The Current Theoretical Assumptions of the Bobath Concept As Determined

Physiotherapy Theory and Practice, 23(3):137À152, 2007 Copyright # Informa Healthcare ISSN: 0959-3985 print/1532-5040 online DOI: 10.1080/09593980701209154 The current theoretical assumptions of the Bobath concept as determined by the members of BBTA Sue Raine, Grad Dip Phys, BSc in Physiotherapy, MSc Team Lead Physiotherapist, Walkergate Park for Neurorehabilitation and Neuropsychiatry, Benfield Road, Newcastle upon Tyne, UK The Bobath concept is a problem-solving approach to the assessment and treatment of individuals following a lesion of the central nervous system that offers therapists a framework for their clinical practice. The aim of this study was to facilitate a group of experts in determining the current theoretical assumptions underpinning the Bobath concept.A four-round Delphi study was used. The expert sample included all 15 members of the British Bobath Tutors Association. Initial statements were identified from the literature with respondents generating additional statements. Level of agreement was determined by using a five-point Likert scale. Level of consensus was set at 80%. Eighty-five statements were rated from the literature along with 115 generated by the group. Ninety-three statements were identified as representing the theoretical underpinning of the Bobath concept. The Bobath experts agreed that therapists need to be aware of the principles of motor learning such as active participation, opportu- nities for practice and meaningful goals. They emphasized that therapy is an interactive process between individual, therapist, and the environment and aims to promote efficiency of movement to the individual’s maximum potential rather than normal movement. Treatment was identified by the experts as having ‘‘change of functional outcome’’ at its center. For personal use only. Introduction The Bobath concept was developed as a living concept, with the understanding that as thera- The Bobath concept is a problem-solving pists’ knowledge base grows, their view of treat- approach to the assessment and treatment of ment broadens (Raine, 2006). Although it is individuals with disturbances of function, move- recognized that the Bobath concept has under- ment, and tone due to a lesion of the central ner- gone considerable developments since its incep- vous system (Raine, 2006). Based on the systems tion (Partridge and de Weerdt, 1995), many approach to motor control, the concept offers researchers continue to base their assumptions therapists working in neurology a framework and treatment principles, entirely on Bobath’s for their clinical practice (Raine, 2006). The third edition textbook published in 1990 Bobath concept is the most commonly used (Langhammer and Stanghelle, 2000; van Vliet, approach in the United Kingdom for the man- Lincoln, and Robinson, 2001). Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 agement of people with neurological problems Pomeroy and Tallis (2002) state that develop- (Davison and Walters, 2000; Lennon, 2001). ments in the approach are impossible to deter- Berta Bobath (1970) initiated the concept, and mine and criticize Bobath proponents for not her therapeutic developments revolutionized the publishing these changes. Lennon (1996) sug- assessment and treatment of patients worldwide. gests that updating the theory orally, through Accepted for publicaiton 5 July 2006. Address correspondence to Sue Raine, BSc, MSc, Team Lead Physiotherapist, Walkergate Park for Neurorehabilitation and Neuropsychiatry, Benfield Road, Newcastle upon Tyne NE6 4QD, UK. E-mail: [email protected] 137 138 Raine/Physiotherapy Theory and Practice 23 (2007) 137À152 postgraduate courses and not through the publi- as qualified Bobath Instructors ranged between cation of literature, contributes to problems in 2 and 25 years. The number of experts totaled evaluating the theoretical framework of the 15, and the response rate for each round was Bobath concept and encourages the misconcep- set at 80%. tion that the approach has not developed since Following a review of the literature between 1990. Pomeroy and Tallis (2002) believe that to 1990 and November 2003, 347 statements were improve the evidence base, there is a need to identified that either defined the Bobath concept define the current theoretical framework and or its theoretical underpinning. Eighty-five were therapeutic interventions in enough detail for chosen by two independent therapists and the their effectiveness to be evaluated. Both surveys researcher as representative of the statements and focus groups have used experienced phy- describing the theoretical assumptions and were siotherapists to identify the theoretical assump- included in nine themed sections within the tions of the Bobath concept (Lennon, Baxter, postal questionnaire (another 10 statements and Ashburn, 2001; Lennon and Ashburn, relating to the definition of the Bobath concept 2000). The information collected in these studies were also included and reported in a second was based almost entirely on individual thera- paper [Raine, 2006]). Level of agreement was pists’ ‘‘interpretations’’ of information delivered rated on a five-point Likert scale. in postgraduate courses over different time peri- Following collation of the data from each ods. The aim of this study was to facilitate a questionnaire, feedback was provided in the sub- group of experts in determining the current sequent questionnaire identifying the indivi- theoretical assumptions underpinning the dual’s rating in relation to the group opinions. Bobath concept. An opportunity was also pro- The respondent was then given the opportunity vided for the experts to identify statements that to change his or her rating in view of the feed- were not representative of the Bobath concept. back, along with an opportunity to rate the new statements generated by the group. See Figure 1 for a summary of the procedure. Methodology In between the third and fourth questionnaire rounds, the results were presented to the experts A four-round Delphi study was used to estab- as a group. Their attention was drawn to simila- For personal use only. lish the level of consensus for a number of state- rities in wording and meaning of some of the ments taken from the literature relating to the statements, and they were instructed to identify theoretical assumptions of the Bobath concept their ‘‘preferred’’ statements in the fourth and and to provide an opportunity for respondents final round. to generate additional statements (Raine, Related statements had been grouped into 2006). The Delphi is a method for structuring nine categories in the first questionnaire and group communication (Linstone and Turoff, retained throughout the four rounds, although 1975) that entails the distribution of a series of some statements could have been placed in more questionnaires interspersed with controlled opi- than one category. Feedback from the group nion feedback (Ziglio, 1996). On the basis that indicated that there were some category head- they are responsible for disseminating the cur- ings that were preferred over others to represent rent understanding and practice of the Bobath the current Bobath concept, and these preferred concept in postgraduate courses, the total mem- category headings were used to summarize the bership of the British Bobath Tutors Association results. Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 (BBTA) was chosen as the experts in this study. The experts were all physiotherapists who had Analysis undergone extensive training in the Bobath concept and were qualified as International Bobath Content analysis was used to identify major Instructors to lead the teaching at either basic or themes and descriptive statistics (percentage advanced course levels (IBITA, 2003). They and average and dispersion) to identify the level each retained a high level of patient contact of consensus and rank the statements in order of (minimum of 300 hours annually), in addition preference. To achieve consensus, a level of 80% to their teaching commitments. Their experience of the respondents’ votes within either the Raine/Physiotherapy Theory and Practice 23 (2007) 137À152 139 For personal use only. Figure 1. Delphi study procedure. agreement or disagreement categories had to be Statement generation reached. Reliability was assessed by using a sensitivity analysis on the data provided by the per- Eighty-five statements relating to the theor- centage and average and dispersion methods. etical assumptions of the Bobath concept were included in the first round. An additional 115 Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 statements were generated in subsequent rounds; Results 102 of these were reworded versions of the orig- inal statements, and 13 were completely new. Response rate There was an 85.7% (12=14) response rate Sensitivity analysis and level achieved in the first round, with 93.3% (14=15) of consensus in the second and third, and 92.9% (13=14) in the fourth. There was one consistent nonrespon- The data from both the percentage and aver- der throughout the study. age and dispersion methods of analysis were 140 Raine/Physiotherapy Theory and Practice 23 (2007) 137À152 identical in the ranked order of statements. Bobath concept (Lennon and Ashburn, 2000; There were, however, fewer statements in the Lennon, Baxter, and Ashburn, 2001). The aim

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