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The Bobath concept is a broad and ever-evolving approach in neurological rehabilitation that is applied in patient assessment and treatment (such as with adults after stroke, or children with cerebral palsy). The goal of applying the Bobath concept is to promote motor learning for efficient motor control in various environments, thereby improving participation and function. This is done through specific patient handling skills to guide patients through initiation and completion of intended tasks. This approach to neurological rehabilitation is multidisciplinary, primarily involving physiotherapists, but may also include occupational therapists and speech and language therapists. In the United States, the Bobath concept is also known as 'neuro-developmental treatment' (NDT).
The concept that this approach can 'evolve' and still be called Bobath has been challenged on the grounds that several of the key original teachings of the founders have now been abandoned, whilst the ideas / concepts of other (non Bobath) therapists & scientists have unjustifiably been given the name of Bobath.
Despite widespread acceptance of the Bobath concept in stroke rehabilitation, literature has not found it to be superior compared to other treatment approaches. This international review demonstrated that the Bobath approach produced significantly inferior results to alternative treatments in 80% of trials that showed an effect. The authors also noted that in some European countries Bobath was now regarded as obsolete and is therefore no longer taught to therapists. They concluded that specific techniques recommended in national guidelines, rather than such named approaches, should be the basis of rehabilitation; the Bobath approach is not recommended in any national stroke guidelines.
In the UK, an NHS review of stroke rehabilitation concluded that the strength of evidence that task specific functional training and strength training are effective, whilst Bobath is not, means that it is now difficult to justify the continued use of the Bobath concept or any of its techniques.
The Bobath concept is named after its inventors: Berta Bobath (physiotherapist) and Karel Bobath (a psychiatrist/neurophysiologist). Their work focused mainly on patients with cerebral palsy and stroke. The main problems of these patient groups resulted in a loss of the normal postural reflex mechanism and normal movements. At its earliest inception, the Bobath concept was focused on regaining normal movements through re-education. Since then, it has evolved to incorporate new information on neuroplasticity, motor learning and motor control. Therapists that practice the Bobath concept today also embrace the goal of developing optimal movement patterns through the use of orthotics and appropriate compensations, instead of aiming for completely "normal" movement patterns.
Application in stroke rehabilitation
In Neurodevelopmental Treatment (NDT), postural control is the foundation on which patients begin to develop their skills. Patients undergoing this treatment typically learn how to control postures and movements and then progress to more difficult ones. Therapists analyze postures and movements and look for any abnormalities that may be present when asked to perform them. Examples of common abnormal movement patterns include obligatory synergy patterns. These patterns can be described as the process of trying to perform isolated movement of a particular limb, but triggering the use of other typically uninvolved muscles (when compared to normal movement) in order to achieve movement. Obligatory synergy patterns can be further subdivided into flexion and extension synergy components for both the upper and lower extremities. This approach requires active participation from both the patient and the therapist. Depending on the patient, rehabilitation goals may work to improve any or all of the following: postural control, coordination of movement sequences, movement initiation, optimal body alignment, abnormal tone or muscle weakness. Treatment will therefore address both negative signs such as impaired postural control, and positive signs such as spasticity.
Intervention strategies and techniques for NDT consist of therapeutic handling, facilitation, inhibition and key points of control. Therapeutic handling is used in order to influence the quality of the patients' movements and incorporates both facilitation and inhibition. Facilitation is a key technique used by Bobath practitioners to promote motor learning. It is the use of sensory information (tactile cue through manual contacts, verbal directions) to reinforce weak movement patterns and to discourage overactive ones. The appropriate provision of facilitation during the motor task is regulated in time, modality, intensity and withdrawal, all of which affects the outcome of motor learning. Inhibition can be described as reducing parts of movement/posture that are abnormal and interfere with normal performance. Key points of control generally refers to parts of the body that are advantageous when facilitating or inhibiting movement/posture.
Activities assigned by a Physical Therapist or Occupational Therapist to an individual who has suffered from a stroke are selected based on functional relevance and are varied in terms of difficulty and the environment in which they are performed. The use of the individual's less involved segments, also known as compensatory training strategies, are avoided. Carryover of functional activities in the home and community setting is largely attributed to patient, family and caregiver education.
