and extension.
- Forward and reverse motion. The latter with knee flexion avoiding pulling the hip upwards. When taking
a step back, the patient should gradually transfer weight to the sole of the foot. Backward march improves
forward march.
- Avoid lowering the shoulder girdle and tilting the head.
- Walk with PCC in extension and external rotation of lower limbs, extension of fingers and ABD of the
thumb. Thus controlling the pelvis by keeping it forward before taking the step. Allow time for knee
release during swing of the affected MI.
-Practice rotations of the shoulder girdle (makes arm swinging possible) and pelvic girdle (inhibits total
patterns). It can be performed in front of the patient or from behind. Promote diagonal movements.

ADDITIONAL TREATMENT ACTIVITIES FOR THE UPPER LIMB:

- Promote elevation of the affected MS in ABD, external rotation, elbow extension, fingers and ABD of the
thumb.
- Maintain elevated MS with good pattern without assistance.

Dissociation and control of the Elbow:

- MS in elevation, ask him to touch his head, several times, without altering the position of the shoulder.
He is also asked to bring his affected hand to touch the healthy MS from the shoulder, descending to the
hand. - Mobilize the scapula.
- Lying on the affected side as described above, the patient is asked to bring his hand to his mouth and
extend his elbow again.
- Practice the same movement in supine position with the patient's MS in horizontal abduction, asking
him to touch the opposite shoulder with the supinated forearm.
- Sitting with the lower limbs on a table, elbow flexion with supination is requested, bringing the hand
towards the mouth or the opposite shoulder. Keep your hand open.
- With the MS elevated and the forearm pronated, ask for elbow flexion and extension without altering
the position of the shoulder.
- In a bipedal position with the healthy MS supported on a table, ask for 90° abduction, organize the
appropriate components of the entire MS and ask him to rotate the trunk from the feet without altering
the position of the lower limbs.
- With the lower limbs extended and the hands correctly supported on the wall, ask for steps forward
and backward or controlled flexion and extension of the elbows.

Source: Training Management Curricular Management Teaching-learning practice guide Physiotherapy

laboratory. Adriana Guzman Velasco Maria Veronica Torres Jeronimo Londono Angelica Patricia Chamorro
Diana Maria Rivera.

EVALUATION SYSTEM

• Evaluation of being and doing in group work.

• Rubric for performance in practice.

LEARNING OUTCOMES

Acquire skills in the execution of procedures and intervention modalities in neuromuscular domain
alterations, specifically the Bobath concept in children.

EVALUATION QUESTIONNAIRE

1. Explain the concept of stroke

2. What are the stages of stroke after-effects (Hemiplegia)?
3. What are the basic principles on which the Bobath concept is based?
4. What do the words motivation and functionality mean in the Bobath concept?
5. What is Brain Neuroplasticity?
6. Why is Brain Neuroplasticity essential in the treatment of children with neurological disorders?
7. What are the key words in the Bobath concept?
8. What are the specific exercises for each stage of hemiplegia?
9. What are the SMART goals for developing a good treatment plan? Explain each of them.

LITERATURE

Bobath B. Adult hemiplegia. Panamericana Medical Publishing House. 1991. (text

Cano De La Cuerda R, Collado S. Neurorehabilitation. Specific assessment and treatment methods.
Panamericana Medical Publishing House. 2012.
Guerrero Claro I, López Leiva MI. Application of the Bobath method in patients who have suffered a stroke.
TOG (A Coruña), Rev. On the Internet. 2015; 12(22): pag. 18.
Paeth Rohlfs B. Experiences with the Bobath concept. Fundamentals, treatment, cases. 2 ed. Pan-American
Medical Publishing House.2006
Moffat M et al. Neuromuscular Essentials: Applying the preferred Physical Therapist Practice Patterns.
United States of America: APTA.2008.
https://www.fisioterapianeurologica.com