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Bobath vs Brunstrom Approach

What is Bobath Approach

The Bobath concept is a problem-solving approach that is used in the evaluation and treatment of individuals who have disturbances in their movement and postural control as a result of a lesion to the central nervous system.

[1] It was Berta Bobath, a physiotherapist, and her husband Karl Bobath, a psychiatrist and neuropsychiatrist, who first proposed using this method to treat patients who suffered from anomalies in their Central Nervous Systems. Consequently, this method bears their names.

They came up with this method in order to effectively manage the neuro-motor dysfunctions that are characteristic of children who have cerebral palsy (CP). In the past, the most common forms of intervention included the use of braces, passive stretching, and surgery. The Bobath concept offered a new reference that considered children with cerebral palsy to struggle with issues related to postural control and movement in opposition to gravity [2].

In 1983, a group of experienced Bobath instructors came together and founded an international association with the intention of facilitating the development of Bobath Concept. The organization has been operating under the name International Bobath Instructor Training Association (IBITA)[1] since the year 1996.

What exactly is NDI?

The neurodevelopmental treatment is based on the premise that normal postural reflex mechanisms are essential to the performance of a motor skill. This is the basis for the treatment. The righting and equilibrium reactions, reciprocal innervation, and coordination patterns are the components that make up the normal postural reflex mechanisms. The release of abnormal tone and tonic reflexes, which can be seen in children with cerebral palsy (CP), interfered with the development of righting and equilibrium reactions 

It is an interactive approach to problem-solving that focuses on continuing reassessment with attention to individual goals, developing working hypotheses, treatment plans, and relevant objective measures to evaluate interventions. In other words, it pays attention to the individual.

This method is applicable to patients of any age who have sustained damage to their central nervous system, regardless of the severity of that damage. This distinguishes the approach from other forms of treatment, such as motor relearning or constraint-induced movement therapy, both of which can only be effective on individuals with a high level of functioning[1].

The International Classification of Functioning, Disability, and Health is adhered to by it perfectly. It places an emphasis on two interdependent aspects that are important for optimizing the recovery of motor function after a stroke:

control of one’s posture in relation to one’s performance on a task and

control over individual movements in order to produce sequences of movements that are coordinated with one another.

In addition, the Bobath concept has traditionally placed a significant amount of emphasis on the role that sensory inputs play in both the control and learning of motor skills.

The Bobath Concept Applied in a Clinical Setting

Motor control

The Bobath Concept is concerned with the patient’s sensory, perceptual, and adaptive behavior in addition to the motor problem that affects the entire patient. It is an approach that is goal-oriented as well as task-specific, with the purpose of organizing the internal (proprioceptive) and external (exteroceptive) environment of the nervous system in order to facilitate the effective operation of the individual. It is a process that involves interaction between the patient and the therapist [3].

The following are the primary focuses of therapy:neuromuscular system, the spinal cord, and higher centers to effect changes in motor performance, neuroplasticity, a nervous system that interacts with one another, and the individual expression of movement all come into play. overcoming a reduction in neural drive caused by damage to the UMN through the selective activation of receptors in the skin and the muscles [3].

It is important for therapists to be familiar with the fundamentals of motor learning, which include active participation, opportunities for practice, and meaningful goals. Training in the Bobath concept must be conducted in a variety of actual life settings, as opposed to merely performing exercises in the therapy department. Muscle activation patterns and sensory input that are specific to the task allow for successful completion of the task in a variety of contexts and environments, taking into account the requirements of both perceptual and cognitive processing [1].

During therapy, abnormal, repetitive movement patterns that get in the way of function will be addressed (IBITA 2007). Its purpose is to improve residual function while simultaneously preventing the development of spasticity. Through manipulation of muscle length and range, therapists have the ability to exert non-neurological control over hypertonia.

The goal of the therapist’s work on tone is not to normalize tone but rather to improve movement. There are three ways to lower tone:

  • the loosening up of tight muscles and arthritic joints,
  • elongation of the muscle,
  • practice of movement patterns that are closer to normal, and
  • by carrying out operational responsibilities in a manner that is both more effective and requires less effort
  • weight-bearing.
  • Sense organs and apparatus
  • Musculoskeletal system

The Bobath method addresses the issues that arise as a result of damage to the developing central nervous system and have an effect on a person’s sensory-motor, cognitive, perceptual, social, and emotional development. These issues are caused by damage to the developing nervous system.

It is not a method, but rather an approach or a concept. It acknowledges that even clients with the most severe forms of neurodisability have the potential for improved function.

It acknowledges the necessity of conducting a comprehensive assessment of each patient’s functional skills. Given the current state of knowledge and evidence Patients who have suffered neurological injuries can benefit greatly from this strategy during the rehabilitation process.

