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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 and its international tutors / instructors, have embraced neuroscience and the developments in understanding motor control, motor learning, neuroplasticity and human movement science. They believe that this approach continues to develop.
Recent Criticism of the Bobath Appoach
The concept that Bobath can “evolve” and still be called Bobath has been challenged by the president of the American Academy of Cerebral Palsy and Developmental Medicine and the chair of the UK Association of Chartered Physiotherapists in Neurology (ACPIN). These eminent physiotherapists believe that several of the key original teachings of the founders have now been abandoned, whilst the ideas / concepts of others (non Bobath therapists & scientists) have unjustifiably been given the name of Bobath.
There is widespread use of the Bobath concept amongst therapists in stroke rehabilitation. Yet, a large review of randomized controlled trials (RCTs) of Bobath for stroke rehabilitation found only three instances of significant differences in favour of Bobath, yet 11 in favour of alternatives. The authors concluded:- “evidence-based guidelines, accepted rules of motor learning, and biological mechanisms of functional recovery, rather than therapist preference for any named therapy approach should serve as a framework from which therapists should derive the most effective treatment”.
National evidence based guidelines for stroke rehabilitation have been published for England, Netherlands, USA, Canada, Australia and New Zealand; yet in none of these is the Bobath approach recommended. The above international review pointed out that the approach is now regarded as “obsolete” in some European countries and it is therefore no longer taught.
In the UK, an NHS review of stroke rehabilitation by Professor Tyson concluded that "the strength of evidence that task specific functional training and strength training are effective, whilst Bobath is not, indicates that a paradigm shift is needed in UK stroke physiotherapy..... it is increasingly difficult to justify the continued use of the Bobath concept or its associated techniques".
The Bobath (NDT) approach is also widely used on children with cerebral palsy (CP). However when the effectiveness of interventions for the treatment of CP was reviewed by Novak et al. they concluded “Consequently, there are no circumstances where any of the aims of NDT could not be achieved by a more effective treatment. Thus, on the grounds of wanting to do the best for children with CP, it is hard to rationalize a continued place for traditional NDT within clinical care”. They consequently recommended “ceasing provision of the ever-popular NDT”.
The dichotomy between the popularity and institutional funding of this approach versus the negative findings of most RCTs has been excused on the grounds that RCTs may not be suitable for neurorehabilitaion. Yet, the British Bobath Tutors Association website does quote the minority of RCTs that support their approach.
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 the Bobath Concept, 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 Bobath consist of therapeutic handling, facilitation, and activation of 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 Concepts theoretical underpinning and practice is clearly documented in a contemporary book published by Wiley Blackman in 2009: Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation' written by the British Bobath Tutors Association (BBTA) and edited by Raine, Meadows and Lynch-Ellerington. The chair of ACPIN (Association of Chartered Physiotherapists in Neurology) reviewed this book and concluded :- “I am not really sure that it is clear from the book what the Bobath approach actually is”, “often the prose turns into jargon” and “this book will do little to quell the critics; in fact it will no doubt give them more fuel for the fire”.
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 the Bobath Concept as the optimal type of treatment, neither did they show evidence of non-efficacy because of methodological limitations. 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.
Bobath therapy is nonstandardized as it responds, through clinical reasoning and the development of a clinical hypothesis, to the individual patient and their movement control problems. The decisions about specific treatment techniques are collaboratively made with the patient, and are guided by the therapist, through the use of goal setting and the development of close communication and interaction. Working to develop improved muscle tone, appropriate to the task, the individual and the environment, will enable better alignment and activation of movement, and allow for recruitment of, for example, arm activity in functional situations within various positions.
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.
- Occupational therapy
- Physical therapy
- Speech and language pathology
- Brunnstrom Approach
- Frenkel exercises
- 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 (2007) Pass the torch, please! Developmental Medicine & Child Neurology 49 723–723.
- Mayston (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.available at https://stroke.ahajournals.org/content/40/4/e89.full.pdf+html
- 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/.
- Novak et al. (2013) 55 885-910. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev. Med. Child Neurol. Available at :- http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pdf.
- 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.
- Mayston (2010) Review of “The Bobath Concept: Theory and clinical practice in neurological rehabilitation”. Synapse Spring 2010.
- 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.