Case History in The Bobath Concept in Adult
Case History in The Bobath Concept in Adult Neurology 동의의료원 재활치료센터 서성우. 김경모
About the Author ØSchool of Physiotherapy, New castle-upon-Tyne, England, in 1978 ØTrained as a Bobath Instructor with BBTA ØIBITA as a Bobath Instructor in 1991 ØIBITA as a Advanced Bobath Instructor in 2004 2008 Gerg Thieme Verlag ØCurrently. Chairperson of IBITA
Past Medical History, Social History, Activities, and Participation Ø Sissel은 81세의 미망인이다. Ø Acute stroke으로 입원하기 전의 그녀는 fit, healthy하고 active하였다. Ø 그녀는 basement flat(flat 주택 1층)에 혼자 살았다. Ø 그녀가 flat에 access하기 위해서는 concrete steps을 올라가야 한다. Ø Sissel은 사회적으로 active하고 친구가 많으며 노인들을 위한 club의 member이다. Ø 그녀의 취미는 뜨개질과 코바늘 뜨개질(knitting and crocheting)이다
■ Body Functions and Structure ØPosture: slightly fiexion ØLeft hand foot: some overactivity, fixation ØRight arm: internal rotation, adduction, flexion ØRight hand: swolen ØRight wrist: malalignment ØRight radius and ulnar: subluxed in a palmar direction ØBoth legs: slightly internal rotation
■ Body Functions and Structure ØFoot rest removed ØNot able to transfer weight to the left leg when the right leg is lefted. ØPress her left arm down on the armrest and clench her fist ØThe right leg feels heavy and inactive except for some hold in internal rotation and adduction at the hip
■ Body Functions and Structure ØFacilitation her moving forward by a rhythmical weight transfer from hip to hip ØThere is a distinct resistance against weight transfer to the left when her right pelvis and hip is being moved forward in the chair. ØThe alignment around the hips and pelvis is then adjusted to prepare for more activity during the next phase of the movement.
■ Body Functions and Structure Ø Cannot stand up inaided. Ø 그녀에게는 some thoracolumbar extension과 slight pelvis anterior tilt의 달성 그리고 forward move하 기위한 upper trunk에 대한 facilitation과 handling이 필요하다. Ø Right hip 그리고 knee에 약간의 input과 support가 주어졌는데 이것 은 leg에서 motor activity의 spontaneous recruitment(수의적 동 원)가 없기 때문이다.
■ Body Functions and Structure Ø Standing에서 Sissel's right hip과 knee activity가 없어서 full support가 필요하다. Ø Standing에서 짧은 시간이 지난 후에 그녀는 점차적으로 adjust되고 더 많은 extension activity를 하게 되었다.
■ Body Functions and Structure Ø Head와 neck의 flexor activity와 left trunk sideflexion, 그리고 arms과 hips의 flexion을 통하여 position을 hold하고 있다. Ø 이런 position에서는 hip adductor 그리고 inward rotator activity가 더욱 더 쉽게 관찰된다.
■ Body Functions and Structure Ø Left side: forward rotation and flexion(observe the clavicle which is more prominent on the left side) Ø Left arm, leg: active and fix on to her left thigh and push into the floor
■ Body Functions and Structure Ø Her left foot pushes against the floor and brings her even further back. Ø Compensation: 1. Right shoulde rgirdle protraction and head forward 2. Left side forward rotation and flexion Ø Right arm: actively internal rotation, adduction Ø Right shoulder girdle, elbow, wrist and hand: Increased flexor activity
■ Body Functions and Structure Ø 손수건을 잡기 위해서 right hand를 뻗었다. 그녀는 open hand하고 그녀의 arm을 forward move하였다. Ø 그녀는 arm movement에 선행해서 upright를 할 수 없는데 그것은 anticipatory postural adjustment를 recurit하지 못하기 때문이다. Ø 이러한 adjustment가 없이 그녀가 더 멀리 reach 한다면-이것은 right shoulder의 extensor activation으로 설명된다- forward 로 fall 할 것이다.
