International Bobath Instructors Training Association

Yohanes Edy Priyono, SFT

LEARNING OBJECTS 1
1.
.

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.

2.

LEARNING OBJECTS 2
3. Be able to analyze and facilitate normal posture and movement control during functional activity.
.

4. Understand the functional consequences of lesions of the CNS. 5. Observe and analyze abnormal movement and influence this through intervention

LEARNING OBJECTS 3
6.

Understand the relationship between assessment and treatment and appreciate the ongoing process of

Problem analysis Problem solving Goal setting Treatment Evaluation

LEARNING OBJECTS 4
7.

Adapt and apply appropriate theoretical principles of treatment to the individual patient/ client within his environment. Develop effective handling skill and incorporate them with appropriate environmental and other influences in order to regain function. To continue learning through critical reading, selfevaluation and sharing with others.

8.

9.

HISTORY
BERTA BOBATH KAREL BOBATH REMEDIAL GYMNAST & PT (1907-1991)

M.D. & PSYCHIATRIST (1905-1991)

REVOLUTIONARIES WESTERN CEREBRAL PALSY CENTRE, 1951 THE BOBATH CENTRE

IBITA & EBTA

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

BASIC PRINCIPLE

R.I.Ps (Reflex Inhibiting Posture) R.I.Ps (Reflex Inhibiting Pattern ) T.I.Ps (Tone Influence Pattern)

DEVELOPING CONCEPT

Reflex Inhibiting Postures (RIPs) Reflex Inhibiting Patterns (RIPs) Tonal Influences Patterns (TIPs) Normal Postural Reflex Mechanism (NPRM) Central Postural Control Mechanism (CPCM)

THE PATIENT MRS BOBATH TREATED ALL LOOKED VERY SIMILIAR

PATIENTS WITH ESTABILISHED SPASTICITY

REFLEX INHIBITING POSTURES

REFLEX INHIBITING PATTERNS

TONAL INFLUENCES PATTERNS

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. (IBITA, 1995)

PLASTIC ADAPTATION
A calculated physiological stress

Black Box

Getting worse

Getting better

GRAVITY

SYNERGY PATTERN

Upper Limb : Lower Limb Agonist : Antagonist

TONE INFLUENCE PATTERN

NONE NEURAL FACTORS

y BIOMECHANICS y MUSCLE PROPERTIES

Abnormal tone Abnormal pattern of movement/posture TIPs Tone(neural) Tone(non neural)

Biomechanical Proprioceptive reflexes Cutaneous reflexes alignment Feedback/feedforward mechanism More normal postural tone More efficient and effective control of posture and movement for function More efficient Force production

NONE NEURAL FACTORS

Classic length- tension curve Maximum tension around its mid-length - shortened, lengthened muscle - Hypertonia, Hypotonia - cant produce adequate tension and force to produce an efficient movement

NONE NEURAL FACTORS

1.

VISCO-ELASTIC PROPERTIES Elasticity: the length

How extensible are the muscle fibers ?

Viscosity: the Velosity

How quickly can the length of the muscle be extended ?

Plasticity : the Time

How long does it take to return ?

Contracture: shortenning, reduced number of sarcomeres in reduced for force output

TONE PRODUCED THROUGH THE ACTIVATION OF MOTOR UNITS

MOTOR UNIT

THE MOTOR NEURON

ALL THE MUSCLE FIBERS IT INNERVATES

MOTOR UNIT
Relationship between fiber type, motor unit type and histochemical profiles of muscle fibers
Fiber type I SO (Slow O.) S Low High High Low Low Rich Small II FOG (Fast O & G) FR High Medium-High Medium-High High High Rich Medium-Small IIB FG (Fast G.) FF High Low Low High High Sparse Large

Motor unit type Histochemical profiles Myofib. ATPase NADH dehydro. SDH Glycogen Phosphorylase Capillary supply Fiber diameter

FG
FastFast-twitch Glycolytic (involved in phasic movement)

WHITE FOG
FastFast-twitch Oxidative Glycolytic

PINK SO
SlowSlow-twitch Oxidative (involved in tonic movement)

RED
B. HWANG 1999

NUMBER OF MOTOR UNIT & INNERVATION RATIO

Muscle
Extensor Rectus 1st Lumbricals Brachioradialis Tibialis Anterior Gastrocnemius

Number of Motor Unit

2970 96 333 445 579

Innervation Ratio 9 108 410 562 1934

RECRUITMENT ORDER

CURRENTLY CONCEPT
NO LONGER EMPIRICAL
The

CNS is a complex organization consisting of systems & sub systems. CNS can adapt and change its structural organization

The The

manipulation of afferent input can therefore directly effect a change in the structural organization of the CNS within the structure of the CNS can be organized or disorganized producing adaptive or maladaptive sensorymotor behavior.