The term “neuro-developmental treatment” is the term that is most commonly used to describe the Bobath concept in the United States (NDT). It is predicated on the brain’s inherent capacity for reorganization (neuroplasticity)

Physiotherapists, occupational therapists, and speech and language therapists are all involved in this approach because it is a multidisciplinary approach. People who have a pathophysiology of the central nervous system have difficulties with their posture and movement, which leads to limitations in their functional activities.

The NDT/Bobath approach is continually improved as new concepts, theoretical frameworks, and empirical findings emerge within the field of movement studies. Although there have been modifications made to the general idea behind NDT, certain aspects have not changed.

The following are aspects that have not changed:

  • It focuses on finding solutions to problems and making evaluations.
  • Tone has a direct impact on the functional tasks that a person is tasked with performing and plays an important part in movement pattern and postural control.
  • The primary method for improving both functional and postural performance of tasks is handling those tasks.
  • During the course of treatment, individuals are strongly encouraged to engage in active participation.
  • The importance of functional training in relation to developmental milestones
  • Aspects that have been modified include the following:
  • Tone has the potential to influence both neural and non-neural components.
  • It’s not often that spasticity is a major contributor to a patient’s movement disorders.

In addition, as the characteristics of the population affected by CNS pathophysiology shift over time, the approach is constantly evolving to accommodate these shifts.

What about the Brunstrom Approach

The Brunnstrom approach is a form of movement therapy that is utilized by a large number of clinicians today. The recovery of stroke patients is the primary focus of this method, which places a strong emphasis on the synergic pattern of spastic muscles at each stage of the process. This method does not offer any type of specialized training for its practitioners.

This method was developed in the 1960s by a Swedish physical therapist by the name of Signe Brunnstrom. Her research on hemiplegia was grounded in a number of established neurophysiological theories of motor control. She utilized a number of different trial and error methods, gauging responses, both motor and verbal, to each procedure or based on observations of patients. Stroke patients can be rehabilitated using a variety of approaches; however, there is very little evidence to support these approaches.

Brunnstrom developed the principles of movement strategy by making assumptions about the motor control and reactions of stroke patients. These assumptions formed the basis for the principles. The following is a list of these [1]:

Recovery from stroke appears to result in development in reverse as reflexes are used to facilitate and learn purposeful movements. Reflexes become modified into purposeful movements during normal motor development; however, recovery appears to result in development in reverse during this process. Brunnstrom held the view that no reasonable training method should be overlooked and stated, “It may very well be that a subcortical motion synergy that can be elicited on a reflex basis may serve as a wedge by means of which limited amount of willed movement can be learned.” Brunnstrom held this view because he believed that no reasonable training method should be left untried.

It is possible to elicit the desired motion or tonal changes by employing proprioceptive and exteroceptive stimulation.

After a stroke, the patient’s recovery of voluntary movement occurs in stages, beginning with mass patterns and progressing to discrete movements under their own control. The repetitive motions are referred to as limb synergies.

Learning new movements requires a lot of practice and repetition.

Learning is facilitated when it is done in the context of the ADLs.

The following is a list of the fundamental principles of movement therapy:

The treatment proceeds in the order of development, beginning with reflexes and moving on to voluntary and then functional movements.

  • When there is no motion, movement can be facilitated by using reflexes, associated reactions, and proprioceptive/exteroceptive stimuli to develop muscle tension. This can be done even when there is no motion.
  • When combined with voluntary effort, reflexes and associated reactions produce semi-voluntary movement, which in turn provides sensory feedback and satisfaction.
  • Movement can be elicited by providing a variety of stimuli to the subject. In contrast, a tactile stimulus will only allow the muscles in the stimulated area to respond, whereas resistance (a form of proprioceptive stimulation) will cause impulses to spread to other muscles and produce a reaction associated with them.
  • If the patient makes a voluntary effort, the clinician will ask them to maintain (isometric) a response. It is requested of him that, if at all possible, he perform an eccentric contraction (controlled lengthening) followed by a concentric contraction (controlled shortening).
  • Even if there is a possibility of only partial movement, the reversal of movement is emphasized throughout each session.
  • As soon as the patient demonstrates voluntary control, facilitation techniques are immediately discontinued. As a result of the low level of stereotypicality in responses to exteroceptive stimuli, tactile stimuli are the last to be eliminated. After stage 3, there is no longer any use for the primitive reflexes.
  • The performance of activities of daily living (ADL) similar to those already performed voluntarily is emphasized more
  • After the correct movement has been elicited, it needs to be practiced and repeated.

An evaluation is carried out in order to decide on a course of treatment and to determine the outlook for the condition. It includes determining the following, among other things:

This test evaluates the patient’s ability to identify movements and touches without having to look. The results either provide the therapist with an indication that they should use visual feedback to compensate for lost sensation or assist in the choice of which facilitation technique the therapist should use.degree of return to previous levels of voluntary control

Brunnstrom provided a list of stages of recovery for the hand, as well as the upper and lower extremities.

