Bobath Approach for Adult With

Neurological Conditions

Irfan

Understanding from theory to treatment

by

Disampaikan pada :

Pekan Pelatihan Dan Seminar (PEPSI)

Physiotherapy with Love

Surabaya, 19 – 21 Januari 2012

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

REMEDIAL GYMNAST AND PHYSIOTHERAPIST M.D. AND PSYCHIATRIST

BERTA BOBATH KAREL BOBATH

WESTERN CEREBRAL PALSY CENTRE, 1951

HISTORY

REVOLUTIONARIES

THE BOBATH CENTRE

IBITA

THE NEUROSCIENCE OF

HUMAN MOVEMENT

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.

The Central Nervous System

Old New• Top down

• Tracts

• Reflex activity

• Electrical activity

• All or nothing

• Hard wired

• Irreparable

• Multi- input

• Systems

• Modulation

• Neurotransmitters

• Multi - level processing

• Plastic

• Re - organisation

Assumptions

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

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 4

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

MI PM -SMA

LMN

POSTURAL

SET

Primary Motor Areas Association Motor Areas

Hodges & Richardson 1997

Anticipatory Mechanisms

EMG Activity of each of the trunk muscles relative to that of the prime mover

POSTURAL STABILITY

With GLOBAL

Deep Core Muscle attached to each spinal segment provide segmental stability

POSTURAL STABILITYWith Dee Muscle

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.

SIPRE MOTOR CORTEX

PARIETAL AREASMI

SII PRE FRONTAL

CORTEX PRE MOTOR

CORTEX

SELECTIVE MOVEMENTFractionation

-Againts Gravity-

1.Vestibulo-spinal system

2. Reticulo-spinal system

-Selective-1. rubro-spinal system

2. cortico-spinal system

Balance

Head control

Eye tracking task

Wakefulness

Modification of sensory

Motor control

Control the muscles of the

extremity

•Force, velocity, and direction

movement

Postural Stability

Efficient Biomechanical

Function

MaximiseForce

Generation

Minimise Joint Load

Proximal Stability for

Distal mobility

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 muscle’s 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 interneuronsautogenic 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 arhytmicpattern 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

2

• Response to contact and handling

3• Reaction to being moved

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

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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

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Irfan, M. 2010. Fisioterapi Bagi Insan Stroke. Yogyakarta : Graha Ilmu.

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