The Bobath approach to the management of children with cerebral palsy was pioneered and developed by Dr Karel and Mrs Berta Bobath. Begun in the 1940’s the Bobath Concept is now well known and accepted in many countries as one of the leading approaches. The main aim of treatment is to encourage and increase the child’s ability to move and function in as normal a way as possible. More normal movements cannot be obtained if the child stays in a few positions and moves in a limited or disordered way. The aim of management is to help the child to change abnormal postures and movements so that he or she is able to comfortably adapt to the environment and develop a better quality of functional skills.
Each child’s postural (muscle) tone is changeable, not only in relation to activity and moods, but also in response to being handled. The first stage towards achieving functional activity is to enable the child with spasticity to be less stiff and the child with athetosis to gain some control over their posture and movement. Therapists can help parents to understand their child’s needs. They are shown the most appropriate ways or positioning in helping their child to move and to incorporate these into the child’s daily life.
The able-bodied child can move about to explore the environment. In the first stages he learns about himself. He kicks and then brings his toes to his mouth. He plays with his hands and fingers; he fingers his food and handles objects, bringing them to his mouth. Without much help, and quite naturally, he moves from one stage of development to another. Each new experience prepares the way for the next until ultimately he can do the more complex tasks that are required of him as he grows up. The child with cerebral palsy also grows and develops, but his pattern of growth and development are delayed or arrested at a certain stage. The brain controls all movements, so that when some part of the brain is damaged, as in cerebral palsy, the control is disordered resulting in movement problems. Each case is different from another and each child has to be treated according to his need. A child may be able to move his lower limbs more easily than his upper, or the other way round. This will interfere with his development. Sometimes many stages of movement development are missing altogether. If, for example, the child cannot lie on his tummy, lift his head up, or support himself with his arms he will not learn to use the muscles of his neck and his back which he needs for sitting up straight or standing up. This may also interfere with the control of breathing and speech. If he uses one side of his body more than the other, e.g. rolling always to one side and not the other, his body will not develop symmetrically. This will make the development of balance, eye-hand co-ordination, perceptual skills and movements difficult. It can also contribute to the development of contractures, deformities and hip dislocation. If a child can stand up only by stiffening his legs he will tend to stand on his toes and in time his legs will become even stiffer. He will also move about on the floor on his tummy, using his arms to pull himself along. This may result in his arms being bent too much at the elbows and therefore, at a later stage, he may find it difficult to stretch them out to reach for objects, or so support himself on his extended arms which is also necessary to get himself up from the floor in the future. All these factors need to be kept in mind when considering each child. We need to look ahead to see what are the most essential movements required for the future and work to attain them. This means that each child, despite the severity or type of problem, needs a variety of movements and positions during the day – each child’s family will be taught how to do this in the most effective and helpful way for their child. If a child is unable to explore his environment, he needs to be helped to do so. He needs to see, touch, feel and experience different situations, e.g. inside the cupboards, different textures and different environments. In all situations the child should be helped to participate as much as possible – there is usually something each child can do, no matter how small, to make him feel a part of what is happening. This helps the child to develop a sense of self-worth, responsibility and to develop independence. Play is another way in which a child learns to develop appropriate behaviour and ‘social rules’ necessary for later adult life. A child engages in many types of play which are important for social intellectual and perceptual development. The therapist will help the families to develop their child’s play by giving advice on the most helpful positions and ways of handling. Advice is also available about the types of toys and activities which will be of the most help at each stage of development for the baby, infant, pre-school and school child as well as the adolescent.
Although some children with cerebral palsy cannot express themselves through speech, there are many alternatives to this. It is important that each child is encouraged to be a fully active participant in life in as many ways as possible. All children should be encouraged to think for themselves, to make choices and decisions, to have their own opinions, solve problems (with guidance only when necessary), and to understand the needs and desires of those around them. As with any child it is important to provide the opportunity for these experiences (within limits!) so that each child can develop to be the individual that he or she is. It also helps, as with all children for a child to learn about discipline.
Some children with cerebral palsy may not develop full independence in activities such as dressing, eating/drinking, bathing, toileting and personal hygiene. Their mobility may also be restricted. Special equipment may be used for movement and positioning to help participation in these activities. The therapists can give advice on ways to help the child to participate maximally.
Some children with cerebral palsy have difficulty in learning to use speech. This may be associated with a general difficulty in learning to use and understand language, or primarily due to difficulty in controlling the co-ordination of the muscles of breathing and articulation. Speech is one of many ways in which people communicate with each other. We all depend largely on the use of facial expressions, body language (movements associated with speech), eye movements and gestures to express ourselves. These are the foundations on which young babies begin to communicate long before speech is well developed. The child with cerebral palsy should be encouraged to use all these aspects of communication together with vocalisation and speech to their fullest extent. It is important to avoid anticipating the child’s needs and preferences as much as possible, and to allow the child to express himself by using vocalisation, looking or pointing. In as many ways as possible, it is important to talk and play with all children and this is especially so for the child with cerebral palsy. Interactions should be two-way, with the child given time to participate in and initiate activities and conversations. A speech and language therapist can offer advice from the beginning to maximise all aspects of the development of communication. A child with limited speech development may be able to use quick eye pointing to communicate. Another child might communicate by the use of signing or pointing to symbols and pictures. These alternative ways of expression can help to reduce frustration of not being understood or heard, and often accelerate the development of speech and understanding of language.
The development of more mature eating and drinking skills is an important basis for the production of speech sounds. Many children with cerebral palsy have difficulties in learning to eat and drink. With careful positioning and handling, it is possible to make meal times easier as well as more comfortable, sociable, less stressful and safe (so that the risk of food going down the “wrong way” is reduced). It is common for children with cerebral palsy to be very sensitive to touch around their faces and inside their mouths. This, plus the need for a child to have a balanced diet, can make the meal times stressful and unpleasant socially. Some children can be fearful of meal times because early experiences have been painful or frightening. As well as good positioning, the therapist can advise on the texture and presentation of food to help encourage more mature, efficient eating/drinking skills. It is also helpful for a child to put his fingers and toys into his mouth to build up tolerance to touch and reduce the level of over-sensitivity. Careful teeth cleaning also helps in this process. The careful assessment and planning of meal times can be an enjoyable way of incorporating therapy into the routine of daily life.