The Bobath Concept was established by the physiotherapist Berta Bobath and her husband Dr Bobath. Prior to the Bobath Concept emphasis was put on an orthopaedic approach using a range of treatments including massage, heat and splints (Raine, 2009, p.1). However, whilst treating a stroke patient, Berta Bobath found that facilitating movement in the affected limb had a profound effect on regaining function and with input from her husband they formed the Bobath Concept (Raine 2009, p.2). The Bobath Concept is still used by many practitioners with Lennon (2003, p.456) finding that out of the 1022 practitioners that took part in a questionnaire relating to stroke rehabilitation 67% preferred to use the Bobath Concept. However, despite significant use within neurological rehabilitation it has not been proven to be superior to other treatment approaches (Kollen et al, 2009, p.90). There are a number of neurological rehabilitation approaches available to practitioners. In studies analysing the use of approaches within physiotherapy for stroke patients it is apparent that the Bobath Concept and Motor Relearning are by far the most popular approaches with Johnstone and Proprioceptive Neuromuscular Facilitation (PNF) being used by some therapists (David and Waters 2000, p.74). This essay will aim to critically discuss the use of the Bobath Concept in stroke rehabilitation with reference to its current criticisms and lack of evidence to suggest its superiority compared with the other approaches
Stroke is caused by deprivation of oxygen to part of the brain causing loss of consciousness and neural damage (Baer and Durward, 2004, p.76). Johansson (2000) suggest that the notion of plasticity comes from Merzenich and colleagues who found evidence to suggest that cortical maps can be modified by sensory input, experience and learning as well as in response to a lesion within the brain. This could therefore explain why the facilitation of movement advocated in the Bobath Concept works well.
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The British Bobath Training Association (no date) suggests that the contemporary Bobath Concept consists of the facilitation of movement within the patients environment utilising a problem solving approach to enhance the motor control of the body. This concurs with the International Bobath Instructors Training Association (IBITA 2008, p.1). At the time of its inception the Bobath was revolutionary as it promoted the regaining of function in the affected limb instead of merely finding ways to compensate for the affected limbs dysfunction which in turn leads to the regain of motor control of the affected limb (Graham et al 2009, p.57).
The Bobath Concept has developed over time and as a result the IBITA have put together a document to outline a set of current theoretical assumptions of the Bobath Concept to include:
‘1. Linking participation, activities and underlying impairments
2. Organization of human behaviour and motor control
3. The consequences of injury and dysfunction in the execution of movement
4. Recovery
Neural and muscle plasticity
Motor learning
5. Measurement of outcome’ (IBITA 2008, pp.1).
The IBITA state that the Bobath Concept has promoted the link between treatment activities and the patient’s activities of daily living for a number of years and that specific goals must be set for the individual patient (IBITA 2008, p.2). This suggests that the Bobath Concept is a very individual approach and there are no set criteria that address every patient in the same way. Lennon and Ashburn (2000, p.670-671) performed a focus group with expert therapists. Both groups in the study suggested that goal setting was an important component of the therapy. However, one group stated that goals were decided in the assessment and based upon the patient’s problem areas where as the other group stated that goals were based on regaining motor control and movement. It can be seen in these groups that although goals were seen as important therapists may not be making them patient specific. There are drawbacks with this study in that the group was very small however as the study was a focus group this would have been necessary to remain in control in the group situation. Furthermore, the therapists were chosen though selection from their interest group (Association of chartered physiotherapists with an interest in neurology and physiotherapists interested in the care of older people) and as a result it is unclear whether these therapists are actually Bobath focused practitioners. Raine (2007, p.147) argues that in their study they found that goal and task orientation that was functional to the patient was a major feature of Bobath therapy. The participants were all members of the BBTA and had extensive Bobath training and therefore it would be accepted that their understanding of the assumptions behind the Bobath Concept would be great as they are teaching the concept to others. However, the study does not show the carryover of these assumptions to the practitioners that are not members within the BBTA.