The following describes the stages of recovery for both the upper and lower extremities[2]:

The progression looks like this for the hand:

  • The involved side displays flaccidity in the muscles.
  • The patient shows no or very little evidence of spasticity, and active finger flexion is either impossible or very difficult.
  • The patient is able to keep their grip on a handle that has been placed in their hand, but they are unable to release it by voluntarily extending their fingers. There is a possibility of reflex extension.
  • The patient is able to release the pressure by making a lateral movement with their thumb while extending their fingers only slightly or by using their normal functional synergy. That is to say, he or she is able to grasp with the fingers while the wrist is extended and is also able to release the grasp with the fingers while the wrist is flexed.
  • The patient is able to voluntarily extend the mass of their digits, and they can control both a cylindrical and spherical grasp, albeit with limited functionality.
  • The patient exhibits voluntary extension of fingers, lateral, palmar, and three-point prehension, and individual finger movements are possible. Individual finger movements are possible.

Despite the fact that patients progress through these stages, a patient in particular may cease treatment at any stage. There is currently no method that can accurately predict how patients who have suffered a stroke will fare in their road to recovery.

During the evaluation process, there is no facilitation used. Each motion is first demonstrated on the patient’s unaffected side, and then the patient is asked to perform it on their affected side on their own volition.

On the basis of Twitchell and Brunnstrom’s concept of sequential stages of motor return in the hemiplegic stroke patient, the Fugl-Meyer scale was developed as the first quantitative evaluative instrument for measuring sensorimotor stroke recovery. The Fugl-Meyer scale was the first instrument of its kind. The Fugl-Meyer is a clinical examination method that has been extensively tested on the stroke population. This method is well-designed, and it is both feasible and effective. The motor domain, which is worth a total of 100 points and has been subjected to the most in-depth evaluation, is its primary value. [3] Despite this, the Fugl-Meyer test is still relevant, and it is possible that this is because it uses a hierarchical scoring system that is based on the level of difficulty in carrying out the tasks. [4]

Stages Pattern

  • The patient shows signs of flaccidity, including very little or no resistance to passive motion and no initiation of voluntary movement.
  • Spasticity starts to develop, and the beginning of synergies is possible, either as a result of voluntary effort or an associated reaction.
  • Because of spasticity, there is increased resistance, and limb synergies are performed voluntarily.
  • Spasticity is less noticeable than it was earlier, and it is now possible to combine movements in ways that are distinct from synergies.
  • There is very little resistance from spasticity, and independent of synergy, it is possible to perform individual movements as well as complex movement combinations.
  • It is challenging to demonstrate spasticity unless the movements being performed are done so quickly, and synergies do not get in the way of the performance.

The influence that tonic reflexes have on the movement of the patient

When there is no movement present, an evaluation of the patient’s tonic reflexes is necessary to start the treatment process. Asymmetrical and symmetrical tonic neck reflexes, tonic labyrinthine and lumbar reflexes, and tonic neck reflexes are the types of primitive reflexes that are typically present.

The influence that associated reactions have on the movement of the patient. Involuntary movement or patterned reflexive tonal increase in those muscles that are anticipated to be in contrast to cause movement are associated reactions. When other unaffected extremities are resisted or when effort is made in an affected extremity, these reactions are seen in the extremities that have been affected. These are assessed so that it can be determined which method of facilitation can be used.

The following reactions are associated with patients who have suffered a stroke:

  • Flexor Synergy
  • Extensor Synergy

The Phenomenon of Raimeste’s (Resistance to Hip abduction or adduction of noninvolved extremity causes same motion in involved leg)

When there is resistance to the flexion of the non-involved leg, the involved extremity will extend, and when there is resistance to the extension of the non-involved side, the involved extremity will flex.

The involved hand will react with a grasping motion if the grasp of the non-involved hand is resisted. When the patient tries to flex the leg or when the patient’s attempt to flex the leg is resisted, flexor movement or tone may be elicited in the involved arm. The term for this kind of reaction is homolateral synkinesis.

Souque’s Phenomenon occurs when the tone of the involved arm is increased above horizontal, which causes the fingers to extend and abduct.

The Bobath approach is focused on preventing abnormal patterns of movement and promoting normal motor development. This approach is based on the principle that movement is a fundamental aspect of human development and that abnormal patterns of movement can interfere with normal motor development. The Bobath approach is designed to promote normal motor development by providing an environment that encourages normal movement patterns and by providing opportunities for practice and reinforcement of these patterns.

On the other hand, The Brunstrom approach is focused on using the abnormal pattern of movement for functional activities. This approach helps to improve the quality of life for patients with various neurological disorders. The focus on using the abnormal pattern of movement helps to improve the coordination and balance of the patient. This approach is also beneficial in helping the patient to regain their independence.