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The Bobath concept is an approach to Neurology 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 the initiation and completing of intended tasks. This approach to neurological rehabilitation is multidisciplinary, primarily involving Physical therapy, 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.
The Bobath concept is named after its inventors: Berta Bobath (Physical therapy) 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 standard postural reflex mechanism and regular movements. The Bobath concept was focused on regaining regular movements through re-education at its earliest inception. Since then, it has evolved to incorporate new information on neuroplasticity, motor learning, and motor control. Therapy 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 ultimately "normal" movement patterns.
The Bobath Centre in Watford, UK is a specialist therapy, treatment & training facility and the home of the Bobath Concept.
The strategies and techniques utilized in Bobath therapy encompass therapeutic handling, facilitation, and activation of pivotal control points. Therapeutic handling is a method applied to influence movement quality, combining both facilitation and inhibition approaches. Facilitation plays a central role in Bobath therapy, fostering motor learning by utilizing sensory cues (such as tactile contact and verbal guidance) to reinforce weak movement patterns and discourage excessive ones. The precise application of facilitation during motor tasks involves considerations of timing, modality, intensity, and withdrawal, all of which impact the outcome of motor learning. Inhibition entails diminishing abnormal movement or posture elements that hinder normal functioning. Key control points often denote advantageous areas of the body for facilitating or inhibiting movement and 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.
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 the recruitment of, for example, arm activity in functional situations within various positions.
There is a 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 that therapists should base their treatment methods on “evidence-based guidelines, accepted rules of motor learning, and biological mechanisms of functional recovery, rather than therapist preference for any named therapy approach”. This review pointed out that the approach is now regarded as “obsolete” in some European countries and it is therefore no longer taught.
In 2018, a major review of upper limb interventions following stroke found significant positive effects for constraint and task specific-therapies and the supplementary use of biofeedback and electrical stimulation. However, they concluded that the use of Bobath therapy was not supported. Furthermore, a 2020 review of Human leg rehabilitation following stroke concluded that Bobath therapy was inferior to task specific training and that prioritising Bobath therapy over other interventions is not supported by current evidence.
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 is effective, while 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"
/ref>Mepsted R 2018 Bobath physiotherapy. Evidence based or habit based?
https://www.slideshare.net/MepstedRoger/bobath-physiotherapy-evidence-based-or-habit-based?qid=a70137d6-d8d1-4b36-be37-1957bf301af5&v=&b=&from_search=7 See also an interesting exchange of letters between the above authors and Bobath tutors.
National evidence-based guidelines for stroke rehabilitation have been published for England, Netherlands, Canada, Australia, and New Zealand; yet in none of these is the Bobath approach recommended. Conversely, in 2016 the American Stroke Association concluded that although the effectiveness of NDT/Bobath (compared with other treatment approaches) had not been established that it still “may be considered” as a treatment option for mobility. This, however, was their lowest classification of acceptable treatment. Their two highest recommendation groups (“should be performed” and “reasonable to perform”) contained a variety of treatments for which there was much better evidence. NDT/Bobath was not listed as an option for arm/hand rehabilitation. Also, in 2016, the revised RCP guidelines for stroke made no mention of Bobath/NDT, whilst many alternatives were recommended. Importantly they stated that if a treatment was not mentioned, then it was not recommended and need not be funded. They also stated that therapists using such methods must objectively review their options in light of the evidence supporting the recommended alternatives. Furthermore, patients receiving such interventions should be informed that it was outside mainstream practice.RCP 2016, “National Clinical Guideline for Stroke” Section 1.8 A highly significant 2021 “position paper” by the Academy of Neurologic Physical Therapy of the American Physical Therapy Association concluded that, despite its lack of an evidence base, NDT/Bobath methods were still favoured by some therapist in the USA. To overcome this problem, they described a range of strategies that will be implemented to encourage best evidence-based practices and de-implement traditional (NDT/Bobath) methods of working at both an individual and organizational level.
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 neurorehabilitation. Yet, the British Bobath Tutors Association website does quote the minority of RCTs that support their approach.
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