The IBITA (2008, p.3-4) suggests that when a central nervous system is compromised it directly effects movement. They also suggest that because the nervous system in interactive in its nature all aspects of function can be compromised including motor control, sensory loss, cognitive, behaviour, sensory and cognitive. The IBITA (2008, p.3-4) suggest that these changes can cause changes in muscle tone, muscle strength, muscle endurance, muscle length and muscle stiffness. Therefore, this reasoning has lead the IBITA (2008, p.3-4) to explain the use of compensatory mechanisms in their third assumption. They describe compensatory mechanisms as the results of the above changes to the muscular systems and because the body can no longer function effectively the patient will learn to adapt and compensate and if this is not addressed the patient will learn these compensatory mechanisms. As a result, the Bobath Concept suggests that it will limit the use and recovery of the neural pathways that have not been damaged. Therefore, the Bobath Concept suggests that these compensatory mechanisms are detrimental to patient’s overall recovery and could lead to further secondary complications if the compensatory mechanisms learnt are inappropriate. This assumption has lead to some confusion within the Bobath Concept. Kirker et al (2000, p.624) found that when standing following a stroke patients were more stable when placing their weight through the unaffected limb. They state that this compensation was necessary in early mobility of a stroke patients and that it did not have any adverse effect when developing normal movements patterns and recover. Kirker et al (2000, p.647) was then used in the study by Kollen et al (2009, p.e94), looking at the effectiveness of Bobath in stroke patients, to criticise the this assumption that compensatory mechanisms are detrimental and suggests that the Bobath assumption with regards to standing and walking could lead to a higher risk of falls. As a result, Meadows and Williams (2009, p.25) suggests that the Bobath Concept has recognised that perfect movement is not always possible however the Bobath Concept suggests that where possible they can be minimised. However, this appreciation of compensatory mechanisms is not apparent in the IBITA’s description of the Bobath Concept’s theoretical assumptions suggesting that the need for some compensatory mechanisms has not reached the Bobath Concept as a whole.
There is a sense that although the IBITA (2008, P.1) suggest the Bobath concept has developed and changed over time to incorporate new theories and interventions it has not been fully carried over into practice (Tyson et al 2009, p.454). The study by Tyson et al (2009 p.449) was carried out via survey aimed at physiotherapists in the UK treating stroke patients. Seventy four physiotherapists completed the survey which consisted of a list of interventions which the therapist was asked to show on a scale whether they believed them to be a part of Bobath therapy or not (Tyson et al 2009, p.449-450). The conclusion of this study was that the definitions of the changing and developing Bobath Concept are not being followed through in practice (Tyson et al 2009, p.454). This concurs with current evidence by Kollen et al (2009, p.) who suggest that as a result of the changing and developing theoretical assumptions underpinning the Bobath Concept it is now not clear what actually constitutes to the Bobath Concept. This could be the reason for the lack of carryover of the new theories into practice. This suggests that the Bobath Concept has changed so much that what therapists recognise as Bobath may not necessarily be the same as the promoted Bobath Concept. However, the IBITA (2008, p.7) clearly states that at the beginning of the Bobath Concept being founded Mr Bobath stated that the concept will continue to change and develop over time and the IBITA (2008, p.7) state that this will continue to be the case. As a result, the Bobath Concept is able to continue adding theories to their practice as they see fit. This also means that what was seen as the original Bobath Concept may become lost as a result of new evidence and in the case of some assumptions it is already the case. Lettinga et al (1999, p.477) suggests the Bobath Concept was seen to be utilising the hierarchical model to guide their practice. However, Lettinga et al (1999, p.477) suggest that at the time this theory was being largely disputed in light of new advancing understanding of the nervous system. However, the IBITA (2008, p.2) suggests that the non hierarchical of the systems theory is used. Notice that in 1999 the hierarchical model was being disputed and by 2008 the model was no longer being used within the Bobath Concept. This appears to suggest that the Bobath Concept is actually changing from original assumptions in order to fit in with current evidence. This is good practice as a practitioner and the Chartered Society of Physiotherapists (CSP) highly regards evidence-based practice with members being required to keep a portfolio of their evidence-based practice and continued professional development (2009, pp.1-2). However, if the Bobath Concept keeps changing its underpinning theories and assumptions it cannot be regarded as a true concept and should just be regarded as evidence based practice which ultimately is it beginning to become.
