Physiotherapy Theory and Practice, 23(3):137 152, 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 determ- ined 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 indivi- dual’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]
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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 con- cept 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) 137 152 139 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 sen- sitivity 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) 137 152
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 average and dispersion method that reached of this study was to determine the current theor- the 80% level of consensus. The percentage etical underpinning using an expert sample. The method more accurately represents 13 of 15 total membership of BBTA, clinicians respon- respondents (80%) rather than a mean of the sible for the dissemination of the current under- distributed scores. The statements presented standing and practice of the Bobath concept here are based on the results of the percentage within the United Kingdom, were the experts method. in this study. Response rates were high, with A total of 200 statements were presented for 85% in the first round and 93% in each of the rating: following rounds, which compares well to pre- vious allied health Delphi studies (Deane et al, . 159 (80%) achieved the 80% level of consen- 2003; Ashburn et al, 2004). This study shows sus for agreement concurrent validity (Raine, 2006), and the sensi- . 52 (26%) achieved 100% consensus for tivity analysis verified that both the percentage agreement and average and dispersion methods were com- . 20 (10%) achieved the 80% level for disagree- parable in the ranking of statements and identi- ment fication of consensus. . 9(5%) achieved 100% consensus for disagree- For the 85 statements that were presented in ment round 1, the respondents offered 113 reworded . 3(2%) achieved 80% level of consensus for versions that provided subtle but important neutral opinion changes in meaning, which had an impact on . 21 (11%) did not achieve consensus for either the level of consensus. Only 13 completely agreement or disagreement new statements were generated during the study, which suggested that the initial list of Where there were several reworded versions statements was already comprehensive. The of one statement, the group’s preferred state- experts agreed that 43 of the original statements ment was identified by its ranked order. In total, and 50 generated by the group were representa- tive of the current theoretical assumptions
For personal use only. 93 statements were identified as representing the Bobath concept; 43 of these were taken from the (Table 1a i). published literature. Table 1a i provides a list of these statements within the nine categories. Statements representing the current Twelve statements from the literature were identified as misrepresenting the Bobath concept theoretical assumptions of the Bobath and can be found in Table 2. concept Normal movement (Tables 1a and 2) Level of consensus between rounds Although the experts agreed with previous authors who suggest that therapists need to be Group consensus for statement ratings skilled in the analysis of normal movement improved throughout each of the four question- (Lennon and Ashburn, 2000; Lennon, Baxter naire rounds. The main variation in ratings and Ashburn, 2001), they stated that the aim between respondents was the extent of their level of therapy is to promote ‘‘efficiency of move- Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 of agreement or disagreement for a particular ment’’ to the individual’s maximum potential statement. and not to achieve normal movement. The experts highlighted that selective move- ment of the trunk and limbs, both concentric Discussion and eccentric, are interdependent and interactive with a postural control mechanism (BBTA, Previous studies have collected the views of 2003). Therefore, the recovery of selective move- neurological physiotherapists in an attempt to ment is a prerequisite for efficient postural con- identify the theoretical assumptions of the trol, alignment, and function. Balance in an Raine/Physiotherapy Theory and Practice 23 (2007) 137 152 141
Table 1. Statements representing the current theoretical assumptions of the Bobath concept.
Table 1a. Normal movement . Abnormal coordination of movement patterns, poor balance, sensory deficits, and abnormal tone are the main physical problems of people with hemiplegia. . Recovery of movement following brain injury occurs both proximally and distally. . Therapy aims to promote efficiency of movement to the individual’s maximum potential rather than normal movement. . Therapists need to be skilled in the analysis of normal movement. . In therapy there is a need to address the problem of an individual’s specific ability to create tone against gravity for the necessary postural stability on which selective movement is based. . Treatment aims to optimize postural and movement strategies to improve efficiency. . Therapists handling techniques give patients control over aspects of their stability and alignment and guide them to achieve more efficient movement patterns. . Within therapy there is an emphasis on the patient learning to generate movements as efficiently as possible. . If the CNS is damaged; it has to compensate; it is the therapists’ job to guide patients’ recovery so that they can achieve their maximal functional potential within the constraints of the damaged CNS. . A primary concern of the Bobath concept is the activation of the patient to overcome postural hypotonia. . Therapists need to be skilled in movement analysis. . Selective movement of the trunk and limbs, both concentric and eccentric, are interdependent and interactive with a postural control mechanism. Therefore, the recovery of selective movement is a prerequisite for efficient postural control, alignment, and function. . Rehabilitation is a process of learning to regain motor control and should not be the promotion of compensation that can occur naturally as a result of a lesion and also as a result of therapy.
