The Bobath concept is an approach to neurological rehabilitation that is applied in patient

assessment and treatment (such as with adults after stroke,[1] or children with cerebral palsy[2]).
The goal of applying the Bobath concept is to promote motor learning for efficient motor control
in various environments, thereby improving participation and function. This is done through
specific patient handling skills to guide patients through initiation and completion of intended
tasks.[3] This approach to neurological rehabilitation is multidisciplinary, primarily involving
physiotherapists, occupational therapists and speech and language therapists. In the United
States, the Bobath concept is also known as 'neuro-developmental treatment' (NDT).[1]

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.

Criticism
The concept that Bobath can “evolve” and still be called Bobath has been challenged by the
president of the American Academy of Cerebral Palsy and Developmental Medicine and the
chair of the UK Association of Chartered Physiotherapists in Neurology (ACPIN).[4][5] These
eminent physiotherapists believe that several of the key original teachings of the founders have
now been abandoned, whilst the ideas / concepts of others (non Bobath therapists & scientists)
have unjustifiably been given the name of Bobath.

There is widespread use of the Bobath concept amongst therapists in stroke rehabilitation. Yet, a
large review of randomized controlled trials (RCTs) of Bobath for stroke rehabilitation found
only three instances of significant differences in favour of Bobath, yet 11 in favour of
alternatives.[6] 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.[7]

In the UK, an NHS review of stroke rehabilitation by Professor Tyson concluded that "the
strength of evidence that task specific functional training and strength training are effective,
whilst Bobath is not, indicates that a paradigm shift is needed in UK stroke physiotherapy..... it is
increasingly difficult to justify the continued use of the Bobath concept or its associated
techniques".[8] More recently Professor Tyson and Dr Mepsted have both written comprehensive
and critical reviews of Bobath/NDT methods, theory and effectiveness.[9][10] See also an
interesting exchange of letters between the above authors and Bobath tutors.[11]

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 an 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.[12] 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 the light of the
evidence supporting the recommended alternatives. Furthermore, patients receiving such
interventions should be informed that it was outside mainstream practice.[13]

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.[14]
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.

History
The Bobath concept is named after its inventors: Berta Bobath (physiotherapist) and Karel
Bobath (a psychiatrist/neurophysiologist). Their work focused mainly on patients with cerebral
palsy and stroke. The main problems of these patient groups resulted in a loss of the normal
postural reflex mechanism and normal movements.[15] At its earliest inception, the Bobath
concept was focused on regaining normal movements through re-education. Since then, it has
evolved to incorporate new information on neuroplasticity, motor learning and motor
control.[1][16] Therapists that practice the Bobath concept today also embrace the goal of
developing optimal movement patterns through the use of orthotics and appropriate
compensations, instead of aiming for completely "normal" movement patterns.[1][16]

Stroke rehabilitation
In the Bobath Concept, postural control is the foundation on which patients begin to develop
their skills. Patients undergoing this treatment typically learn how to control postures and
movements and then progress to more difficult ones. Therapists analyze postures and movements
and look for any abnormalities that may be present when asked to perform them. Examples of
common abnormal movement patterns include obligatory synergy patterns. These patterns can be
described as the process of trying to perform isolated movement of a particular limb, but
triggering the use of other typically uninvolved muscles (when compared to normal movement)
in order to achieve movement. Obligatory synergy patterns can be further subdivided into flexion
and extension synergy components for both the upper and lower extremities. This approach
requires active participation from both the patient and the therapist.[17] Depending on the patient,
rehabilitation goals may work to improve any or all of the following: postural control,
coordination of movement sequences, movement initiation, optimal body alignment, abnormal
tone or muscle weakness.[1][16] Treatment will therefore address both negative signs such as
impaired postural control, and positive signs such as spasticity.[18]

Intervention strategies and techniques for Bobath consist of therapeutic handling, facilitation,
and activation of key points of control. Therapeutic handling is used in order to influence the
quality of the patients' movements and incorporates both facilitation and inhibition.[17]
Facilitation is a key technique used by Bobath practitioners to promote motor learning. It is the
use of sensory information (tactile cue through manual contacts, verbal directions) to reinforce
weak movement patterns and to discourage overactive ones. The appropriate provision of
facilitation during the motor task is regulated in time, modality, intensity and withdrawal, all of
which affects the outcome of motor learning.[16] Inhibition can be described as reducing parts of
movement/posture that are abnormal and interfere with normal performance. Key points of
control generally refers to parts of the body that are advantageous when facilitating or inhibiting
movement/posture.[17]

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.[15]

The Bobath Concepts theoretical underpinning and practice is clearly documented in a

contemporary book published by Wiley Blackman in 2009: Bobath Concept: Theory and
Clinical Practice in Neurological Rehabilitation' written by the British Bobath Tutors
Association (BBTA) and edited by Raine, Meadows and Lynch-Ellerington. The chair of ACPIN
(Association of Chartered Physiotherapists in Neurology) reviewed this book and concluded :- “I
am not really sure that it is clear from the book what the Bobath approach actually is”, “often the
prose turns into jargon” and “this book will do little to quell the critics; in fact it will no doubt
give them more fuel for the fire”.[19]

Research
Paci (2003) conducted an extensive critical appraisal of studies to determine the effectiveness of
the Bobath concept for adults with hemiplegia following a stroke. Selected trials showed no
evidence proving the effectiveness of the Bobath Concept as the optimal type of treatment.[20]
Paci (2003) recommended that standardized guidelines for treatment be identified and described,
and that further investigations are necessary to develop outcome measures concerning goals of
the Bobath approach such as quality of motor performance.[20]
Bobath therapy is nonstandardized as it responds, through clinical reasoning and the
development of a clinical hypothesis, to the individual patient and their movement control
problems. The decisions about specific treatment techniques are collaboratively made with the
patient, and are guided by the therapist, through the use of goal setting and the development of
close communication and interaction. Working to develop improved muscle tone, appropriate to
the task, the individual and the environment, will enable better alignment and activation of
movement, and allow for recruitment of, for example, arm activity in functional situations within
various positions.[21]

A study by Lennon et al.[22] concluded that even under idealized conditions (patients with
optimal rehabilitation potential, advanced trained therapists, unlimited therapy input and a
movement analysis laboratory) the Bobath approach had no effect on the quality of gait for
patients with a stroke.