In order to compare approaches with the Bobath Concept it is important to first understand their role in therapy and their efficacy. The Motor Relearning approach has been strongly related to the authors Carr and Shepherd in many articles (Chan et al 2006, p.192; Dean et al 2000, p.409; Krakauer 2006, p.84) and relates to the performance and learning of tasks described by Thach (1998, p.185). Carr and Shepherd (1987, p.4) state that although they value the work of others such as Bobath and Brunnstrom they felt, at that time, rehabilitation had new ideas and a vast increase in available research that needed to be incorporated. The theory behind this approach, suggested by Carr and Shepherd (1987, p.7), is that the patient is made aware of their capability to bring about muscle contraction and movement and therefore once practiced often enough it becomes natural.
The Motor Relearning approach suggests that in order for it to be successful it must be practiced over and over (Carr and Shepherd, 1987, p.7). However Krakauer (2006, p.85) suggests that giving a rest between practice sessions actually improves outcome. Woldag et al (2003, p.728) also provide evidence to suggest that constant practice does not necessarily improve outcome. However, this can achieved if encouraged to practice when they can at home. Krakauer (2006, p.85) also advocates the use of variety in rehabilitation when using the Motor Relearning approach. He suggests that increased variety of tasks allows the patient to generalise these tasks when they get home compared to patients who learn the same task constantly and cannot then convert this into their activities of daily living. This article highlights that therapists must ensure that the patient has a significant rest period in between tasks and variety in their tasks in order for the rehabilitation to be effective. The Bobath Concept has incorporated the Motor Relearning approach into their practice (IBITA 2008, p.5). Because the Bobath Concept uses many interventions within its practice patients are not constantly practicing the same tasks which Krakauer (2006, p.85) suggests is detrimental to the speed of improvement. Furthermore, the Bobath Concept also provides the variety that is advocated by Krakauer (2006, p.85) due to its many interventions.
The Johnstone Approach centres its focus on the restoration of normal movement (Johnstone 1995, p.xv). This resounds closely to the principles behind the Bobath Concept. The Johnstone Approach recommends starting rehabilitation at the trunk (Johnstone 1995, p.32). It is proposed that when we move the postural muscle must adjust appropriately in order to cope with the destabilising brought about by the movement (Johnstone 1995, p.32). As a result, the Johnstone Approach emphasises that postural control must be addressed with progression on to limb movement (Johnstone 1995, p.32). Furthermore, the approach uses movement patterns seen in infants in that the first thing infants learn is head, neck and rolling movements. Hence the approach suggests rehabilitation of movement encourages rolling with movement of eyes and the head and Johnstone (1995, pp.43-44) suggest that these movements may evoke reflex movements also. Johnstone (1995, p.44) then goes on to suggest the infants obtain movements from proximal to distal and therefore promotes the development of motor function in the upper limb and then the lower limb. The Johnstone also advocate the use of pressure splints to maintain and influence correct position of joints and reduce spasticity (——————–).
Evidence for this approach is somewhat lacking. Davidson and Waters (2000, p.69-80) carried out a study regarding the approaches used within physiotherapy for stroke rehabilitation. The Bobath Concept and Motor Relearning were by far the most utilised approaches (Davidson and Waters 2000, p.74). The Johnstone approach was described by the researchers as being declined by their participants with only 2% of respondents using the approach. However, the study found that 87% of respondents choose to encompass aspects from numerous approaches within their practice and therefore Johnstone may be incorporated to practice but other approaches may be utilised by the therapist more readily. The limitation with this study is that no where does it ask participants to describe what they believe their chosen approaches involve and therefore it not unclear whether their assumptions on their chosen approach matches the description of that approach. Tyson et al (2009, p.1499) found evidence of this mismatch between the assumptions of therapists and the official description of the Bobath Concept. Future studies in this area should attempt to to identify the differences in assumptions and actual approach values between therapists. A possible explanation for the difference could be that many therapist appear to utilise more than one approach as demonstrated in Davidson and Waters (2000, p.73). As a result, using a mixed approach could lead to the aim of each approach being intermingled and producing mixed aims when attempting to explain them.