Changes

CURRENTLY CONCEPT
Movement controls dependent upon and intact, integrated neurological and musculoskeletal system Selective movement control of the trunk & the limbs, both concentric and eccentric are interdependent and interactive with a postural control mechanism

CURRENTLY CONCEPT
Rehabilitation is a process of learning to regain motor control and should not be the promotion of the compensation. The cellular mechanisms underlying learning are the same mechanisms that take place during motor
development-refinement & re-learning of motor control.

GOALS OF CONCEPT

To

identify and address the specific areas of low tone in the anti-gravity musculature. seek to control the amount and diversity of proprioceptive input. identify the primary goals for function in the individual person, and to understand the nature of how that function is performed efficiently Normally

To

To

GOALS OF CONCEPT
To

facilitate specific motor activity without overflow of irradiation that could elicit associated reactions. minimize compensation and therefore sensory/motor neglect of the affected body parts. identify when and how voluntary controls can be used effectively.

To

To

THE BOBATH CONCEPT IS UNFINISHED AND WE HOPE THAT IT WILL GROW AND DEVELOP IN YEARS TO COME ( K. BOBATH, 1986)

ASSESSMENT

The systematic acquisition of information that is meaningful in providing the clinician with a comprehensive picture of the patients abilities and problems.

Shumway Cook & Woolacott.1995

Purpose

The purpose of the assessment process is to measure/evaluate the patients potential. Bobath 1991. The Bobath Concept currently uses a problem solving approach-gathering information through

Method
Observation Analysis Palpation Assessment of change or potential for change Measurement.

The problems
Neurological deficit. i.e. Positive and negative signs of an Upper Motor Neurone Syndrome Lesion. Compensations. A normal occurrence to replace the loss of a motor/sensory/perceptual function. Pre-morbid status lifestyle, trauma, illness

Stages in the Assessment Process

Creation of the database Clinical Assessment Interpretation of findings Formulation of the problem list.

Creation of the Database

Gathering of information from relevant sources.

You. The patient. Medical notes. The family.

Clinical assessment
Determine the patients current level of function Are there tonal problems or weakness Can the patient move voluntarily and if so selectively I.e.single joint movement to command. Is their evidence of CPG activity. Are their sensory /perceptual disturbances.

Interpretation of findings

The analysis and interpretation of assessment findings is very individual. It is based upon your theoretical knowledge and clinical experience.

Formulate problem list

Identify key problems by

y Discussion with the patient y Understanding the movement difficulties y Understanding the sensory deprivation. y Identifying the ability of the patient to learn

Upper motor neurone syndrome

Negative signs
y y y y y y

Positive signs
y Clonus y Associated reactions y Non-Neural changes in

Weakness Fatigue Sensory loss Acute hypotonia Cutaneous hypereflexia Diaschisis

muscle. y Spasticity y Dysynergic movement patterns y Fixation strategies.

Negative Signs of the Upper Motor Neurone Syndrome

Weakness-Neural and non-neural. Fatigue-shock and decreased neural transmission. Sensory loss-cortical and cerebellar Acute hypotonia sensory and or cerebellar due to diaschisis. Cutaneous hypereflexia-corticospinal drive reduction.

Diaschisis
The secondary denervation of a functionally interactive part of the CNS with the area damaged in the primary trauma. Effects the cerebro-thalamic-striato-cerebellar loops cerebro-spinal pathways cerebellar-spinal pathways

End Result

Goal setting Treatment Plan Documentation Evaluation Outcome measures.

Goal Setting
Focuses the team on the needs of the individual patient. Provides a structured and objective way of planning and documenting progress. Involves and motivates patients and carers in the rehabilitation process.

Goal setting

Goals should be SMART specific. measurable. achievable. realistic. time limited.

S M A R T

Treatment plan
Takes into account Health needs of the patient Personal needs and expectations Social and environmental factors

Treatment is a learning experience.

task THERAPIST

environment

individual

INDIVIDUAL

The Bobath Concept inherently seeks to primarily change the individual so that they can continually achieve a greater number of tasks in ever challenging environments. This is the role of Motor Learning.

Task
Selection of the task Organising a hierarchy of the component parts of the task. Use of verbal v non verbal clues and directions. Understanding of how the task can be incorporated into function.

Environment.

The therapist seeks to find optimum yet challenging and ever changing environments in order to improve the patients goal acquisition. Novel and known environments potentiate differing aspects of learning.

DOCUMENTATION
An essential and integral part of the care plan. Allows for effective communication. Monitors standards. Audit. Medico-legal purposes.

The Bobath Concept

The goal of treatment is to optimise function through the facilitation of improved postural control and selective movement. Only active participation produces motor improvement. The patient must be interested and enjoy success.