Bobath Approach for Adult With Neurological Conditions

Understanding from theory to treatment

Disampaikan pada : Pekan Pelatihan Dan Seminar (PEPSI) Physiotherapy with Love Surabaya, 19 21 Januari 2012

by

Irfan

Learning Objective
Understand

the history and development of the changing principles of the Bobath concept. Understand the concepts of neurophysiology and neuroplasticity with regard to the Bobath concept. Be able to analyze and facilitate normal posture and movement control during functional activity.

Learning Objective
Observe

and analyze abnormal movement and influence this through intervention Develop effective handling skill and incorporate them with appropriate environmental and other influences in order to regain function. Relationship of the new neurophysiology and that included in the Bobath Concept

HISTORY
BERTA BOBATH
REMEDIAL GYMNAST AND PHYSIOTHERAPIST

KAREL BOBATH

M.D. AND PSYCHIATRIST

REVOLUTIONARIES

WESTERN CEREBRAL PALSY CENTRE, 1951

THE BOBATH CENTRE

IBITA

THE NEUROSCIENCE OF HUMAN MOVEMENT

The Central Nervous System

The CNS consists of several anatomically and functionally tightly connected systems and subsystems.

The relative importance of each system is decided by the task, the context, the state of the body and previous experiences. CNS is not rigid and hierarchical in its function, but multidirectional and adaptable.

Assumptions
Old
Top down Tracts Reflex activity Electrical activity

New
Multi- input Systems Modulation Neurotransmitters

All or nothing
Hard wired Irreparable

Multi - level processing

Plastic

Re - organisation

NEUROPLASTICITY ?
Plasticity in normal brain

Damaged brain plasticity

NEUROPLASTICITY
Diaschisis

(neural shock) Unmasking

Merupakan proses yang dapat terjadi antara lain :
Denervation supersensitivity Silent synapses recruitment

Sprouting
Axonal regeneration Collateral sprouting

Professional pianist

Ipsilateral motor pathway

Only active participation produces motor improvement or learning, which passive imposition of postures and movements can have no practical values. (Brooks, 1986)

The Cerebral Cortex in Movement

Brain Regions Associated with Motor Functions

Cortical field Nomenclature Approximate Brodman Location Area 4

Primary motor area (MI / MsI) Premotor areas Supplementary motor cortex (SMA / MII) Premotor cortex (PM) Primary somatosensory (SI / SmI) Secondary somatosensory (SII / Smll) Posterior parietal Prefrontal

Area 6
Area 1,2, 3 Caudal area 2 Area 5,7 Rostral to area 6

Primary motor area (MI, Area 4)

MI Fractionation (Selective movement). Adapts its output in response to sensory input. 40% of all Pyramidal Tract Neurons (PTNs) originate in the MI PTNs of the MI are also active before movement Postural set.

Asosiasi motorik/Pre Motor Area

Premotor areas (Association motor areas, area 6). Premotor areas can be subdevided into the suplementary motor area (SMA) and the Lateral premotor cortex (PMI). Premotor areas have direct projections to spinal cord, but they are not as extensive as those from the MI

Primary Motor Areas

Association Motor Areas

MI

PM -SMA

LMN
POSTURAL SET

Anticipatory Mechanisms

Hodges & Richardson 1997 EMG Activity of each of the trunk muscles relative to that of the prime mover

POSTURAL STABILITY With GLOBAL

POSTURAL STABILITY With Dee Muscle

Deep Core Muscle attached to each spinal segment provide segmental stability

Primary Somatosensory Area (SI)

Most cells within the SI fire after movement starts. SI are responding to sensory feedback signals generated by the movement. Somatosensory information does not arrive directly to the SI, but first projects to specific nuclei within the thalamus. SI is composed of multiple sensory field. The majority of sensory input to the MI is regulated by the SI

Secondary somatosensory area (SII)

Connects reciprocally with the SI, MI , prefrontal cortex and posterior parietal cortex. Respond to somatic sensation relay from the thalamus. Very active during exploratory movement by the hands.

SI

PRE MOTOR CORTEX PARIETAL AREAS

MI

SII

PRE FRONTAL CORTEX

PRE MOTOR CORTEX

SELECTIVE MOVEMENT
Fractionation

-Againts Gravity1.Vestibulo-spinal system 2. Reticulo-spinal system

Balance Head control Eye tracking task

Wakefulness Modification of sensory Motor control

-Selective1. rubro-spinal system 2. cortico-spinal system

Control the muscles of the extremity Force, velocity, and direction movement

Efficient Biomechanical Function

Proximal Stability for Distal mobility

Postural Stability

Maximise Force Generation

Minimise Joint Load

Spinal Lower Motor Neuron

Reflexive Behavior

Afferent

Receptor

Ia
Ib II III IV

Muscle spindle primary endings

Golgi tendon organs Encapsulated endings: Spindle secondary endings Hair,Viceral, Cold, and pain receptors Primary nociceptors (pain), postganglionic atonomic afferent

Stretch Reflex
All reflexes can be modified by signals from the brain. Stretch reflex Ia and II fiber activities

The spindle sends its massage to the spinal cord, cerebellum, reticular in the brain stem, and motor cortex. Essential for our awarness of limb position (proprioception). Not only detect movement, but they also to the presenting and regulation of muscle tone.