Unfortunately there does not appear to be any studies comparing the efficacy of the Johnstone approach with the Bobath Concept. As a result it is not possible to directly compare the efficacy of these two approaches within this essay. Although the Johnstone approach does not appear to be highly regarded for stroke rehabilitation their principles could be useful for transfers and for teaching a patient to perform sit to stand and walking. This is because the approach utilise the steps we take as infants to progress the patient (Johnstone 1995, p.43-44). These steps are logical and can provide the patient with a simple progression and assistance in these functional movements. Small interventions such as turning your head before rolling over can make difficult movements for stroke patients easier to perform. This approach relates to the Bobath Concept in that Meadows and Williams (2009, p.31-32) state that postural control (which involves the trunk) is a key component required for movement to occur. Therefore, like the Johnstone Approach the Bobath Concept focuses much of its work on postural control to allow for movement of the limbs (Meadows and Williams, p.31-32). It would appear that the difference is that the Bobath Concept does not break down movements into steps taken in infancy like the Johnstone Approach. Like the Motor Relearning approach the Bobath appears to have incorporated some of the theory of the Johnstone approach into their own practice.
The Proprioceptive Neuromuscular Facilitation (PNF) approach was founded in the 1950s by Dr Kabat (Voss et al 1985, p.xii). The PNF approach aims to excite the proprioceptors within the body in order to achieve regain in function and is based on movement patterns with the attempt to reduce tone deficits (Pasiut et al 2005, p.16). Voss et al (1985, p.xii) suggest that this is done by the combination of maximal resistance and then a stretch which stimulates the proprioceptive components. However, Jackson (2004, p.402) suggests that there has been a change in thought about the use of maximal resistance and instead the resistance applied is dependent on the needs of the patients.
None of the above approaches appear to have been proven to be superior or inferior to the Bobath Concept. Langhammer and Stanghelle (2000, p.367) found that Motor Relearning was more effective in patients with stoke than the Bobath Concept. However, Langhammer and Stanghelle (2003, p.734) found in their follow up study that not only was there no difference in functional movement but that both groups showed a decline. This could be attributable to normal aging process. However, it does resound with the findings of Dean et al (2000, pp.409-412) that there is a gap in service provision with regards to rehabilitation once their supervised rehabilitation ceases. Lennon (1996) cited in Raine (2009, p.147) posed criticism to the Bobath Concept for not incorporating the Motor Relearning theory into their practice. However, it is evident in Meadows and Williams et al (2009, pp.26-28) that motor learning is incorporated in the Bobath Concept however this could be due to the criticisms of Lennon (1996). Van Peppen et al (2004, p.851) results showed that patients receiving conventional rehabilitation fair better than patients receiving specific approaches like that of the Bobath Concept. Again this is in disagreement to the Bobath Concept as it does not advocate the approach in isolation and in fact encourages the use of other interventions to compliment the Concept (Raine 2009, p.15).
It is apparent in the evidence that the Bobath Concept alone is inferior to the Motor Relearning approach however in the Bobath Concept’s defence it does not advocate the use of Bobath in isolation and does seem to approve of the Motor Relearning approach. Furthermore, evidence suggests both approaches do not last in the long term. Therapists should look to decrease this decline by educating patients as to what they must do at home to maintain their progress regardless of the approach that they use. Furthermore, therapist must use functional tasks throughout Motor Relearning techniques so the patient can carry over these principles to their activities of daily living.
