Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

Effectiveness of the Bobath concept in the

treatment of stroke: a systematic review

María J. Díaz-Arribas, Patricia Martín-Casas, Roberto Cano-de-la-Cuerda &

Gustavo Plaza-Manzano

To cite this article: María J. Díaz-Arribas, Patricia Martín-Casas, Roberto Cano-de-la-Cuerda &
Gustavo Plaza-Manzano (2019): Effectiveness of the Bobath concept in the treatment of stroke: a
systematic review, Disability and Rehabilitation, DOI: 10.1080/09638288.2019.1590865

To link to this article: https://doi.org/10.1080/09638288.2019.1590865

Published online: 24 Apr 2019.

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2019.1590865

REVIEW ARTICLE

Effectiveness of the Bobath concept in the treatment of stroke:

a systematic review
Mar
ıa J. D
ıaz-Arribasa , Patricia Mart
ın-Casasa,b , Roberto Cano-de-la-Cuerdac and
Gustavo Plaza-Manzanoa,b
a
Department of Radiology, Rehabilitation and Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, Complutense University of
Madrid, Madrid, Spain; bInstituto de Investigaci
on Sanitaria del Hospital Cl
ınico San Carlos (IdISSC), Madrid, Spain; cDepartament of
Physiotherapy, Occupational Therapy, Rehabilitation and Physical Medicine, Faculty of Health Sciences, Rey Juan Carlos University,
Alcorc
on, Spain

ABSTRACT ARTICLE HISTORY

Purpose: To evaluate the effectiveness of the Bobath concept in sensorimotor rehabilitation after stroke. Received 21 September 2018
Materials and methods: A systematic literature review was conducted on the Bobath concept from the Revised 3 February 2019
first publication available to January 2018, consulting PUBMED, CENTRAL, CINAHL and PEDro databases. Accepted 3 March 2019
Fifteen clinical trials were selected in two consecutive screenings. Two independent researchers rated the
KEYWORDS
studies according to the PEDro scale from which a best evidence synthesis was derived to determine the Bobath concept;
strength of the evidence. neurodevelopmental treat-
Results: The Bobath concept is not more effective than other approaches used in post-stroke rehabilita- ment; stroke; physical
tion. There is moderate evidence for the superiority of other therapeutic approaches such as forced use of therapy; rehabilitation;
the affected upper limb and constraint-induced movement therapy for motor control of the upper limb. systematic review
Conclusions: The Bobath concept is not superior to other approaches for regaining mobility, motor con-
trol of the lower limb and gait, balance and activities of daily living of patients after stroke. There is mod-
erate evidence regarding the superior results of other approaches in terms of the motor control and
dexterity of the upper limb. Due to the limitations concerning the methodological quality of the studies,
further well-designed studies are needed.

ä IMPLICATIONS FOR REHABILITATION

The Bobath concept is not superior to other approaches for patients after stroke.

The treatments that incorporate overuse of the affected upper limb via intensive treatments with
high-repetitions with or without robotic aids present greater effectiveness in the motor control of the
upper limb and dexterity.

Introduction
From the first orthopedic approaches that promoted the compen-
sation of lost functions, many physical therapy interventions have
been applied for the treatment of individuals post stroke. Since
the 1950s, different lines of physical therapy have been devel-
oped, based on advances in movement neurophysiology and pos-
tural control (neurophysiological approaches), as well as advances
in neuroscience regarding how learning takes place in the human
brain (cognitive approaches).
One of the most popular neurophysiological and, in part, cog-
nitive approaches in the field of neurorehabilitation is the Bobath
Concept or Neurodevelopmental Treatment [1,2]. According to
the International Bobath Instructors Training Association [3], the
aim of the Bobath concept is to optimize the functions of the per-
son after a stroke by improving the postural control and via the
facilitation of selective movements, orienting these towards activ-
ities of daily living or specific activities, as necessary from a com-
prehensive point of view [4–7]. This treatment concept has been
spread from the United Kingdom, Switzerland and Australia [8] to
other countries across the globe [9].
The Bobath concept has evolved from its beginnings in the
late 1940s, by incorporating new knowledge on neuroscience to
its theoretical foundations [2–4,10,11] mainly regarding three
aspects: the plasticity of the central nervous system [12], learning
and sensorimotor control [13,14] and plasticity of muscle struc-
tures [15,16] (Table 1).
At present, the Bobath concept continues to be one of the
most taught and applied treatment approaches for the manage-
ment of patients after a stroke, although the three reviews per-
formed to date on the effectiveness of the Bobath concept
[17–19] conclude that this treatment concept does not demon-
strate a greater effectiveness compared with other treatment
approaches used in neurorehabilitation. Moreover, the effective-
ness of a rehabilitation procedure must be measured in terms of
its relevance on body structures and function, activities and par-
ticipation. Because of this, the classification of results according to
the domains of the International Classification of Functioning,
Disability and Health [19,20] is highly recommended.
The present review was conducted considering the popularity
and widespread use of this concept and recent novel publications,

CONTACT Patricia Mart
ın-Casas pmcasas@enf.ucm.es Departamento de Radiolog
ıa, Rehabilitaci

on y Fisioterapia, Facultad de Enfermer
ıa, Fisioterapia y
Podolog
ıa, Plaza de Ramo
n y Cajal n 3, 28040 Madrid, Espan
~a
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 M. J. D
IAZ-ARRIBAS ET AL.

Table 1. Neuroscientific foundations that the Bobath Concept incorporates to clinical practice.
Novel incorporations to the Bobath
concept treatment principles
On CNS plasticity
On how learning takes place
On the plasticity of the
muscle structure
CNS: Central nervous system.
Neuroscientific foundation
1. Resolution of the diaschisis: disorders affecting
the function of brain regions that are distant
from the lesion, although functionally related.
2. “Unmasking": increased activity of alternative
brain areas adjacent to the lesion.
3. Increased activation of ipsilateral pathways,
especially after a stroke.
4. Cortical and subcortical reorganization (mor-
phological plasticity) via processes of synapto-
genesis and axonal growth (sprouting) which
are stimulated by the processes of learning
and cognitive-behavioral retraining.
1. Concept of sensorimotor control.
2. Concept of task-oriented training.
1. The muscle structure as a cell tissue with visco-
elastic properties.
2. The peripheral nervous structure that slides
within the myofascial structure.
Practical applications
1. Treatment of the “healthy” side. When there is an injury to a
brain hemisphere, the contralateral side also suffers neuro-
plastic changes that may affect recovery.
2. Comprehensive treatment of the whole body, based on
knowledge of the CNS pathways and interactions between
the different parts.
3. Forced use of the affected upper limb via inhibition of
the less affected side.
4. Mirror therapy, performing bilateral training with recipro-
cal movements.
1. Normal function is prioritized considering that a poor motor
pattern does not improve with repetition. As of 2009, certain
compensatory strategies are incorporated.
2. The performance of activities in a known functional environ-
ment is promoted.
3. Repetitive activities are promoted, performed with the great-
est possible quality of movement.
1. The strengthening of muscles used in functional tasks is
incorporated.
2. Neuromeningeal stretching and mobilization techniques are
incorporated within functional activities.

since the last review performed in 2009 [19]. The aim of this
review was to assess the effectiveness of the Bobath concept in
the rehabilitation of patients after stroke in terms of mobility,
motor control and dexterity of the upper limb, motor control of
the lower limb and gait, balance and activities of daily living.
Material and methods
Study selection
A literature review was conducted of studies published on the
Bobath concept in adult subjects, from its beginnings until
January 2018. The following databases were searched: PUBMED,
Cochrane Library Plus (CENTRAL), CINAHL and PEDro, by two inde-
pendent researchers (MJD and RCC). A PICO question was used to
organize the search strategy and facilitate the analysis of retrieved
studies: P (adult patients with central nervous system involve-
ment/stroke), I (Bobath concept), C (other rehabilitation methods
not Bobath concept) and O (mobility, motor control and dexterity
of the upper limb, motor control of the lower limb and gait, bal-
ance and activities of daily living).
The search terms used were “Bobath” OR “Neurodevelopmental
Treatment”, filtering the results for studies that included only adult
patients (”adult”, NOT “children”, NOT “infant”, NOT “paediatric
physical therapy”, NOT “child development disorders”). Initially we
did not filter the results by the term “stroke”, as we found that
doing so eliminated relevant results. To obtain the clinical trials, we
filtered the results with the terms “clinical trials” and “randomized
clinical trial”.
In the following databases: CENTRAL, CINHAL and PEDro, the
search terms were included as free-text terms, whereas in
PubMed, these terms were also included as Medical Subject
Headings terms. In the CINAHL database only academic publica-
tions were selected.