For personal use only. . Movements must be owned by the patient and be experienced both with and ultimately without the handling of the therapist. . The Bobath concept directs treatment to overcome weakness of neural drive after an upper motor neurons lesion, through selective activation of cutaneous and muscle receptors. . The therapist can only decrease compensation if patients are given control over their posture and balance that is causing the compensation. Obviously, there may be many reasons interfering with this such as sensory and perceptual problems. . Therapists both teach movements and make movement possible by using the environment and the task appropriately. . Balance in individuals is achieved through improving their orientation and stability in relation to postural control. . Movements may have to be cognitive (e.g., corticospinal system and the hand and during initiation of goal-directed movements). . Patients should not be stopped from moving in a certain way unless they have been provided Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 with an alternate strategy, that achieves the same goal. Table 1b. Normalizing tone . Aim of treatment is to create the appropriate alignment of soft tissues and joints and to access optimal muscle activation to achieve the functional task. . Hypertonicity is a combination of disinhibition, plastic reorganization, and mechanical changes. . Spasticity is difficult to quantify and is not universally understood to be the same by everyone.
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Table 1. Continued. Table 1b. Normalizing tone . Bobath therapists seek to find the causal effect of associated reactions rather than merely changing the pattern produced by the associated reaction. . Therapists emphasize the reduction of increased tone and facilitation of movement by cutaneous, proprioceptive, and other handling techniques. . Therapists work on tone to improve movement not to normalize tone for its own sake. . Therapy addresses abnormal=inefficient stereotypical movement patterns that interfere with function. . There may be an element of conscious control over muscle tone, but the aim is for patients to develop control of their balance and movement on an automatic basis to initiate and control functional movements. . Weight bearing can help normalize tone but only if the patient is able to adapt and change muscular alignment actively. . A major treatment goal is to prevent the establishment of spasticity and maximize residual function. . Patients may use associated reactions as a pathologic form of postural fixation when stability cannot be accessed. . Aim is to control rather than inhibit associated reactions. . The significance of hypertonia varies considerably from individual to individual and so its impact also varies. . Therapists do not normalize tone, but they can influence hypertonia at a nonneural level by influencing muscle length and range. . Associated reactions are abnormal, stereotyped movement patterns of the affected side that are involuntary and triggered in many ways. . Associated reactions are phasic contractions lacking a background of postural control.
For personal use only. . Associated reactions interfere with the recovery of function and the ability to perform efficient and effective movement. Table 1c Function . The therapist must address both the specific movement components of the task and the functional activity to achieve goals. . A role of the therapist is to facilitate balance and selective movement as a basis for functional activity and successful goal acquisition. Successful goal acquisition in a given task must then be practiced to improve efficiency and promote generalization. . Therapy is aimed at giving the patient movement choices. . Therapy is based on the assessment of the patient’s potential. . The therapist should not stop the patient from walking; however where walking may be detrimental to recovery, the patient may be advised to walk only with the appropriate facilitation or walking aid. Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 . Preparation is of no value in itself; it must be incorporated into functional activity. . In therapy normal movement is facilitated and must be put into a functionally relevant task to be meaningful to the patient and promote carryover. . The therapist’s handling is modified as the individual achieves independence. . Treatment has ‘‘change of functional outcome’’ at its center. . Goals need to be realistic according to the client’s potential and appropriate to the environment encountered during daily life. (Continued) Raine/Physiotherapy Theory and Practice 23 (2007) 137 152 143
Table 1. Continued.