Dickstein et al (1986, p.1236) found no significant difference in the improvement of patient’s ability to perform activities of daily living when using PNF compared with conventional therapy and the Bobath Concept. However, this study is outdated and therefore cannot be used to define the relationship between the efficacy of the Bobath Concept and PNF especially as the Bobath Concept has undergone many changes since 1986 and therefore it is unlikely the Concept tested in this study represents the Bobath Concept at present day.
There have been numerous review studies carried all coming to the conclusion that the Bobath Concept is not superior to any other approaches (Kollen 2009, p.e93; Paci 2003, p.5; Pollock et al 2008, p.519). Kollen (2009, p.e93) performed a view of only randomised controlled trials all of which had a PEDro score of more than four. The studies reviewed were therefore of good quality and the number of collective patients from the studies was 813. Kollen (2009, p.e93) points out that the studies did not provide details of what the approaches tested consisted of and suggests that as a result it is unclear whether pure Bobath was utilised in the studies. As a result Kollen (2009, p.e95) suggests future research into the area should ensure that the Bobath Concept utilised is up to date. Paci (2003, p.2-3) also provide a review of literature however they did not focus on purely randomised control trials thus the evidence presented less reliable than that of Kollen (2009, p.e89-e97). However, they did come to the same conclusion for Kollen (2009, p.e89-97) to later concur with. Pollock et al (2008, p.519) also provided a review study which constituted to 1087 patients in total and again came to the same conclusion as Paci (2003, p.5) and Kollen (2009, p.e93). However, Pollock et al (2008, p.519) did find that a mixed approach to stroke physiotherapy was more efficacious than any approach alone. Many therapists working within stroke have adopted this eclectic approach. Lennon (2003, p.456) found in their study that 67% of therapists utilise principles from many approaches rather than strictly one approach and 31% of therapist use only an eclectic approach. However, even this can be confused in stroke rehabilitation with Tyson and Selley (2007, p.398) finding that those therapist in their study that were suggesting the used an eclectic approach were actually describing a traditional Bobath approach. It is evident that studies are finding that the Bobath approach is not superior to any other method of stroke rehabilitation however the studies have many flaws in their lack of description and defining the approaches they are utilising. This is further exacerbated by the misinterpretation of different approaches especially Bobath.
In conclusion there does not appear to be a superior approach. As presented in the early parts of this essay the Bobath Concepts appears to be changing and developing all the time and its original ideas are falling behind. As a result, there is confusion between practitioners as to what actually constitutes to the concept. This therefore questions all the studies looking at the efficacy of the Bobath Concept. There is a lack of explanation in the studies as to what the therapists consider as their Bobath approach. Therefore, what is considered as the Bobath approach in one study maybe completely different in another study. Furthermore, if a study utilises more than one Bobath therapist without having a set therapy criteria it questions whether the standard of Bobath received by patients was the same. Another problem faced by researchers looking at the efficacy of the Bobath Concept is that the Bobath Concept appears to incorporating all the approaches into their practice if it is evidence based. As a result, when comparing the Bobath Concept to another incorporated approach they are essentially testing similar things. An example of this is studies comparing the Bobath Concept with the Motor Relearning approach. The Bobath Concept incorporates Motor Relearning and therefore the researcher will be testing an approach that is present within both groups. Taking this into consideration it is unsurprising that there is no evidence that any approach is more superior within stroke patients. The Bobath Concept’s principle of evolving to incorporate new evidence is plausible however seen as the concept appears to no longer be the same as the original it could just merely be considered an evidence-based approach to stroke rehabilitation. The Charted Society of Physiotherapy (CSP) has produced an article suggesting that many countries have moved away from the Bobath Concept and adopted an evidence-based approach in neurological rehabilitation (CSP 2010, p.1-2). Furthermore, the article suggests that the UK may be next to follow this trend (CSP 2010, p.1-2). However, it should be noted that this source is anecdotal in nature and therefore cannot be regarded as definite and factual. Researchers should focus their attention to which interventions are efficacious rather than trying to find out what specific approaches are superior as approaches tend to have many overlaps.