Additionally, in the first screening round, the following inclu-
sion criteria were applied to retrieved studies:

Randomized controlled trials (not pilot studies) evaluating
the effectiveness of the Bobath concept.

Patients with central nervous system involvement.

Adults (18 years).

Articles written in English German, French or Spanish.
Following these criteria, we analyzed the references of the
randomized controlled trials included in the three systematic
reviews [17–19] that had been previously performed concerning
the Bobath concept.
In the second stage of screening, the following exclusion crite-
ria were applied:

Randomized controlled trials failing to clearly specify that the
applied treatment was based on the Bobath concept or stud-
ies using a multimodal approach.

Randomized controlled trials presenting the same results in a
different article, including only the main article.

Randomized controlled trials based on the treatment of
patients with neurological disorders other than stroke.

Randomized controlled trials basing the design of the Bobath
intervention exclusively on the reference of the first edition
of the original book on the concept written by Berta Bobath
in 1970 [21] and 1978 [22] and/or whose intervention meth-
odology is based on old theoretical foundations of the
approach. This last criterion was established, bearing in mind
the considerations provided in the last review on the Bobath
concept, conducted in 2009 [19], which rules out any scien-
tific contributions that are not updated with regards the evo-
lution of the concept (i.e. interventions based on the
treatment of the hemiplegic side alone, or the encourage-
ment of inhibitory postures against spastic patterns, or the
consistent performance of treatments from proximal (trunk)
to distal (extremities)).

Randomized controlled trials in which the control group
received a placebo intervention or similar or any type of
intervention lacking a scientific justification for its application
in patients with stroke.
 BOBATH CONCEPT IN THE TREATMENT OF STROKE 3

PUBMED COCHRANE CINAHL PEDro

126 entries 114 entries 76 entries 65 entries
CENTRAL
109 entries

72 records discarded as they were not

clinical trial son the effectiveness of
120 non- Bobath:
duplicate entries • Systematic reviews (1)
• Reviews (4)
• Pilot studies (6)
• Comparative non-controlled studies (3)
• Case studies (12)
• Other (Letters, editorials, foundations
(including Bobath and nursing) (22)
• Bobath studies, Memorial Hospital (7)

14 discarded due to the inclusion criteria:

• Did not assess the effectiveness of Bobath
47 RCTs (5)
(pre-selected) • Language different to English, German,
Spanish or French (8)
• A critique and not a RCT (1)

18 discarded due to exclusion criteria:

• “Bobath-derived” intervention" (1)
• Unsure whether the intervention was only
33 RCTs Bobath or combined (12)
after the first screen • Studies with the same data (2)
• Study design with very old Bobath
foundations, not up-to-date (2)
• ECA of neurological patient without stroke
(1)

15 RCTs
after the second screen

Figure 1. Flow diagram of the selected studies.

Classification of the studies for analysis
Following the criteria established in the previous review [19], the
studies were grouped according to the main outcome measures:
mobility, motor control of the upper limb and skills, motor control
of the lower limb and gait, balance and activities of daily living.
Each of these outcome measures may be grouped according
to two of the three main domains of the International
Classification of Functioning, Disability and Health [23]: disorders
of body functions and structures (impairments), activity disorders
(activity limitations) and disorders concerning participation (par-
ticipation restrictions) [24].
Assessment of the methodological quality of studies
The methodological quality of included studies was assessed via
the Physiotherapy Evidence Database [25,26], which evaluates
the internal quality and the results of the randomized controlled
trials. This scale comprises 11 questions with yes or no answers
(yes = 1; no = 0), providing a total score which ranges between
0 (poor methodological quality) and 10 (excellent methodo-
logical quality). The first item of the scale does not refer to the
methodological quality of the randomized controlled trials but
rather its external validity, which is excluded from the
total score.
 4 M. J. D
IAZ-ARRIBAS ET AL.

Based on the physiotherapy evidence database scale and in

score
5/10
4/10
7/10
7/10
7/10
6/10
5/10
8/10
8/10
8/10
6/10
7/10
7/10
7/10
7/10
Total
order to assess the evidence of the interventions, the Van Tulder
criteria were applied [27], where the selected studies were
11. The study provides
both point measures
and measures of
variability for at
grouped by levels of evidence, according to their methodological

key outcome.
least one
quality. A study with a physiotherapy evidence database score of

0
1
1
1
1
1
1
1
1
1
1
1
1
0
1
6 or more, is considered level 1 (high methodological quality)
(6–8: good, 9–10: excellent) and a score of 5 or less is considered
level 2 (low methodological quality) (4–5: moderate; <4: poor).
Due to the clinical and statistical heterogeneity of the results,
10. The results of

are reported for

between-group

a qualitative review was performed conducting a best-evidence

key outcome.
comparisons

at least one
statistical

synthesis [19,28]. This classification indicates that if the number of

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
studies displaying the same level of evidence for the same out-
come measure or equivalent is lower than 50% of the total num-
ber of studies found, no evidence can be concluded regarding
or, data for at least
received treatment

one key outcome

any of the methods involved in the study.

9. Outcomes for

was analyzed
subjects who

by “intention
to treat”.
1
0
1
1
1
0
0
1
1
1
1
1
1
1
1
Results
The search strategy initially identified 126 records in PUBMED,
85% of subjects.

114 in Cochrane Library Plus (109 in CENTRAL), 76 in CINAHL and

from more than
1 key outcome
were obtained
8. Measures
of at least

65 in PEDro. After removing duplicates, two independent

0
1
1
1
1
1
0
1
1
1
1
1
0
1
1

researchers analyzed the papers referring to the Bobath concept

in the adult (n ¼ 120), these included: 1 systematic review [19], 4
reviews [17,18,29,30], 47 randomized and/or controlled clinical tri-
1 key outcome.

als [31–78], 6 pilot studies [79–84], 3 comparative and non-con-

Pedro Scale Items

7. Blinding

measured
assessors

at least

trolled studies [85–87], 12 case studies, 22 letters, editorials or

of all

who

0
0
1
1
1
1
1
1
1
1
0
1
0
1
1
Table 2. Score on the methodological quality of the studies according to the Physiotherapy Evidence Database (PEDro) scale.

theoretical foundations of the Bobath concept), 7 studies per-

The first item (gray column) is not computes as it refers to the external validity of the study and not the internal validity.

formed at the Bobath Memorial Hospital, where the Bobath con-

cept was not applied and 18 unrelated studies.
blinding of all

administered
6. There was

the therapy.
therapists

Figure 1 displays a flow-chart of the study selection process.

who

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Forty-seven randomized controlled trials. were pre-selected to be

included in the review based on a consensus method to resolve
any disagreements regarding the selection of manuscripts.
subjects.
blinding
5. There

Additionally, a third reviewer was consulted in the case of dis-

of all
was

0
0
0
0
0
0
0
0
0
0
0
0
1
0
0

agreements among both reviewers.

Of the 47 studies, 14 were discarded based on the inclusion
similar at baseline

most important
4. Groups were

criteria: not evaluating the effectiveness of the Bobath concept

regarding the

prognostic
indicators.

[31–36], written in a language other than English, German, French

1
0
0
1
1
1
1
1
1
1
1
1
1
1
1

or Spanish [37–44] or featuring a critique and not a randomized

controlled trial [45]. Therefore, after the first screening 33 poten-
tially relevant clinical trials were identified.
3. Allocation

Of these, 18 were discarded during the second stage of screen-

concealed.
was

ing: 13 were discarded as they did not clearly specify whether the
1
0
1
0
0
0
0
1
1
1
0
0
1
1
0

treatment applied was based on the Bobath concept [47–50] or

whether this was administered together with other therapies
2. Random
allocation.