Table 1d. Systems approach . Human motor behavior is based on continuous interaction between the individual, the environment, and the task. . The CNS is a complex organization consisting of systems and subsystems. It uses a shifting focus of control depending on many biomechanical, neuroanatomical, and environmental influences. . Movement control is dependent on an integrated neurological and muscular system. . The person is evaluated in terms of total function within changing environments, and the intervention process is individualized to his or her bio-psycho-social needs. . The concept involves the whole patient: sensory, perceptual, and adaptive behavior as well as motor problems. . Treatment is tailored to the client’s individual needs. Table 1e. Motor learning . If efficiency in the motor skill is inadequate, the individual may look at movement components to improve skill (e.g., a tennis coach may encourage practice of a component to perfect the tennis stroke). . Therapy is an interactive process between individual, therapist, and the environment. . As soon as patients are able to practice aspects of appropriate activity, this is encouraged as part of their rehabilitation program. . The emphasis in treatment is on active participation of the patient on either an automatic or a volitional basis or a combination of both. . Repetition is important in the consolidation of motor control, but it does not mean moving in exactly the same way. . As part of the rehabilitation process, the therapist must consider the 24-hour management of the patient and his=her way of life. For personal use only. . Patients should be given advice on how to move in between therapy sessions to achieve carryover. . Preventative and promotive aspects of therapy need to be addressed. . The Bobath concept is goal oriented and task specific and seeks to alter and construct both the internal (proprioceptive) and external (exteroceptive) environment in which the central nervous system and therefore the person can function efficiently and effectively. . Therapists need to be aware of the principles of motor learning: active participation, opportunities for practice, and meaningful goals. . For learning ...relearning to occur, there needs to be the opportunity to practice. Table 1f. Musculoskeletal system . Altered muscle tone, changes in muscle length and alignment, muscle weakness and incoordination may all limit functional recovery in patients following stroke.
Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 . Influencing muscle length and range enables improved alignment for more efficient muscle activation and effective movement. . Body weight and gravity can be used to strengthen muscles as well as appropriate resisted exercises. . Altered muscle tone, weakness, and altered viscoelastic properties may all impact the patient’s ability to recover efficient movement. . Optimizing muscle length must incorporate the complex relationship of stabilizing and mobility components.
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Table 1. Continued. Table 1f. Musculoskeletal system . Selective and specific strength training may be part of treatment within the Bobath concept. . Muscles need sufficient activity to generate force for action. . Although strength of individual muscle groups is less important than their coordination in patterns of activity, strength may still be an issue for efficient movement in some patients. . If weakness is seen as a lack of or reduced specificity of neuromuscular innervation, this is as much a problem as muscle tone.
Table 1g. Sensory systems . Specific stimulation may be necessary to promote localization of movement (e.g., fingers), but sensory stimulation on its own is not the whole picture; it has to be combined with active movement. . Ultimately, the therapist is aiming to reeducate the patient’s own internal referencing system to provide accurate afferent input to give the patient the best opportunity to be efficient, specific, and have movement choices. . At some stages of skill acquisition, somatosensory referencing may be emphasized over verbal or visual feedback.
Table 1h. Neuroplasticity . The CNS and neuromuscular system can adapt and change their structural organization in response to intrinsic and extrinsic information (i.e., they are plastic). . Changes within the structure of the CNS can be organized or disorganized producing adaptive or maladaptive sensorimotor behavior. . Plasticity underlies all skill learning and is a part of CNS function. . The cellular mechanisms that take place during the development, refinement, and relearning of
For personal use only. motor control can result in long- or short-term learning (i.e., carryover or no carryover). . The manipulation of information can directly affect a change in the structural organization of the CNS through spatial and temporal summation and the facilitation of pre- and post-synaptic inhibition. . Motor skill is based on reciprocal innervation and sequential activation of motor units giving selectivity of movement control. . Therapy addresses the neuromuscular system, spinal cord, and higher centers to change motor performance. . Therapy takes into account neuroplasticity, an interactive CNS, and our individual expression of movement. . Neuroplasticity is a primary rational for treatment intervention. . Each individual patient is assessed in terms of their lesion, individual movement expression, and potential to maximize his or her movement efficiency.
Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 Table 1i. Additional therapies . The Bobath approach can be complemented with other modalities and adjuncts such as structured practice, use of orthotics and muscle strengthening. . Splinting and orthoses may be indicated to gain alignment or a good weight-bearing base for improved proximal and truncal activity. . The Bobath therapist may use motor mental imagery as part of a patients home programme. . The Bobath concept utilises selective constraint through posturing a limb and=or through an environmental support.
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Table 1. Continued.
Table 1i. Additional therapies . Therapists may use a treadmill and this could include facilitation to enable the most efficient pattern. . Using other techniques in parallel, such as Maitland mobilisations, is compatible with the Bobath Concept. . Restraint of the less affected body parts manually during a therapy session may be used to and assist activation of the affected parts.
Lightface statements indicate greater than 80% group consensus; those in bold indicate total consensus.
individual is said to be achieved through stopped from moving in a certain way unless improving their orientation and stability in they have been provided with an alternate strat- relation to postural control. The experts egy, that achieves the same goal. expressed the opinion that in therapy there is a The experts agreed that the main physical need to address the problem of an individual’s problems of people with hemiplegia were not specific ability to create tone against gravity, only abnormal coordination of movement pat- for the necessary postural stability on which terns and abnormal tone (Lennon, Baxter, and selective movement is based. The aim of therapy Ashburn, 2001) but also poor balance and sen- is to optimize postural and movement strategies sory deficits. It was stated that recovery of to improve efficiency. movement can occur both proximally and dis- Lennon (1996) suggested that in the Bobath tally. However, facilitation of movement is not concept there is a great emphasis on decreasing always preferred on an automatic basis as overcompensation of the unaffected side. How- suggested by Lennon and Ashburn (2000). The ever, the experts highlighted that the therapist respondents provided examples such as in the can only decrease compensation if the patient recovery of the hand or initiation of goal- For personal use only. is given control over their own posture and directed movements where it is necessary for balance, which is inadequate and causing the movement to be cognitive. compensation. They agreed that if the CNS is damaged, it has to compensate and that it is Normalizing tone(Tables 1b and 2) the therapist’s job to guide the person’s recovery The experts stated that hypertonicity, rather so that they can achieve their maximal func- than spasticity (Lennon and Ashburn, 2000), is tional potential within the constraints of the a combination of disinhibition, plastic reorgani- damaged CNS (Mayston, 2001). The experts zation, and mechanical changes and that its also agreed that rehabilitation is a process of significance varies considerably between indivi- learning to regain motor control and should duals. The experts believed that spasticity is dif- not be the promotion of compensation that ficult to quantify and is not universally can occur naturally as a result of a lesion or as understood to be the same by everyone. Several a result of therapy (BBTA, 2003). authors link the Bobath concept with therapy The experts suggested that the focus in ther- that focuses on the normalization of tone before Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 apy is not the suppression of patient-generated active movement is facilitated (van Vliet, incorrect movements until normal movement Lincoln, and Robinson, 2001; Langhammer patterns are achieved (Sparkes, 2000). The focus and Stanghelle, 2000). The Bobath experts is on the patient ‘‘learning’’ to generate move- strongly refuted this but agreed that therapists ments as efficiently as possible. Movements must work on tone to improve movement, not to nor- be ‘‘owned’’ by the patient and be experienced malize tone for its own sake (Lennon, Baxter, both with, and ultimately without, the handling and Ashburn, 2001) and that it can be influenced of the therapist. They supported Mayston’s at a nonneural level, by influencing muscle (2001) statement that patients should not be length and range (Mayston, 2001). 146 Raine/Physiotherapy Theory and Practice 23 (2007) 137 152