Monosynaptic reflex
Homonymous muscle.

Reciprocal inervation.

Renshaw cell will inhibit the alpha motor neuron of a contracting muscle and synergist. It will inhibit the antagonist muscles Ia Inhibitory interneuron (disinhibition). Assisting task-appropriate agonist/antagonist cocontraction

Golgi Tendon Reflex

Golgi Tendon Organs (GTOs) monitor changes in muscle force. Ib fibers carry information from GTOs Ib interneurons autogenic inhibition (nonreciprocal inhibition). Ib afferent fibers homonymous motor neuron.

Flexion/Withdrawal Reflex
This reflex responds to noxius stimuli (Cs and Deltas). Synapse with a series of excitatory and inhibitory interneuron flexion response. Excitatory interneurons Hamstring Inhibitory interneuron Quadriceps (reciprocal inhibition) Crossed extension reflex acting on the contralateral limb.

Central Pattern Generators (CPGs)

Grouping of neurons or neural circuits of generating arhytmic pattern of motor activities. Decending inputs (from brainstem or cortex) can act on CPGs to modify their associated movements and even initiate the movement.

BOBATH APPROACH

ORIGINAL CONCEPT
A CONCEPT OF TREATMENT BASED ON THE INHIBITION OF ABNORMAL REFLEX ACTIVITY AND THE RELEARNING OF NORMAL MOVEMENT, THROUGH THE FACILITATION AND HANDLING

BOBATH CONCEPT
is a problem-solving approach to the assessment and treatment of individuals with disturbances of tone, movement, and function due to a lesion of CNS.
The goal of treatment is to optimize function by improving postural control and selective movement through facilitation.

ASSESMENT
OBSERVATION

FEELING
ANALYSIS TREATMENT RE-ASSESSMENT

Observation

Feeling
1

Tone Response to contact and handling Reaction to being moved

2
3

Analysis
Why does the patient move as he does?
What is the compensation ?

Treatment
Postural Set Key points Aim for today Thinking out of the box Test and re-test Practice

Practical Session
Joint Mobilization Possibilities
SIC Spine Ankle and foot
Facilitation on lumbrical position

Central Proximal Distal

Practical Session (postural stability)

Practical Session (postural stability)

Practical Session (postural stability)

Practical Session (postural stability)

Practical Session (proximal & Distal stability)

Practical Session (proximal & Distal stability)

PT HOME PROGRAMME
24

HOURS PHYSIOTHERAPY PROGRAMME POSTURAL POSITIONING FACILITATION

Referensi

Carr, JH. Shepherd, RB. 2004. Stroke Rehabilitation, guideliness for exercise & training optimize motor skills. UK : Butterworth Heinemann. Duvernoy HM, 2005. The Human Hippocampus, Functional Anatomy, Vascularization, Third Edition. NY : Springer-Verlag Berlin Heidelberg.

Gallahue, D. L. 1998. Understanding Motor Development. USA: McGraw Hill companies.

Gallahue, D. L. 1998. Understanding Motor Development. USA: McGraw Hill companies. Goodman. Cavallaro, C. and Boissonnault, G.W. 1998. Pathology : Implication for the physical therapist. Philadelphia: W.B. Sounders Company. Hendelman, W. 2006. Atlas of Functional Neuroanatomy.2Sc. Ed. Boca Raton : CRC Press. Hendelman, W. 2006. Atlas of Functional Neuroanatomy.2Sc. Ed. Boca Raton : CRC Press. Irfan, M. 2010. Fisioterapi Bagi Insan Stroke. Yogyakarta : Graha Ilmu. Leonard, Charles T. 1998. The Neuroscience of Human Movement. USA : Mosby.

Noback RC, Strominger LN, Demares RJ, Ruggeiro DA, 2005. The Human Nervous System, Sixth Edition, NY : Humana Press
Purves D, Ugustine GJ, Fitzpatrict D, Hall WC, Lamantania AS, Mcnamara JO, William SM, 2004. Neuroscience, Third Edition, USA : Sinauer Associates Publishers.