[46,51–53,56–58,61,62]. Two studies were excluded as they pre-

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

sented the same results in different papers [59–62]. Subsequently,

we discarded two studies [63,64] and maintained three [65–67]
after confirming that these latter studies had treatment sessions
1. Eligibility

specified
criteria

with a sufficiently updated content of the Bobath concept. Lastly,

were

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

one study [68] was excluded, as this was a randomized controlled

trial on adult patients with cerebral palsy.
Finally, we included 15 randomized controlled trials in the pre-
Huseyinsinoglu et al. [78]
Langhammer et al. [59]
Van der Lee et al. [67]

Suputtitada et al. [73]

sent review (Table 2). These randomized controlled trials (Table 3)

Krukowska et al. [72]
Van Vliet et al. [76]
Dickstein et al. [65]

were grouped according to their main outcomes measures con-

Dias D et al. [71]
Gelber et al. [66]

Wang et al. [77]

Tang et al. [70]

Platz et al. [61]
Lum et al. [74]

Lum et al. [75]

cerning: mobility, motor control of the upper limb and/or dexter-

Luft et al. [69]

ity, motor control of the lower limb and/or gait, balance, and
Activities of daily living. The scales and tests used for the assess-
Study

ment, and their relation to the International Classification of

Functioning, Disability and Health domains, are gathered in
10
11
12
13
14
15

Table 4.
1
2
3
4
5
6
7
8
9
Table 3. Characteristics of the randomized controlled trials analyzed.
Sample
(N, age (SD), time
Study (reference) after lesion)
1. Dickstein et al. [65] PNF vs. N ¼ 131. Stroke.
Bobath vs. conven- (E1:36; E2 ¼ 38; C ¼ 57)
tional treatment Age in all groups ¼
70.5 ± 7.65
Time since lesion ¼
“CVA recent”.
2. Gelber et al. [66] N ¼ 27. Ischemic stroke.
NDT vs. Functional retrain- (C ¼ 12; E1 ¼ 15)
ing approach. Age (SD) ¼ E1 ¼ 73.8 (2);
C ¼ 69.8 (2.9)
Time since lesion (days) ¼
>30 days.
3. van der Lee et al. [67] N ¼ 62. Stroke.
Forced use of the upper (C ¼ 31; E1 ¼ 31)
extremity vs. NDT. Age (IR) ¼
E1 ¼ 59 (52-64)
C ¼ 62 (51-67)
Time since lesion (years) ¼
E1 ¼ 3.4 years.
C ¼ 2.7 years.
4. Langhammer and N ¼ 53. Stroke acute.
Stanghelle [59] (C ¼ 24; E1 ¼ 29)
Bobath vs. motor relearn- Age (SD) ¼ 78 (9)
ing program. Time since lesion (days) ¼
three days.
5. Lum et al. [74] N ¼ 27. Stroke
Robot-assisted movement (E:13; C ¼ 14)
training vs. NDT. Age (SD) ¼
E: 63.2 (3)
C: 65.9 (2.4)
Time since lesion (SD)
(months) ¼
E: 30.2 (6.2)
C: 28.8 (6.3)
Interventions
(E/C, duration, frequency, treatment
and follow-up period)
E1: PNF. E2: Bobath. C: Conventional
treatment (traditional exercises and
functional activities).
Treatment period ¼ 6 weeks, 5 days/
week during 30-45 minutes.
Follow-up period ¼ No. Assessments
only upon completion of treatment
E1: NDT.
C: Traditional functional retraining.
Treatment period ¼ from admission
until discharge. Days/week ¼ Not
described. Min/session ¼ Not
described.
Follow-up period ¼ pre- and post-
treatment (discharge), 6 months
and one year.
E1 ¼ Forced use of the affected upper
limb.
C ¼ NDT.
Treatment period ¼ 2 weeks,
5 days/week, 6 hours/session
Follow-up period ¼ At baseline (2
measurements). In the first 2 weeks
of treatment (2 measurements). At
3 and 6 weeks after the start of
treatment (short term). At 6 months
and one year (long term).
C: Bobath
E1: Motor Relearning Program.
Treatment period ¼ Number of weeks:
Not described. 5 days/week, 40 min/
session.
Follow-up period ¼ Three days after
admission to the hospital, 2 weeks
post-treatment and three months
after the stroke.
C: NDT.
E: Robot-assisted therapy. Robot-
assisted shoulder and elbow move-
ments are performed by a robot for
manipulation.
Treatment period ¼ 24 one hour ses-
sions during 2 weeks.
Follow-up period ¼ At 1, 2 and
6 months
Outcome measures

Barthel Index.

Muscle tone graded using a scale
of five points.

Motor control (ankle and
wrist joint).

ROM and muscle balance.

Ambulatory (four-category scale).

Functional
Independence Measure.

Gait Parameters (ambulate 15.2
meters: gait velocity and stride
length in three walking trials).

Box and block test.

Nine Hole Peg Test.

Personal Care and Occupation of
the Rehabilitation
Activities Profile.

Action Research Arm test.

Fugl-Meyer Assessment scale
(upper extremity section).

Motor Activity Log.

Motor Assessment Scale.

Sødring Motor Evaluation Scale.

Barthel Index.

Nottingham Health Profile.

Fugl-Meyer assessment
(upper-limb).

Barthel Index.

Functional Independence Measure
(the self-care and transfers sec-
tions. ADL).

Strength of the affected limb (8
joint actions, maximum voluntary
contractions)

Reach of affected arm.
Results
Statistically significant differences were not
found between the three treatment groups
nor in the ADLs, nor in the muscle tone of
the extremities, nor in the range of motion
and strength of the ankle nor in the
gait skills.
No differences were found between both
treatments regarding mobility parameters
in general, movements of the upper limb,
gait or activities of daily living.
Forced use therapy of the upper limb pre-
sented a greater and longer lasting
improvement compared to NDT in the dex-
terity of the affected arm (Action Research
Arm test) and a temporary although clinic-
ally relevant improvement in the use of the
affected arm during ADLs (amount of use
according to the Motor Activity Log). The
effect of forced use therapy was clinically
relevant among patients with sensorimotor
disorders and heminegligence.
Although the motor relearning program
achieved a greater improvement in the con-
trol of the upper and lower limb, the differ-
ence with Bobath was not statistically
significant three months post-stroke. In the
publication by Langhammer in 2011, which
is based on the same data as this study but
one year later, statistically significant differ-
ences were found with improved results in
the case of MRP in items related with
upper limb movement (Motor Assessment
Scale and Sødring Motor Evaluation Scale).
The treatment of the upper limb assisted by a
robot presents statistically significant differ-
ences compared to conventional therapy
based on Bobath both regarding the key
outcome measures as well as secondary
outcomes.
BOBATH CONCEPT IN THE TREATMENT OF STROKE
(continued)
5

Table 3. Continued.
Study (reference)
6. Suputtitada et al. [73]
Constraint-induced therapy
vs. NDT.
7. Luft et al. [69]
NDT vs. BATRAC
(Bilateral arm training with
rhythmic auditory cueing)
8. Wang et al. [77]
Bobath vs. ortho-
pedic approach.
9. Platz et al. [61]
Impairment-oriented train-
ing (Arm
BASIS training) vs. Bobath.
10. Van Vliet et al. [76] Bobath
vs. movement science
based (MSB).
11. Tang et al. [70]
Motor task oriented
vs. Bobath
Sample
(N, age (SD), time
after lesion)
N ¼ 69. Stroke.
(C ¼ 36; E1 ¼ 33)
Age (SD) ¼
E1 ¼ 60.1 (4.8)
C ¼ 58.7 (4.2)
Time since lesion (years) ¼
1 to 3 years.
N ¼ 21. Ischemic stroke.
(C ¼ 12; E1 ¼ 9)
Age (SD) ¼
E1 ¼ 63.3 (15.3)
C ¼ 59.6 (10.5)
Time since lesion (months)
¼ week, 1 hour/session.
E1 ¼ 75.0 (37.9-84.5)
C ¼ 45.5 (22.6-66.3)
N ¼ 44. Stroke.
(E:23; C ¼ 21)
Age (SD) ¼
E: 61 ± 6; C:58 ± 2)
Time since lesion (days) ¼
E:20 ± 20.8
C: 28.8 ± 6.3
N ¼ 62. Ischemic stroke.
(E1:21; E2 ¼ 21; C ¼ 20)
Age (SD) ¼ C: 60.9 (14.0);
E1:60.6 (10.5) E2:62.5
(12.9)
Time since lesion (SD)
(weeks) ¼ C: 4.6 (1.6);
E1: 6.5 (3.9); E2:
6.2 (3.6)
N ¼ 120. Stroke.
(E:60; C ¼ 60)
Age (SD) ¼
C: 73.3 (10.4);
E1:75 (9.1)
Time since lesion (weeks)
¼ 2 weeks.
N ¼ 47. Stroke and cogni-
tive deficit.
(C ¼ 22; E1 ¼ 25)
Age (SD) ¼ E1 ¼ 56.84
(11.03); C ¼ 54.86
(13.40)
Time since lesion (days) ¼
E1 ¼ 73.56 (130.41); C ¼
55.27 (66.67)
Interventions
(E/C, duration, frequency, treatment
and follow-up period)
E1 ¼ constraint-induced movement
therapy (CIMT).
C ¼ NDT.
Treatment period ¼ 2 weeks, 5 days/
week, min/session: Not described.
Follow-up period ¼ No. Assessments
only upon completion of treatment
C: Standardized dose-matched
Neurodevelopmental Treatment
exercises.
E1: BATRAC (Bilateral arm training with
rhythmic auditory cueing)
Treatment period ¼ 6 weeks, 3 days/
Follow-up period ¼ 2 weeks pre- and
post-treatment.
C: Bobath .
E: Orthopedic approach.
Treatment period ¼ 4 weeks, 5 days/
weeks, 40 min sessions.
Follow-up period ¼ No. Assessments
are performed upon completion of
the treatment.
E2: Arm BASIS training.
E12: Bobath
C: Therapy with exercises (with or
without increased treatment times).
Treatment period ¼ 4 weeks. Neither
duration nor days are specified
Follow-up period ¼ No. Assessments
only upon completion of treatment.
C: Bobath
E: MSB
Treatment period ¼ Does not specify
the time nor frequency. The treat-
ment is performed according to
“what the patient needs”, treatment
duration up to 6 months.
Follow-up period¼At 1, 3 and
6 months.
C ¼ NDT. E1 ¼ problem-oriented
willed-movement (POWM).
Treatment period ¼ 8 weeks, 5-6
days/week, 50 min/session.
Follow-up period ¼ No. Assessments
only upon completion of treatment
Outcome measures