■ Body Functions and Structure Ø “÷”: extensor activity reduce Ø “+”: head, neck, upper trunk flexor activity increase Ø She has mild to moderate paresis of her hip and right leg Right side view
■ Body Functions and Structure Right side(R): most affected side Left side(L): less affected side Ø Right side: 1. Increased activity adduction, internal rotation and flexion of both shoulder and hip 2. Mild to moderate paresis of extensors and abductors of both shoulder and hip Ø Left side: increased activity in general(active shorting) 1. Shoulder: depression(a mild to moderate pressure from the shoulder in depression at the same time as she pulls her weight on to her left side resulting in what would look like an elevated shoulder) 2. Pelvis: elevation Front View
■ Body Functions and Structure Right side(R): most affected side Left side(L): less affected side Ø Shoulder girdle: rotatory components Ø Left side: active Ø Right side: 1. Paresis 2. Increased activation of both hip adductors and medial hamstrings Behind View
Clinical Reasoning and Hypothesis ■ System Control 1 Ø 그녀는 right hand와 arm에 약간의 voluntary activity를 보여 주고 있다. Ø 이것은 corticospinal system이 부분적으로 intact하고 그녀의 right arm 과 leg에 있어서 더 좋은 selective recovery에 대한 potential이 good하다는 것 을 제시하고 있다.
■ System Control 2 Ø Balance은 severe affect하지만 intact sensation과 vision을 가지고 있다. Ø 넘어지는 것에 대한 인지를 할 수 있고 balance를 regain하기 위한 시도를 할 것이다. Ø 이것은 visual, vestibular, 그리고 somatosensory information에 기초를 둔 basic balance mechanism이 intact하다는 것을 시사하고 있다. Ø 그러나 그녀의 skin, muscles, tendons, 그리고 joint는 right side의 low tone과 reduced motor control에 의해 적절이 stimulation되지 못한다. Ø 이러한 것들은 vestibular system의 function에 indirectly로 영향을 미쳐서 Sissel의 balance problem의 원인이 될 것이다.
■ System Control 3 Ø 그녀의 right side의 muscle은 전반적으로 hypotonic한데 특히 trunk, pelvis, 그리고 right leg가 가장 hypotonic하다. Ø 그래서 그녀의 proximal stability는 감소하였다. Ø 이것은 그녀가 cortico-reticulospinal 그리고 cortico-rubrospinal pathway lesion에 영향을 받는다는 것을 의미하는 것이다. ■ System Control 4 Ø Postural control을 위한 recruitment timing이 방해(disturb)를 받는다: Ø 그녀 arm의 voluntary activation의 background가 되는 anticipatory postural adjustment의 recurit을 할 수 없다; Ø 따라서 그녀는 forward reach 하기 위해 자신을 upright 할 수 없다.
■ System Control 5 Ø Postural control, 특히 postural stability에 영향을 미치는 중대한 3가지 문제점은? ☞ Foundation for: • 1. recruiting activity in relation to opposing gravity • 2. weight transfer • 3. selective function Ø Body segment 사이의 interplay의 감소로 인해 balance 그리고 transfer ability 그리고 active move 그리고 independence가 감소되었다. ■ System Control 6 Ø perceptual 또는 cognitive dysfunction은 보이지 않는다: Ø 그녀는 그녀 자신이나 environment에 대해 주의가 깊고 training대한 motivation이 있다.
■ Hypothesis Ø Main problem: Reduced postural control 1. 2. 3. 4. inappropriately timed activation of postural activity Right side decreased proximal stability Right side decreased tone Right side decreased activation Ø 따라서 그녀는 fall tendency에 oppose하기 위해 그녀의 less affected side(left side)의 activation이 증가되었다: Ø 이것은 right와 left side의 imbalance을 증가시켰고 all three planes 대한 malalignment를 초래한다. Ø 결과적으로 right side의 activity의 동원(recurit) chance에 대한 방해 (disturbance)가 증가되어서 더 많은 postural control의 loose를 초래한다. 이러한 것들은 reduced postural control과 interplay를 초래한다. Ø 따라서 stability, weight transference, balance, 그리고 movement에 대한 postural background가 감소된다.