Table 2. Statements taken from the literature, which the experts agree are NOT representative of the theoretical assumptions of the Bobath concept. Normal movement . Therapy is aimed at the reeducation of normal movement. Normal tone . Patients needs to learn to consciously exert control over their muscle tone during activities of daily living mainly by using reflex-inhibiting patterns or positions. . Therapy focuses on the normalization of tone before active movement is facilitated. . Reflex inhibitory and facilitatory strategies are used in the treatment of hemiplegic patients. Function . Patients are not encouraged to walk independently until they can walk with normal patterns without increased spasticity. Motor learning . Unsupervised patient practice is strongly discouraged because the adoption of an incorrect pattern of movement is deemed detrimental to rehabilitation. Musculoskeletal system . Body weight and gravity are used to facilitate normal movement but not to increase muscle strength. . Muscle tone is seen as a greater problem than weakness in patients following stroke. . Therapists discourage resistive exercises in patients with hemiplegia. . It is muscle coordination that is disturbed in stroke patients, not muscle strength. Neuroplasticity . Therapy does not take into account neuroplasticity, an interactive CNS, or our individual expression of movement. Additional therapies . Therapists are unlikely to prescribe walking aids or orthotics to enable a patient to walk independently more quickly because this may reinforce abnormal tone and movement, For personal use only. thereby proving detrimental to recovery.
Lightface statements indicate greater than 80% group consensus; those in bold indicate total consensus.
The group concurred that associated reac- with function (Lettinga, Helders, Mol, and tions are abnormal, stereotypical movement Rispens, 1997) by creating the appropriate align- patterns of the affected side that are involun- ment of soft tissues and joints to access optimal tary and triggered in many ways (Lennon, muscle activation to achieve the functional task 1996). They are phasic contractions lacking a (Mayston, 2001). The experts opposed the background of postural control that interfere suggestion that current Bobath therapists use with the recovery of function and the ability reflex inhibiting patterns or positions (Wagenaar to perform efficient and effective movement et al, 1990; Hesse et al, 1998; Langhammer and (Lynch-Ellerington, 2000). The experts also Stanghelle, 2000). They strongly agreed that agreed that patients may use associated reac- there may be an element of conscious control Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 tions as a pathologic form of postural fixation over muscle tone, but the aim is for patients to when stability cannot be accessed. The aim in develop control of their balance and movement therapy is to control rather than inhibit associa- on an automatic basis to initiate and control ted reactions. functional movements. Sackley and Lincoln A major treatment goal is not to reduce spas- (1996) reported that weight bearing through the ticity but to prevent its establishment and to affected limb would normalize tone. However, maximize residual function (Cornall, 1991). the experts agreed that this would only happen Therapists address abnormal or inefficient if patients were able to adapt and change muscu- stereotypical movement patterns that interfere lar alignment actively. Raine/Physiotherapy Theory and Practice 23 (2007) 137 152 147
Function (Tables 1c and 2) statements emphasized that the CNS is a com- Lennon and Ashburn (2000) suggest the role plex organization of systems and subsystems of the therapist is to give patients enough bal- and the importance of the continuous interac- ance and movement to be able to achieve their tion between the individual, environment and functional goals. However, the experts stated the task (Shumway-Cook and Woollacott, that the role of the therapist is to facilitate bal- 2001). The concept involves the whole patient, ance and movement as a basis for functional their sensory, perceptual, and adaptive behavior activity and successful goal acquisition, which as well as their motor problems. The inter- in a given task must then be practiced to vention process is individualized to the patient’s improve efficiency and promote generalisation. bio-psycho-social needs. Unlike results of pre- It was agreed that the therapist must address vious studies (Lennon, Baxter, and Ashburn both the specific movement components of the 2001), the experts reported the importance of task and the functional activity to achieve the an integrated neurological and muscular system goals and that the therapists handling is modi- in movement control. fied as the individual achieves independence (IBITA, 1999). Although the experts agreed with Motor learning (Tables 1e and 2) Lennon (1996) that normal movement