Action Research Arm test.

Hand grip and pinch strength
(dynamometry measures).

Functional Magnetic Resonance
Imaging for elbow movements.

Fugl-Meyer Motor
Performance Test.

Wolf Motor Arm Test.

University of Maryland Arm
Questionnaire for Stroke.

elbow and shoulder strength
(dynamometry)

Stroke Impairment
Assessment Set.

Motor Assessment Scale.

Berg Balance Scale.

Stroke Impact Scale.

Fugl-Meyer assessment
(upper-limb).

Action Research Arm test.

Rivermead Motor Assessment.

Motor Assessment Scale.

Ten hole peg test.

6 m walk test.

Modified Ashworth Scale.

Nottingham Sensory Assessment.

Barthel Index.

Extended Activities of Daily
Living scale.

Mini-Mental State Examination.

Stroke Rehabilitation Assessment
of Movement.
6
Results
The CIMT group presented a greater improve-
ment than the NDT group, which was stat-
istically significant for the Action Research
Arm test, strength of the thumb pincer
group for the affected upper limb, however
in the case of the grip strength, the
improvement was not statistically signifi-
M. J. D
IAZ-ARRIBAS ET AL.
cant.
In the short term, only patients who received
BATRAC training presented a reorganization
of the motoneuronal networks contrale-
sional to the affected upper limb in
patients with stroke.
Patients treated with Bobath present a greater
improvement (not statistically significant)
compared to patients treated with the
orthopedic treatment approach according
to the MAS and SIS scales.
The treatment performed on the upper limb
using Arm BASIS training, with increased
exercise time is greater to Bobath with
increased exercise time.
No significant differences in overall mobility or
functional independence were found
between both groups.
Upon completion of the treatment period,
statistically significant improvements were
found in patients treated with POWM com-
pared to Bobath (NDT).
(continued)
Table 3. Continued.
Sample Interventions
(N, age (SD), time (E/C, duration, frequency, treatment
Study (reference) after lesion) and follow-up period) Outcome measures Results
12. Lum et al. [75] N ¼ 30 Stroke. C: Neurodevelopmental Treatment.
Functional A greater and significant improvement was
NDT vs. Mirror Image (C ¼ 6; E1 ¼ 9; E2 ¼ 5; E1: Grupo 1: MIME unilateral (practic- Independence Measure. found in the FIM scale in the group that
Movement Enabler E3 ¼ 10) ing 12 manual movments)
Motor Status Score. employed the robotic device in a combined
(MIME). Age (years)¼ E2: Grupo 2: MIME bilateral.
Motor Power examination manner compared to Bobath in the short
C: 59.9 ± 5.5 E3: Grupo 3: MIME combined.Half the (strength in the upper limb on a term. In the long term (6 months), the
E1: 62.3 ± 2.8 time unilaterally and the other half, 5-point scale). improvements in all three groups
E2: 69.8 ± 4.0 bilaterally.
Modified Ashworth scale. are similar.
E3: 72.2 ± 11.7 Treatment period ¼ 4 weeks, 15 ses-
Time since lesion (weeks) sions of 50 min duration.
¼ CVA Follow-up period ¼ Post-treatment
C: 10.6 ± 2.7 and at 6 months.
E1:13.0 ± 2.1
E2:10.0 ± 1.9
E3:6.2 ± 1.0
13. Dias et al. [71] N ¼ 40 Stroke. E: Gait Trainer and partial weight sup-
Motricity Index. Both groups showed improvements immedi-
Bobath vs. “Gait trainer” (E ¼ 20; C ¼ 20) port.
Toulousse Motor Scale. ately after treatment, whereas only the
and partial Age¼ C: Bobath.
Modified Ashworth scale. group treated with Gait trainer and partial
weight support E: 70.35 ± 7.36 Treatment period ¼ 5 weeks, 5 ses-
Berg Balance Scale. weight support maintained this improve-
C: 68 ± 10.69 sions/week de 40 minutes.
Rivermead Motor ment at three months.
Time since lesion Follow-up period ¼ pre- and post- Assessment Index.
(months)¼ treatment and 3 months
Motor Assessment Scale.
E: 47.10 ± 63.83 after treatment.
Fugl-Meyer Assessment scale.
C: 48.45 ± 29.51
Functional Ambulation Category.

Barthel Index.

Time up and go.

Step test.
14. Huseyinsinoglu et al. [78] N ¼ 24. Stroke. E: CIMT. 3 h/day. C: Bobath. 1 h/day.
Wolf Motor Function Test. CIMT and Bobath have a similar effectiveness
CIMT vs. Bobath. (E ¼ 13; C ¼ 11) Treatment period ¼ 10 consecutive
Motor Activity Log-28. for the improvement of functional skills,
Age¼ days.
Motor Evaluation Scale for Arm in speed and quality of movement of the
E:49.1 ± 13.7 Follow-up period ¼ No. Assessments Stroke Patients (MESUPES). affected arm in patients with a high level
C: 48.2 ± 15.4 only upon completion of treatment
Functional of arm function.
Time since lesion¼ Independence Measure. CIMT is more effective than Bobath in improv-
E: 10.6 ± 6.1 months ing the quantity and quality of the move-
C:13.1 ± 6.3 months ment with the affected arm.
15. Krukowska et al. [72] N¼72. Stroke. E1: PNF. E2: PNF. C1: Bobath. C2:
Stabilometer platform (Total area NDT-Bobath method for improving the bal-
Bobath vs. Proprioceptive (E1 ¼ 17; E2 ¼ 17; Bobath. of support and path length (COP: ance of the body is a more effective
Neuromuscular C1 ¼ 17; C2 ¼ 21) Treatment period ¼ 6 weeks, 5 ses- (Center Of Pressure) measure method of treatment in comparison with
Facilitation. Age¼ sions/week. Duration of each ses- foot pressure). the PNF method.
E1: 52.32 ± 7.95 sion: not described.
E2: 53.16 ± 6.95 Follow-up period ¼ No. Assessments
C1: 51.72 ± 5.95 only upon completion of treatment
C2: 53.64 ± 6.62
Time since lesion (months)
¼ Six months.
C: Control group; CIMT: Constraint-induced movement therapy; CVA: Cerebrovascular accident; E: Experimental Group; IR: Interquartile range; PNF: Proprioceptive neuromuscular facilitation; ROM: Range of movement.
BOBATH CONCEPT IN THE TREATMENT OF STROKE
7
 8
Table 4. Tests used in each of the 15 randomized controlled trials included in the study together with the component and the International Classification of Functioning, Disability and Health code which they are
mainly related to.
Body structures (s)
Body functions (b) Activities (d) Participation (e)
(Impairment) (Activity limitation) (Participation restriction)
Mobility
Muscle tone [five points scale] [1].
Functional Independence Measure [2].
Stroke Impact Scale [8].
Dickstein [1]
Modified Ashworth Scale [10].
Stroke Impairment Assessment Set [8].
Gelber [2]
Nottingham Sensory Assessment [10].
Motor Assessment Scale [4,8,10].
Langhammer [4]
Rivermead Motor Assessment [10].
Wang [8]
Stroke Rehabilitation Assessment of
Van Vliet [10] Movement [11].
M. J. D
IAZ-ARRIBAS ET AL.