■ Aims of Therapy Ø Main Aims • Participation: To return to her own flat or a flat with adaptations Ø Activity and Body Functions and Structures: Improved Balance • Activity: independent walking ability • Activity: independently perform activities of daily living(ADLs) Ø Short-term Goals • Improved postural control(body functions and structures) • Selective and functional extremities(body functions and structures)
■ Interventions Body Functions and Structures-Activity Ø Body segment 사이, 특히 head, neck, 그리고 trunk의 alignment improve 1. improve the relationship and adaptation to the base of support 2. improve thoracic extension and extension, abduction, and external rotation in shoulder girdles and hips Ø Improved extensor/rotator control에 base를 둔 body segment 사이의 interplay facilitation. Ø Balance, movement, 그리고 transfer에 대해 right side을 free하게 하기 위해 left side로의 weight transference 그리고 stability을 facilitation. Ø Sitting, standing, 그리고 standing to sittingd의 all plane에 대한 weight transference. Ø Improved postural control에 base를 둔 arm function의 recovery explore.
Physiotherapy: Assessment and Treatment as a Continuous Process Ø Weight transfer: 1. COG가 stability와 interplay을 통해 weight bearing side로 move하는 dynamic activity이다. Ø Weight shift: 1. COG의 움직임이 없는 weight의 더 많은 passive shift이다. 2. low muscle activation로 인해 joint strain을 유발한다 3. active postural stability가 아니다.
First Photo Session • Hip internal rotator and adductor eccentric length
• Standing is a postural set that may enhance postural tone, extension, and postural control, if the alignment allows. • The arms are placed in external rotation to enhance extension of the arms and upper trunk.
• Attempts to lift her right leg forward • The weight transfer to the left is not good enough • The alignment is correct: more extension in her trunk and over the left side to facilitate weight transfer through rotation
• Her right leg is facilitated in swing to stance. • She’s trunk, pelvis, and hip are brought over her right leg. • The hip/pelvis is stabilized and the knee supported without hyper-extension.
Sitting before treatment Sitting after treatment • She rights herself more easily and demonstrates less flexor tendency. • The alignment of her legs to the BOS show less adductor and internal rotator component.
Second Photo Session, 4 days Later • Right foot is swollen and inverted more than the left. • Her heel is drawn medially and her right big toe is more adducted than the left. • The forefoot is stabilized at the same time as the soleus and gastrocnemius are mobilized and facilitated to give eccentric length. • The heel is moved in different directions in relation to the forefoot.
• Improved adaptation of the foot to the floor enhances mobility and stability of hips and pelvis • The plinth is raised to hip level, and She stands with her back to it. • She transfers weight in all direction.
• The therapists on She’s right gives length to her pectoralis major to facilitate trunk extension at the same time as she provides stability she’s thorax through the back of her hand facilitate the foot forward on the floor • In stance over the right side, therapist facilitates extension of the hip and pelvis.
First Photo Session Second Photo Session, 4 days Later • She’s foot adapts well to the floor, and the alignment is appropriate. • She therefore automatically recruits knee extension and stabilize herself during the swing phase of the left legs. She is able to look up.
Evaluation at Treatment Process First 4 Days Later Approximately 1 Month
Evaluation at Treatment Process First 4 Days Later Discharged
Evaluation at Treatment Process First 4 Days Later Discharged
Evaluation at Discharge 6 month after stroke • She is now totally independent, and she has started crocheting the most beautiful and fine tablecloths again. • Although she walks without walking aids, she feels that her balance is not as good as before. • She therefore uses her wheelchair for longer distances outside the home.
Thanks You
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