The Bobath Concept is summarized in Adult Hemiplegia: Evaluation and Treatment, by Berte and Karel Bobath. The first, second, and third editions were published in 1970, 1978, and 1990, respectively.
Paci (2003) conducted an extensive critical appraisal of studies to determine the effectiveness of the Bobath concept for adults with hemiplegia following a stroke. Although selected trials showed no evidence proving the effectiveness of NDT as the optimal type of treatment, neither did they show evidence of non-efficacy because of methodological limitations. The Bobath therapy is nonstandardized and the decisions about specific treatment techniques are left to the individual therapist, who decides how to control muscle tone and how to achieve recruitment of arm activity in functional situations with various positions. Paci (2003) recommended that standardized guidelines for treatment be identified and described, and that further investigations are necessary to develop outcome measures concerning goals of the Bobath approach such as quality of motor performance. A study by Lennon et al. concluded that even under idealized conditions (patients with optimal rehabilitation potential, advanced trained therapists, unlimited therapy input and a movement analysis laboratory) the Bobath approach had no effect on the quality of gait for patients with a stroke.
"If they are to offer neurophysiologically sound approaches, clinicians must consider how the central nervous system creates the commands that drive and guide the hand to reach into space and grasp an object or the legs to take steps on flat or uneven ground." (Dobkin, 2000)
- Lennon S, Ashburn, A. The Bobath concept in stroke rehabilitation: a focus group study of the experienced physiotherapists' perspective. Disability and Rehabilitation. 2000; 22(15): 665-674.
- Knox V, Evans AL. Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study. Developmental Medicine & Child Neurology. 2002; 44: 447-460.
- International Bobath Instructors Training Association. Theoretical assumptions and clinical practice. [Internet]. 2006 [updated 2008 September; cited 2011 May 10]. Available from http://ibita.org/pdf/assumptions-EN.pdf.
- Damiano, D. (2007) Pass the torch, please! Developmental Medicine & Child Neurology 49 723–723.
- Mayston, M. (2006) Letter to the editor RAINE: A RESPONSE. Physiotherapy Research International 11 183-186.
- Kollen BJ, Lennon S, Lyons B et al. The effectiveness of the Bobath Concept in stroke rehabilitation. Stroke. 2009; 40(4): e89-97.
- Tyson, S. (2009) 2009 Annual Evidence Update on Stroke rehabilitation – Mobility, NHS Evidence. Available at :-http://arms.evidence.nhs.uk/resources/hub/37914/attachment or http://usir.salford.ac.uk/2740/.
- O'Sullivan, Susan B; Schmitz, Thomas J (2007). Physical Rehabilitation, Fifth Edition. Philadelphia, PA: F.A. Davis Company. p. 490.
- Graham JV, Eustace C, Brock K, Swain E, Irwin-Carruthers S. The Bobath concept in contemporary clinical practice. Topics in Stroke Rehabilitation. 2009; 16(1): 57-68.
- O'Sullivan, Susan (2007). "Physical Rehabilitation", p.60, 512, 720. F.A. Davis, Philadelphia. ISBN 0-8036-1247-8
- O'Sullivan, Susan B; Schmitz, Thomas J (2007). Physical Rehabilitation, Fifth Edition. Philadelphia, PA: F.A. Davis Company. p. 512.
- Paci, M. (2003). Physiotherapy based on the Bobath concept for adults with post-stroke hemiplegia: A review of effectiveness studies. J Rehabil Med. 35:2-7.
- Platz, T., Eickhof, C., van Kaick, S., Engel, U. & Pinkowski, C. (2005). Impairment-oriented training or Bobath therapy for severe arm paresis after stroke: a single-blind, multicentre randomized controlled trial. Clinical Rehabilitation. 19:714-724.
- Lennon, A., Ashburn, D,. Baxter, D.(2006). Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke. Disability and Rehabilitation 28 873-881.
- This article is based on a translation of the corresponding article from the German Wikipedia, accessed on May 4, 2005.
- Last paragraph from NDTA website
- http://www.bobath-es.com (Spanish)
- International Bobath Website
- Theory of Bobath (German)
- Neuro-Developmental Treatment Association Website
- Official Bobath Foundation Website (Spanish)
- Bobath Children's Therapy Centre Wales
- Bobath Scotland
- UK-based Bobath treatment for individuals and tutoring for professionals