Tang [11]
Motor control of the upper limb and dexterity
Fugl-Meyer Assessment scale [upper extremity
Functional Independence Measure [2,5,12,14].
Gelber [2] section] [3,5,7,9].
Box and block test [2].
van der Lee [3]
Strength of the affected limb [8 joint
Nine Hole Peg Test [2].
Langhammer [4] actions] [5]
Action Research Arm test [3,6,9]
Lum [5]
Maximum voluntary contractions [5]
Motor Activity Log [3].
Sputtitada [6]
Hand grip and pinch strength [Dynamometer
Motor Assessment Scale [4].
Luft [7] measures] [6].
The Sødring Motor Evaluation Scale [4].
Platz [9]
Functional Magnetic Resonance Imaging for
Wolf Motor Function Test [14].
Lum [12] elbow movements [7].
Motor Activity Log-28 [14].
Huseyinsinoglu [14]
Motor Status Score [12].

Motor Power examination [strength in the
upper limb on a 5-point scale] [12].

Modified Ashworth scale [12].

Motor Evaluation Scale for Arm in Stroke
Patients [14].
Motor control of the lower limb and gait
Muscle tone graded using a scale of five
Ambulatory [four-category scale] [1].
Barthel Index [1,4].
Dickstein [1] points [1].
Functional Independence Measure [2].
Nottingham Health Profile [4].
Gelber [2] Langhammer [4]
Motor control [ankle/wrist joint] [1].
Gait Parameters [2].
Stroke Impact Scale [8].
Wang [8]
ROM and muscle balance [1].
Motor Assessment Scale [4,8,10,13].
Van Vliet [10]
Stroke Impairment Assessment Set [8].
The Sødring Motor Evaluation Scale [4].
Tang [11]
Nottingham Sensory Assessment [10].
Rivermead Motor Assessment [10,13].
Dias [13]
Motricity Index [13].
Time up and go [10 meters], 6 minutes.[10,13]

Fugl-Meyer Assessment scale [13].
Stroke Rehabilitation Assessment of
Movement [11].

Functional Ambulation Category [13].

Toulouse Motor Scale [13].
Balance
Stabilometer platform [Total area of support
Berg Balance Scale [8,13].
Wang [8] and path length [Center of pressure measure
Rivermead Motor Assessment [10].
Van Vliet [10] foot pressure] [15].
Motor Assessment Scale [4,10].
Dias [13]
Krukowska [15]
Activities of daily living
Functional Independence Measure [2,5,12,14].
Barthel Index [1,4,5,10].
Dickstein [1]
Extended Activities of Daily
Gelber [2] Living scale [10]
Langhammer [4]
Lum [5]
Van Vliet [10]
Lum [12]
Huseyinsinoglu [14]
The number refers to the number of each of the 15 randomized controlled trials, according to Tables 2 and 3.