needs to Bobath proponents have been criticized in the be facilitated within functional tasks, they stated past for not integrating principles of motor that these tasks must be relevant and meaningful learning theories into their theoretical frame- to the patient to promote carryover. They work (Goodgold-Edwards, 1993; Lennon, 1996). agreed with Mayston (2001) that preparation is The experts strongly agreed that therapists need of no value in itself; it must be incorporated into to be aware of the principles of motor learning, functional activity and that therapy is based on which include active participation, meaningful the assessment of the patient’s potential and goals, and opportunities for practice (BBTA, aimed at giving the patient movement choices. 2003). They believed that therapy is an interac- Goals need to be realistic according to the tive process not only between the individual patient’s potential and appropriate to the and the task (IBITA, 1999) but also the environ- environment encountered during daily life. ment (Shumway-Cook and Woollacott, 2001). Treatment was said to have ‘‘change of func- Lennon (1996) stated that active participation For personal use only. tional outcome’’ at its center. of the patient is on either an automatic or voli- One contentious issue within the literature is tional basis in the Bobath concept. However, related to Bobath therapists delaying patients the experts stated that it could also be a combi- walking (Partridge and de Weerdt, 1995; Lennon, nation of both. Although the experts agreed 1996; Rice-Oxley and Turner-Stokes, 1999; Punt, with IBITA (1999) that the individual focuses 2000). The experts refuted the statement that on the goal rather than the specific movement patients are not encouraged to walk indepen- components of the task in the acquisition of dently until they can walk with normal patterns, functional motor skill, they considered that, without increased spasticity (Lennon, 1996). more importantly, the therapist might identify They stated that the therapist should not stop the movement components to improve ability patients from walking. However, where walking when the motor skill is inefficient. may be detrimental to their recovery, patients The experts concurred with Lennon and may be advised to walk only with the appropriate Ashburn (2000), who state that patients should facilitation or walking aid. be given advice on how to move in between ther- Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 apy sessions to achieve carryover and that Systems approach (Tables 1d and 2) repetition is important in consolidation of motor Statements on the systems approach were control, but this does not mean moving in identified from literature published, coinciden- exactly the same way. They also agreed that tally, by proponents of the Bobath concept for learning or relearning to occur, there needs (Lennon, 1996; IBITA, 1999; Panturin, 2001; to be the opportunity to practice (Mayston, BBTA, 2003) and produced the strongest 2001) and that preventative and promotive consensus, with all respondents rating strong aspects of therapy need to be addressed (IBITA, agreement and providing few rewordings. The 1999). The experts disagreed with the suggestion 148 Raine/Physiotherapy Theory and Practice 23 (2007) 137 152
by Sparkes (2000) that unsupervised patient The Bobath experts disputed this and stated that practice is strongly discouraged because of the selective and specific strength training using possibility of the adoption of incorrect patterns body weight, gravity, and appropriate resisted of movement; they suggested that as soon as exercises may be part of treatment within the patients are able to practice aspects of appropri- Bobath concept. ate activity, this should be encouraged as part of their rehabilitation program. Similar to Sensory systems (Tables 1g and 2) Lettinga, Helders, Mol, and Rispens (1997), The experts suggested that providing specific the respondents agreed that therapists must con- sensory stimulation may be necessary to pro- sider the 24-hour management of the patient and mote localization of movement rather than to his or her way of life as part of the rehabilitation facilitate movement in certain patterns (BBTA, process. The experts considered the Bobath con- 2003). Ultimately, the therapist is aiming to cept to be goal orientated and task specific; it reeducate the patient’s own internal referencing seeks to alter and construct both the internal system to provide accurate afferent input giving (proprioceptive) and external (exteroceptive) the patient the best opportunity to be efficient, environment in which the central nervous specific, and have movement choices. The system, and therefore the person, can function experts disagreed