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presentasi pelatihan fisioterapi surabaya
Citation preview
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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