Characteristics and methodological quality of the studies
The 15 randomized controlled trials selected regarding the effect-
iveness of the Bobath concept in stroke presented a total of 781
patients. When both evaluators analyzed the methodological qual-
ity of the same using the physiotherapy evidence database scale
(Table 2), there was no consensus in 15 of the 150 items eval-
uated, this lack of consensus was resolved using the third asses-
sor. The Intraclass Correlation Coefficient presented a Kappa index
value of 0.79, with a “good” strength of agreement.
The 15 randomized controlled trials obtained a score of
between 4 and 8 on the physiotherapy evidence database scale.
Considering that in physiotherapy studies, 8 is the maximum
score that can be achieved, due to the impossibility of hiding the
intervention, 12 studies [59,61,65,70–78] therefore presented a
classification of high methodological quality (level 1) and 3 stud-
ies [65,66,69] had a moderate methodological quality (level 2).
Furthermore, the results of the physiotherapy evidence data-
base scale revealed that all the studies specified the inclusion and
exclusion criteria, with random assignment of study subjects.
Additionally, five of the studies did not perform blinding of the
assessors [65,66,70–72].
Regarding the post-stroke stages for the included studies, four
studies [59,65,76,77] comprised very acute patients (less than one
month post-stroke), whereas six studies were conducted on
patients between one and 12 months post-stroke [61,66,70,72,
75,78] and five studies [67,69,71,73,74] were performed on chronic
patients (more than one year post-stroke).
Bobath concept interventions were heterogeneous, since the
application of this concept does not have an internationally estab-
lished protocol for the treatment of the upper and lower limb or
balance. However, they are all updated with regards the evolution
of the concept. The interventions compared with the Bobath con-
cept were different according to the studies, although mostly
these were interventions based on motor relearning programs.
Regarding the protocols and the treatment dosage, this is highly
variable, and is gathered in Table 3. In general, most studies
included interventions that ranged between 30 and 60 minutes’
duration, 3–5 days per week and 2 to 8 weeks of treatment.
Regarding the data collection and results, all the studies, with
the exception of three [65,69,71] had measures of at least one
key outcome that were obtained from more than 85% of the sub-
jects. All but three studies [66,69,73], performed an intention to
treat analysis. All studies presented results for at least one of the
main outcome variables. Almost all studies presented pre- and
post-treatment assessments, except four of the articles, which also
presented follow-up measurements at three or six
months [71,74–76].
Effectiveness of the Bobath concept compared to
other treatments
To evaluate the effectiveness of the Bobath concept, the 15
randomized controlled trials were grouped according to their
main outcome measures. The relationship between each of these
aspects and the International Classification of Functioning,
Disability and Health are gathered in Table 4.
Mobility
Of the 15 studies, six presented results regarding mobility. Four of
these reported no differences between the treatment applied and
Bobath [59,65,66,76]. In these four articles, the interventions com-
pared with Bobath treatment were: the motor relearning program
[59], PNF and conventional treatment (traditional exercises and
BOBATH CONCEPT IN THE TREATMENT OF STROKE 9
functional activities) [65], traditional functional retraining [66] and
movement science based interventions [76].
Of the two remaining studies [70,77], according to the former,
the Bobath treatment is better than a conventional orthopedic
treatment in the short term and in acute patients. The latter study
concludes that problem-oriented willed-movement is better than
Bobath in the short term and in patients with cognitive problems.
According to the best evidence synthesis, the superiority of
the Bobath concept cannot be concluded, and neither that of any
other approach regarding the mobility of the adult patient after
a stroke.
Motor control of the upper limb and dexterity
Of the 15 studies, nine presented results regarding the upper
limb. Five presented results in which the experimental treatment
presented superior results, compared with Bobath [61,67,73–75].
Of these, two used robotic devices which assisted the movement
of the affected upper limb (Robot manipulator [74] and Mirror
Image Movement Enabler robotic device [75]), two used forced
use of the affected upper limb with restriction of the healthy side
[67,73] and one used the method of specific training of the
affected upper limb (Arm BASIS training [61]).
Four studies did not display statistically significant differences
in favor of either of the two treatments [59,66,69,78]. The study
by Luft et al. [69] presented differences in both groups in some
of the tests in favor of Bobath, whereas others favored Bilateral
Arm training with rhythmic auditory cueing.
The best evidence synthesis suggests the superiority of thera-
peutic approaches of the upper limb based on training using
robotic aids that favor the forced use of the affected upper limb
or those that use forced use strategies together with constraint
induced therapy, compared to the Bobath concept.
Motor control of the lower limb and/or gait
Of the 15 studies, seven presented results regarding the motor
control of the lower limb and/or gait. In five papers, no differen-
ces were found between the treatment applied and Bobath
[59,65,66,71,76]. The interventions compared with Bobath were (in
order): the motor relearning program [59], PNF and conventional
treatment (traditional exercises and functional activities) [65], trad-
itional functional retraining [66], gait trainer and partial weight
support [71] and movement science based interventions [76].
Of the two remaining studies, one found differences in favor
of the Bobath treatment in the short term and in acute patients
using an orthopedic treatment approach [77] and another con-
cludes that the motor control of the lower limb focused on the
concrete task is better than the Bobath concept in the short term
and in patients with cognitive problems (problem-oriented willed-
movement (POWM) method) [70].
According to the best evidence synthesis criteria, we cannot
conclude the superiority of the Bobath concept nor that of any
other approach regarding the motor control of the lower limb
and/or the gait of the adult patient after a stroke.
Balance
Of the 15 studies, five presented results regarding the balance of
the patient with stroke [59,71,72,76,77].
The first three studies concluded that there is no difference
between the treatment applied and the Bobath concept. The
study by Langhammer et al. [59] displays a significant difference
in favor of motor relearning program compared to Bobath upon
completion of the treatment, without this improvement being
maintained at three months’ post-intervention. The most recent
10 M. J. D
IAZ-ARRIBAS ET AL.
study [76] shows a statistically significant difference in favor of
motor relearning program compared to Bobath upon completion
of the treatment, without this improvement being maintained at
three months after the intervention. The last and most recent
study [72] shows a statistically significant difference in favor of
the Bobath concept, compared to the method of proprioceptive
neuromuscular facilitation.
According to the best evidence synthesis criteria, the superior-
ity of the Bobath concept cannot be concluded nor that of any
other approach, with regards balance of the adult patient
post-stroke.
Activities of daily living
Of the 15 studies, eight presented results regarding an
improvement in activities of daily living, either via direct ques-
tionnaires (such as the Barthel Scale [76]) or via scales that
include sections for the assessment of quality of life such as
the Functional Independence Measure or the Stroke Impact
Scale [59,65,66,74,75,77,78].
Six of the studies concluded that there are no differences
between the treatment applied and Bobath [59,65,66,76–78]. The
last two studies [74,75] reported differences in the short term
favoring Mirror Image Movement Enabler compared to the
Bobath concept. These differences were not maintained six
months after the intervention.
According to the best evidence synthesis criteria, the superior-
ity of the Bobath concept or any other approach cannot be con-
cluded regarding activities of daily living of the adult patient after
a stroke.
Discussion
Compared to the last review available on the effectiveness of the
Bobath concept, performed in 2009 (19), the present review dif-
fers in part regarding the studies included and concerning two of
the conclusions. Below, the similarities and differences regarding
each of the categories used to group the studies are discussed, in
which we highlight the most interesting contributions of this
review to clinical practice.
In terms of mobility, the present review discarded four studies
that were included in the previous review [46,52,53,67], and
included two new studies [59,65]. Regarding the motor control of
the lower limb and gait, the former review [19] presented the
same articles included in the present review, with the exception
of the studies by Gelber et al. [66], Dickstein et al. [65] and Dias
et al. [71]. In the category of activities of daily living, the present
review includes three further articles [65,77,78] however, none of
these found statistically significant differences in favor of any of
the interventions.
Despite these differences, the present review reaches the same
conclusion as the former review: we cannot conclude the super-
iority of the Bobath concept nor that of any other approach with
regards the mobility, lower limb motor control and activities of
daily living of adult patients after a stroke.
Concerning motor control of the upper limbs and dexterity,
the former review [19] presented these two aspects of the upper
limb (motor control and dexterity) separately, gathering the same
studies in both sections, with the exception of three articles that
only gathered data on dexterity [63,66,73]. According to the crite-
ria followed for grouping studies in the present review, both
these sections are combined under this category, as all the stud-
ies included sought to obtain greater motor control in the upper
limb to enable greater dexterity.
The former review comprised a total of 12 studies for both
items, whereas in the present review, nine studies are gathered,
discarding four studies [62,63,70,76] and including the study by
Huseyinsinoglu et al. [78], published after the last review on the
Bobath concept [19].
The main novelty of the present review is that our findings
conclude a greater effectiveness of other methods over the
Bobath concept in the treatment of the upper limb of patients
post-stroke. The two studies that displayed greater effectiveness
of forced use of the affected upper limb used constraint induced
therapy [67,73], and are of high methodological quality, with a
large simple size in relation to other studies and with a similar
intervention in both groups.
In one of the last reviews performed on constraint induced
therapy [88] and on forced use of the affected upper limb using
high-repetition techniques [89], the effectiveness of these techni-
ques was proven for the upper limb (although not for the lower
limb or trunk) compared to other approaches. However, the last
review on constraint induced therapy [90], concluded that there is
no evidence of the superiority of this intervention compared to
others in the upper limb of the patient post stroke.
The studies in which robotic devices were used during training
base their intervention on the reorganization and positive plasti-
city of the motor cortex [91] which comes with intensive and
repetitive training of movements of the affected arm with or with-
out constraint of the healthy side. These methods use a robotic
aid to systematize the movement, and involve the forced use of
the affected upper limb. In one of the last reviews on the use of
assistance from robotic devices in the treatment of a patient after
stroke, a greater effectiveness is found for these methods com-
pared to conventional therapy, including the Bobath concept [92].
A later meta-analysis [93] concluded that the greater effective-
ness of these robotic aids is related with the intensive therapy
that the patient undergoes. When the duration/intensity of the
conventional therapy is the same as that performed in the ther-
apy group receiving robotic assistance, there are hardly any differ-
ences between both groups in terms of the motor control,
activities of daily living or strength parameters.
This meta-analysis [93] suggests the need for clinical practice
to implement treatments that combine Bobath and robotic aids
with forced use paradigms, with or without constriction of the
healthy upper limb, considering that, in these contexts, a robotic
aid can repeat a movement during more time and with the same
level/intensity/speed of execution as a therapist [36], although
with a more limited effect on the motor control of the upper
limb [94].
The findings of the present review are in line with the main
meta-analyses and reviews on treatments of the affected upper
limb, reflecting the clinical application of multimodal interventions
and treatments in which manual treatments are used, such as the
Bobath concept (based on motor control and therapeutic exer-
cise) together with intensive therapy based on higher-repetitions
for recovery of the affected upper limb.
In terms of balance outcomes, the previous review [19] failed
to include three studies included in the present review [59,71,72].
The studies by Pollock et al. [83] and Mudie et al. [82] were dis-
carded as these are pilot studies. Furthermore, the former did not
fulfill the exclusion criteria, as it was a study that shows results of
a combined therapy. The latter did not effectively use any vali-
dated outcome measure for balance, such as the Berg Balance
Scale or the Motor Assessment Scale. This randomized controlled
trial concludes that, in the short term, patients treated with the
Bobath concept have a better weight distribution between both