with the blanket statement by efficiently and effectively. Lennon and Ashburn (2000) that therapists strive to develop the patient’s internal reference Musculoskeletal system (Tables 1f and 2) system by limiting the use of visual and verbal It is suggested that the Bobath concept con- feedback and emphasizing manual feedback at siders muscle tone a greater problem than weak- all stages of skill acquisition. They identified ness in patients following stroke (Mayston, that at some stages of skill acquisition somato- 2001). However, the experts agreed that if weak- sensory referencing may be emphasized over ver- ness is seen as a lack of, or reduced specificity of, bal or visual feedback. However, there is a neuromuscular innervation, then weakness is as selective process to both the choice and timing much a problem as muscle tone. The experts of the sensory system used in treatment. agreed that strength of individual muscle groups is less important than their coordination in pat- Neuroplasticity (Tables 1h and 2) For personal use only. terns of movement (Partridge and de Weerdt, There was total consensus for the following 1995; Lettinga, Helders, Mol, and Rispens, statements: 1997). However, they stated that strength may still be an issue for efficient movement in some . The CNS and neuromuscular system can patients. Altered muscle tone, changes in muscle adapt and change their structural organization length and alignment, muscle weakness, and inco- in response to intrinsic and extrinsic infor- ordination may all limit functional recovery in mation (i.e., they are plastic) (BBTA, 2003). patients following stroke. They concurred with . Changes within the structure of the CNS can Mayston (2001) that muscles need sufficient be organized or disorganized producing activity to generate force for action, length and adaptive or maladaptive sensorimotor beha- range to enable improved alignment for efficient vior (BBTA, 2003). activation and effective movement, and a com- . The cellular mechanisms that take place during plex relationship between muscle groups to pro- the development, refinement, and relearning of vide components of stability and mobility. motor control can result in long- or short-term Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 Unlike Mayston (2001), the experts stated that learning (i.e., carryover or no carryover) altered muscle tone, along with weakness and (BBTA, 2003). altered viscoelastic properties, may all impact the . The manipulation of information can directly patient’s ability to recover efficient movement. affect a change in the structural organization Jones, Tallis, and Pomeroy (2003) stated that of the CNS through spatial and temporal Bobath therapists discourage resistive exercises summation and the facilitation of pre- and in patients with hemiplegia and that body weight postsynaptic inhibition (BBTA, 2003). and gravity are used to facilitate normal . Plasticity underlies all skill learning and is a movement and not to increase muscle strength. part of CNS function (Mayston, 2001). Raine/Physiotherapy Theory and Practice 23 (2007) 137 152 149
Table 3. Summary of the theoretical assumptions of the Bobath concept.
Systems approach Function The CNS is a complex organization consisting Treatment has ‘‘change of functional of systems and subsystems. It uses a shifting outcome’’ at its center. focus of control depending on many The therapist must address both the specific biomechanical, neuroanatomical, and movement components of the task and the environmental influences. functional activity to achieve goals. Human motor behavior is based on continuous Goals need to be realistic according to the interaction between the individual, the client’s potential and appropriate to the environment, and the task. environment encountered during daily life. Ultimately, the therapist is aiming to reeducate A role of the therapist is to facilitate balance the patient’s own internal referencing system and selective movement as a basis for to provide accurate afferent input giving the functional activity and successful goal patient the best opportunity to be efficient, acquisition. Successful goal acquisition in specific, and have movement choices. a given task must then be practiced to improve efficiency and promote generalisation.
Motor learning Movement analysis The Bobath concept is goal oriented and task Therapists need to be skilled in the analysis specific and seeks to alter and construct both of normal movement. the internal (proprioceptive) and external Altered muscle tone, changes in muscle (exteroceptive) environment in which the length and alignment, muscle weakness, central nervous system and therefore the and incoordination may all limit person can function efficiently and effectively.
