Central Key Point

[David Kaufmann]

Please can someone help me define 'central key point' in relation to neurological physiotherapy? I am a first year student preparing in advance of tutorials, and have been unable to find the info in any of the 8 books I have in front of me or the internet.

Any help is greatly appreciated.

David

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[Dr Damien]

Dear David

I am not surprised you cannot find any books in neurology to define the term central keypoint for your understanding. It is more or less an arbitrary term and mainly used by Bobath trained physiotherapists. It is unlikely to have an anatomical definition either. For better understanding, it is best to check out literatures that are Bobath based.

I will not make it too complicated but I would give you a basic explanation of what it means. Bobath therapists are very hands on in their treatment of neurological conditions. They therefore advocated "handling" of patients crucial in their managements.

"key points of control" refer to areas on the body wherein postural control is maintained during static or dynamic activities. For some authors, core stability may be another expression. Bobath therapists see the human body as a chain of parts wherein poor control of certain parts will mean an abnormal functioning of another part.
For instance, the thorax sits on the pelvis and the pelvis is attached to the lower limbs. Therefore if there is poor control of the thorax as well as pelvis, there would be inability to move the lower limbs in an effecient functional manner. This would mean that greater effort would be required to carry out this activity (moving the limbs).

central key point of control refers to the postural control between the thorax and pelvis and it serves as a reference point for the bobath therapist to "handle" for instance a stroke patient that is having difficulties in maintaining sitting balance, or stand and take a step.
Other areas of postural control include the peripheral key points, which correlate to the girdles. For instance, a stroke patient may find it difficult to lift his arm simply because the scapular stability (an area of peripheral keypoint) is out of control, or perhaps the key point (thorax over pelvis) control is poor...these would be the areas in which the therapist would work on in achieving postural control.

It is better to understand the term " postural control" and how the body combats gravity when changing postural sets to maintain balance. Bobath therapists are skilled in understanding normal movements, therefore they quickly identify faults in abnormal movement patterns. This they aim to correct through special skills that involve hands on treatment until the patient can carry out the activity in a more fluid and effecient manner. Abnormal tone, musculoskeletal disorders are often the reason for these abnomal movements. This is where the therapists come in...

Example of using Central key point of control in managing a stroke patient.
Mr X cannot maintain his balance in sitting after his stroke, he tends to fall to the right side...and has difficult lifting his right hand up...there is hypotonicity of the left side, and he has difficulty in keeping his head up...

A bobath therapist may interprete this abnormal pattern as,
1) Mr X has poor postural control in sitting, due to his ability to orientate himself in space/midline (he is unable to understand his body map as it relates to his environment), His stronger side is probably more dominant generally pulling him to the right...he also lacks to ability to share his weight equally over his pelvis, He also has poor sensory awareness on his weaker side making him less aware of what that side should be doing in harmony with the stronger side...
His poor head control makes this problem even evident...
Because Mr X is unable to keep his postural control in sitting, he is unable to change his postural set from sitting to standing and each time he tries...he just keeps falling to one side, this effort his energy consumming
The Bobath therapist may hypothesis that:
1) perhaps if the stronger side was longer, this might give room for the actvity of the weaker side with regards trunk postural control.
2) perhaps, if he had better head control, he would be able to orientate himself better and achieve better midline representation
3) perhaps if the weaker side experiences more sensory information maybe the map of the body schema may fire up in the brain
4) if the weight born through the pelivis is equalized, there is a greater chance of recruiting spinal control of the weaker side and less of the stronger side

TREATMENT
the bobath therapist may decide to work in sitting...placing his/her hands on the thorax of the patient (handling a central keypoint) and facilitating trunk elongation...he/she may command " SIT UP" and using his hands show the patient what direction he/she wants...the therapist may ask the patient to hold this position
for a certain count
while doing this the therapist may find out that the patient is finding it hard to do this because the weaker arm hangs loosely...
he may decide to deweight the arm by placing it on a table...so the both central and peripheral keypoints are working to achieve sitting...he may now command the patient to hold his head up...

while doing this he/she may find that the body is still not achieving good balance in midline...because the pelivis is retracting strongly on the weaker side...he may decide to wedge this with a towel to improve the "alignment" of the chain as is necessary for achieving good sitting...

Once Mr X is able to maintain hiscontrol in sitting...several activities can be attempted...and each of this facilitated handling techniques removed until the client is independent...then the therapsit can attempt to sit to stand with the patient as this would be more effecient and easier...

Just a little example of what key points of control mean and how to apply them in Bobath based neurophysio

I hope this has been helpful

[David Kaufmann]

Dear Damien.

Many thanks for your response, this proved very useful in advance of the taught sessions.

Kind regards.

David