sides of the body, without considering that these patients have
greater balance. A correlation has been demonstrated between
the more balanced distribution of weight between both sides of
the body and the reduction in the postural sway of the patient,
without scientifically being able to ensure that this entails a better
balance in the adult neurological patient [95].
The inclusion of these two articles in the former review led to
the conclusion that there is limited evidence of the superiority of
the Bobath concept compared to other interventions. The results
of the present review differ, as we are unable to conclude the
superiority of the Bobath concept nor any other approach, in
terms of the balance of patients after stroke.
A differential aspect of the present review compared to that of
2009 (19) is that we did not include studies in which treatment
with the Bobath concept was combined with other therapies. This
is because we consider that by doing so, a sampling bias may
occur which may bias the results of these studies, thus affecting
the conclusions of the review.
Study limitations
Despite including recent and novel studies on the effectiveness of
the Bobath concept, studies are still being conducted [80] with
important methodological flaws, such as inappropriate randomiza-
tion and lack of blinding during the study procedures. The lack of
control of these factors can lead to false positives or negatives,
which are aspects that two of the latest scoping reviews on the
Bobath concept [29,30] have highlighted as important considera-
tions for the development of the concept.
Another main limitation was the reduced sample size, which
hampered the ability to conclude effectiveness. Also, the use of
non-standardized outcome measures, the heterogeneity of the
protocols employed and of the assessments used. Due to this
methodological heterogeneity and the characteristics of the
patients, we were unable to perform statistical pooling in order to
calculate effect sizes, as occurred in the previous review [19].
Regarding the sample size, more than half of the selected trials
presented less than 25 patients per group. This is considered a
highly insufficient sample in order to interpret the differences
obtained with many of the tests used (Barthel Index, Berg Balance
Scale, Functional Independence Measure Scale, Motor Assessment
Scale, etc.). According to the PEDro scale, each of the selected
articles have an adequate methodological quality to be included
in the review (5), without considering the sample size needed
to conclude treatment efficacy or effectiveness.
In terms of the comparison of treatment effects, very few stud-
ies used designs based on repeated measures, despite the fact
that these are recommended in methodological reviews in physio-
therapy [96]. This type of design reduces the possible contribu-
tions of measurement error, by demonstrating any additional
effect of the treatment on the recovery patterns that are depend-
ent on time in the cases of spontaneous neurological recovery
after stroke.
Conclusions
This systematic review on the effectiveness of the Bobath concept
has highlighted that there is no evidence for the superiority of
this concept in the treatment of patients with stroke on mobility,
the motor control of the lower limb and gait, and activities of
daily living.
BOBATH CONCEPT IN THE TREATMENT OF STROKE 11
Regarding the treatment of balance disorders in individuals
with stroke, as previously mentioned, this review did not deter-
mine a greater effectiveness of the Bobath concept.
Regarding the motor control and dexterity of the upper limb,
a greater effectiveness of other methods is suggested, compared
to the Bobath concept, especially regarding training via forced
use of the affected upper limb with or without the use of robotic
aids and with or without restriction of movement of the healthy
upper limb.
This review confirms the need for further studies on the effect-
iveness of the Bobath concept in stroke patients. Future studies
should have a greater methodological quality, especially regarding
randomization and blinding, both of the assessor as well as the
data analysis, the homogenization of the protocols used and the
outcome measures. Furthermore, an appropriate sample size is
required in order to conclude efficacy, as well as designs incorpo-
rating data analysis by repeated measurements and employing
greater follow-up periods.
Acknowledgements
The authors wish to thank the Faculty of Nursing, Physiotherapy
and Podiatry of the Complutense University of Madrid.
Furthermore, we would like to acknowledge the invaluable sup-
port from Isabel Quintero for her assistance with the translation
of the manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Mar
ıa J. D
ıaz-Arribas http://orcid.org/0000-0002-6231-107X
Patricia Mart
ın-Casas http://orcid.org/0000-0002-5889-1841
Roberto Cano-de-la-Cuerda http://orcid.org/0000-0002-
1118-4234
Gustavo Plaza-Manzano http://orcid.org/0000-0003-1596-5027
References
[1] Lennon S, Ashburn A. The Bobath concept in stroke
rehabilitation: a focus group study of the experienced
physiotherapists’ perspective. Disabil Rehabil. 2000;22:
665–674.
[2] Howle JM. Neurodevelopmental treatment approach: theor-
etical foundations and principles of clinical practice. 2nd
ed. Laguna Beach, California: North American
Neurodevelopmental Treatment Association; 2004.
[3] International Bobath Instructors Training Association.
Theoretical assumptions and clinical practice. [Internet].
2006 [cited 2014 Jan 10]. Available from: http://ibita.org/
pdf/assumptions-EN.pdf
[4] Panturin E. The Bobath concept. Clin Rehabil. 2001;15:
111–113.
[5] Brock K, Jennings K, Stevens J, et al. The Bobath concept
has changed. (Comment on Critically Appraised Paper,
Australian Journal of Physiotherapy 48: 59.). Aust J
Physiother. 2002;48:156–157.
12 M. J. D
IAZ-ARRIBAS ET AL.
[6] Graham JV, Eustace C, Brock K, et al. The Bobath concept
in contemporary clinical practice. Top Stroke Rehabil. 2009;
16:57–68.
[7] Raine S. The current theoretical assumptions of the Bobath
concept as determined by the members of BBTA. Physiol
Ther Pract. 2007;23:137–152.
[8] Pollock A, Baer G, Pomeroy V, et al. Physiotherapy treat-
ment approaches for the recovery of postural control and
lower limb function following stroke. Cochrane Database
Syst Rev. 2007;(1):CD001920.
[9] Davidson I, Waters K. Physiotherapists working with stroke
patients: a national survey. Physiotherapy. 2000;86:69–80.
[10] Gjelsvik BE, Syre L. The Bobath concept in adult neurology.
2nd. ed. Stuttgart-New York: Thieme; 2016.
[11] Bobath-ndt.com [internet]. The Netherlands: International
Bobath instructors training association; 1984 [cited 2014
Jan 25]. Available from: http://www.bobath-ndt.com/con-
cept.php
[12] Nudo RJ, Wise BM, Fuentes F, et al. Neural substrates for
the effects of rehabilitative training on motor recovery after
ischemic infarct. Science. 1996;272:1791–1794.
[13] Levin MF, Panturin E. Sensorimotor integration for func-
tional recovery and the Bobath approach. Motor Control.
2011;15:285–301.
[14] Kwakkel G, Kollen B, Lindeman E. Understanding the pat-
tern of functional recovery after stroke: facts and theories.
Restor Neurol Neurosci 2004;22:281–299.
[15] Silva-Couto MD, Prado-Medeiros CL, Oliveira AB, et al.
Muscle atrophy, voluntary activation disturbances, and low
concentrations of IGF-1 and IGFBP-3 are associated with
weakness in people with chronic stroke. Phys Ther. 2014;
94:957–967.
[16] Pak S, Patten C. Strengthening to promote functional
recovery poststroke: an evidence-based review. Top Stroke
Rehabil. 2008;15:177–199.
[17] Paci M. Physiotherapy based on the Bobath concept for
adults with post-stroke hemiplegia: a review of effective-
ness studies. J Rehabil Med. 2003;35:2–7.
[18] Luke C, Dodd KJ, Brock K. Outcomes of the Bobath concept
on upper limb recovery following stroke. Clin Rehabil.
2004;18:888–898.
[19] Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the
Bobath concept in stroke rehabilitation: what is the evi-
dence? Stroke. 2009;40:e89–e97.
[20] World Health Organization. International classification of
functioning, disability and health: ICF. Geneva: WHO; 2001.
[21] Bobath B. Adult hemiplegia: evaluation and treatment.
London: 1st. Ed. Heinemann Medical Books; 1970.
[22] Bobath B. Adult hemiplegia: evaluation and treatment. 2nd
ed. London: Heinemann; 1978.
[23] Duncan PW, Jorgensen HS, Wade DT. Outcome measures
in acute stroke trials: a systematic review and some recom-
mendations to improve practice. Stroke. 2000;31:
1429–1438.
[24] Stuki G. International Classification of Functioning,
Disability, and Health (ICF): a promising framework and
classification for rehabilitation medicine. Am J Phys Med
Rehabil. 2005;84:733–740.
[25] Beaton DE, Bombardier C, Guillemin F, et al. Guidelines for
the process of cross-cultural adaptation of self-report meas-
ures. Spine (Phila Pa 1976). 2000;25:3186–3191.
[26] pedro.org.au [internet]. Australia: Centro de Fisioterapia
Basada en la evidencia; 1999 [cited 2014 Mar 5] Available
from: http://www.pedro.org.au/spanish/downloads/pedro-
scale/
[27] van Tulder M, Furlan A, Bombardier C, et al. The Editorial
Board of the Cochrane Collaboration Back Review Group.
Updated method guidelines for systematic reviews in the
Cochrane Collaboration Back Review Group. Spine. 2003;28:
1290–1299.
[28] Van Peppen R, Kwakkel G, Wood Dauphinee S, et al. The
impact of physical therapy on functional outcomes after
stroke: what’s the evidence? Clin Rehabil. 2004;18:833–862.
[29] Vaughan-Graham J, Cott C, Wright FV. The Bobath (NDT)
concept in adult neurological rehabilitation: what is the
state of the knowledge? A scoping review. Part I: concep-
tual perspectives. Disabil Rehabil. 2015;37:1793–1807.
[30] Vaughan-Graham J, Cott C, Wright FV. The Bobath (NDT)
concept in adult neurological rehabilitation: what is the
state of the knowledge? A scoping review. Part II: interven-
tion studies perspectives. Disabil Rehabil. 2015;37:
1909–1928.
[31] Van Vliet PM, Lincoln NB, Robinson E. Comparison of the
content of two physiotherapy approaches for stroke. Clin
Rehabil. 2001;15:398–414.
[32] Yagura H, Miyai I, Suzuki T, et al. Patients with severe
stroke benefit most by interdisciplinary rehabilitation team
approach. Cerebrovasc Dis. 2005;20:258–263.
[33] Corriveau H, Arsenault AB, Dutil E, et al. An evaluation of
the hemiplegic patient based on the Bobath approach: a
reliability study. Disabil Rehabil. 1992;14:81–84.
[34] Logigian MK, Samuels MA, Falconer J, et al. Clinical exercise
trial for stroke patients. Arch Phys Med Rehabil. 1983;64:
364–6367.
[35] Sunderland A, Tinson DJ, Bradley EL, et al. Enhanced phys-
ical therapy improves recovery of arm function after stroke.
A randomized control trial. J Neurol Neurosurg. Psychiatry.
1992;55:530–535.
[36] Sterr A, Freivogel S. Intensive training in chronic upper
limb hemiparesis does not increase spasticity or synergies.
Neurology. 2004;63:2176–2177.
[37] Langhammer B, Stanghelle JK. [Physiotherapy after stro-
ke–a randomized controlled trial]. Tidsskr nor Laegeforen.
2001;121:2805–2809.
[38] Xu BH, Yu RQ, Yu W, et al. Effects of early rehabilitation on
activities of daily living and complications in acute stroke
patients. Beijing Da Xue Xue Bao. 2004;36:75–78.
[39] Laursen SO, Henriksen IO, Dons U, et al. Intensive rehabili-
tation after apoplexy: a controlled pilot study. Ugeskr
Laeger. 1995;157:1996–1999.
[40] Gialanella B, Benvenuti P, Santoro R. The painful hemiplegic
shoulder: effects of exercise program according to Bobath.
Clin Ther. 2004;155:491–497.
[41] Krutulyte G, Kimtys A, Krisci unas A. The effectiveness of
physical therapy methods (Bobath and motor relearning
program) in rehabilitation of stroke patients. Medicina
(Kaunas). 2003;39:889–895.
[42] Wang F, Zhang L, Wang J, et al. [Efficacy on hemiplegic
spasticity treated with plum blossom needle tapping ther-
apy at the key points and Bobath therapy: a randomized
controlled trial]. Zhongguo Zhen Jiu. 2015;35:781–784.
[43] Pan HP, Feng H, Li YJ. [Effects of unblocking meridians and
Du-channel massage combined with rehabilitation training
on the motor function improvement of cerebral ischemic
stroke patients]. Zhongguo Zhong Xi Yi Jie He Za Zhi.
2011;31:1474–1478.