For personal use only. functional recovery in patients Therapists need to be aware of the principles following stroke of motor learning: active participation, Selective movement of the trunk and limbs, opportunities for practice, and meaningful goals. both concentric and eccentric, are interdependent and interactive with a Therapy is an interactive process between postural control mechanism. Therefore, individual, therapist, and the environment. the recovery of selective movement is a prerequisite for efficient postural control, Plasticity underlies all skill learning and is a alignment, and function. part of CNS function. In therapy there is a need to address the As part of the rehabilitation process, the problem of an individual’s specific ability therapist must consider the 24-hour to create tone against gravity for the management of the patient and his=her necessary postural stability on which Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 way of life. selective movement is based. Therapy aims to promote efficiency of movement to the individual’s maximum potential rather than normal movement.
(Continued) 150 Raine/Physiotherapy Theory and Practice 23 (2007) 137 152
Table 3. Continued.
Adjuncts to treatment The Bobath approach can be complemented with other modalities and adjuncts such as structured practice, use of orthotics, and muscle strengthening. Selective and specific strength training may be part of treatment within the Bobath concept. Using other techniques in parallel, such as Maitland mobilizations, is compatible with the Bobath concept. Therapists may use a treadmill, and this could include facilitation to enable the most efficient pattern. Splinting and orthoses may be indicated to gain alignment or a good weight-bearing base for improved proximal and truncal activity. Restraint of the less affected body parts manually during a therapy session may be used to try to assist activation of the affected parts.
The experts stated that each individual (Mayston, 2003). The experts concurred with patient is assessed in terms of his or her lesion, Mayston (2001) that the basis for splinting and individual movement expression, and potential orthotics is to gain alignment or a good weight- to maximize movement efficiency. The group bearing base for improved proximal and truncal believed that therapy addresses not only the activity. Lennon, Baxter, and Ashburn (2001) neuromuscular system and spinal cord but also suggested that Bobath therapists are unlikely to higher centers to change motor performance prescribe walking aids or orthotics to enable a (BBTA, 2003). The experts suggested that motor patient to walk independently, more quickly, skill is based on reciprocal innervation and because this may reinforce abnormal tone and sequential activation of motor units giving selec- movement and therefore be detrimental to recov- tivity of movement control, simplifying the orig- ery. There was total disagreement with this state- For personal use only. inal BBTA statement (2003). Neuroplasticity is a ment, and although the experts did not offer an primary rationale for treatment in the Bobath alternative in this case, previous statements indi- concept. cated that the experts would not stop the patient walking and they would consider where appro- Additional therapy (Tables 1i and 2) priate the use of orthoses. The additional therapy statements consider where other therapy techniques or approaches Summary fit in relation to the Bobath concept. It was Five category headings were identified in the agreed that the Bobath approach can be comple- group feedback session. Statements achieving mented with other modalities and adjuncts such consensus consistently throughout the study as structured practice, use of orthotics, tread- have been presented as a summary of the key mill, and muscle strengthening and can include theoretical assumptions of the Bobath concept other techniques such as Maitland mobilisations within these categories in Table 3. (Lennon and Ashburn, 2000; Mayston, 2001, The experts in this study were members of Physiother Theory Pract Downloaded from informahealthcare.com by Hochschule Fresenius / Bibliothek on 06/23/11 2003). The experts agreed that restraint of the only one group within an international organiza- less affected body parts manually during a tion that is responsible for disseminating the cur- therapy session may be used to try to assist rent understanding and practice of the Bobath activation of the affected part, a variation on concept worldwide and based on their individual the initial statement by Mayston (2001). interpretation of the teachings of the Bobaths The experts agreed that, by using the tread- (Raine, 2006). It is important to acknowledge mill, the therapist will include facilitation to that the statements presented here are represen- enable practice of the most efficient pattern, tative only of the expert group in the United which aims to provide the optimal performance Kingdom. It would be valuable to collect the Raine/Physiotherapy Theory and Practice 23 (2007) 137 152 151
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