[44] Klimkiewicz P, Kubsik A, Jankowska A, et al. The effect of
neurorehabilitation on the functional state and muscle
tone of upper limb in patients after ischaemic stroke]. Pol
Merkur Lekarski. 2014;36:191–194.
[45] Mosely A. Treadmill training more effective than Bobath
therapy in improving walking after stroke. Aust J
Physiother. 2005;51:192.
[46] Eich HJ, Mach H, Werner C, et al. Aerobic treadmill plus
Bobath walking training improves walking in subacute
stroke: a randomized controlled trial. Clin Rehabil. 2004;18:
640–665.
[47] Lincoln NB, Parry RH, Vass CD. Randomized, controlled trial
to evaluate increased intensity of physiotherapy treatment
of arm function after stroke. Stroke. 1999;30:573–579.
[48] Ploughman M, Corbett D. Can forced-use therapy be clinic-
ally applied after stroke? An exploratory randomized con-
trolled trial. Arch Phys Med Rehabil. 2004;85:1417–1423.
[49] Miyai I, Fujimoto Y, Yamamoto H, et al. Long-term effect of
body weight-supported treadmill training in Parkinson’s
disease: a randomized controlled trial. Arch Phys Med
Rehabil. 2002;83:1370–1373.
[50] Chantraine A, Baribeault A, Uebelhart D, et al. Shoulder
pain and dysfunction in hemiplegia: effects of functional
electrical stimulation. Arch Phys Med Rehabil. 1999;80:
328–331.
[51] Arya KN, Verma R, Garg RK, et al. Meaningful task-specific
training (MTST) for stroke rehabilitation: a randomized con-
trolled trial. Top Stroke Rehabil. 2012;19:193–211.
[52] Thaut MH, Mcintosh GC, Rice RR. Rhythmic facilitation of
gait training in hemiparetic stroke rehabilitation. J Neurol
Sci. 1997;151:207–212.
[53] Thaut MH, Leins AK, Rice RR, et al. Rhythmic auditory
stimulation improves gait more than NDT/Bobath training
in near-ambulatory patients early poststroke: a single-blind,
randomized trial. Neurorehabil Neural Repair. 2007;21:
455–459.
[54] Taveggia G, Borboni A, Mul
e C, et al. Conflicting results of
robot-assisted versus usual gait training during postacute
rehabilitation of stroke patients: a randomized clinical trial.
Int J Rehabil Res. 2016;39:29–35.
[55] Fil A, Armutlu K, Atay AO, et al. The effect of electrical
stimulation in combination with Bobath techniques in the
prevention of shoulder subluxation in acute stroke patients.
Clin Rehabil. 2011;25:51–59.
[56] Dogru Huzmeli E, Yildirim SA, Kilinc M. Effect of sensory
training of the posterior thigh on trunk control and upper
extremity functions in stroke patients. Neurol Sci. 2017;38:
651–657.
[57] Bakhtiary AH, Fatemy E. Does electrical stimulation reduce
spasticity after stroke? A randomized controlled study. Clin
Rehabil. 2008;22:418–425.
[58] Dechaumont-Palacin S, Marque P, De Boissezon X, et al.
Neural correlates of proprioceptive integration in the con-
tralesional hemisphere of very impaired patients shortly
after a subcortical stroke: an FMRI study. Neurorehabil
Neural Repair. 2008;22:154–165.
[59] Langhammer B, Stanghelle JK. Bobath or motor relearning
programme? A comparison of two different approaches of
physiotherapy in stroke rehabilitation: a randomized con-
trolled study. Clin Rehabil. 2000;14:361–369.
[60] Langhammer B, Stanghelle JK. Bobath or motor relearning
programme? A follow-up one and four years post stroke.
Clin Rehabil. 2003;17:731–734.
BOBATH CONCEPT IN THE TREATMENT OF STROKE 13
[61] Platz T, Eickhof C, van Kaick S, et al. Impairment-oriented
training or Bobath therapy for severe arm paresis after
stroke: a single-blind, multicentre randomized controlled
trial. Clin Rehabil. 2005;19:714–724.
[62] Platz T, van Kaick S, Mo €ller L, et al. Impairment oriented
training and adaptive motor cortex reorganisation after
stroke: an fTMS study. J Neurol. 2005;252:1363–1371.
[63] Basmajian JV, Gowland CA, Finlayson AJ, et al. Stroke treat-
ment: comparison of integrated behavioural–physical ther-
apy vs traditional physical therapy programs. Arch Phys
Med Rehabil. 1987;68:267–272.
[64] Partridge CJ, Edwards SM, Mee R, et al. Hemiplegic shoul-
der pain: a study of two methods of physiotherapy treat-
ment. Clin Rehabil. 1990;4:43–49.
[65] Dickstein R, Hocherman S, Pillar T, et al. Stroke rehabilita-
tion three exercise therapy approaches. Phys Ther.1986; 66:
1233–1238.
[66] Gelber DA, Josefczy PB, Herrman D, et al. Comparison of
two therapy approaches in the rehabilitation of the pure
motor hemiparetic stroke patient. J Neurol Rehabil. 1995;9:
191–196.
[67] van der Lee JH, Wagenaar RC, Lankhorst GJ, et al. Forced
use of the upper extremity in chronic stroke patients;
results from a single-blind randomized clinical trial. Stroke.
1999;30:2369–2375.
[68] Kim SJ, Kwak EE, Park ES, et al. Differential effects of rhyth-
mic auditory stimulation and neurodevelopmental treat-
ment/Bobath on gait patterns in adults with cerebral palsy:
a randomized controlled trial. Clin Rehabil. 2012;26:
904–914.
[69] Luft AR, McCombe S, Whitall J, et al. Repetitive bilateral
arm training and motor cortex activation in chronic stroke;
a randomized controlled trial. JAMA. 2004;292:1853–1861.
[70] Tang QP, Yang QD, Wu YH, et al. Effects of problem-ori-
ented willed movement therapy on motor abilities for peo-
ple with post stroke cognitive deficits. Phys Ther. 2005;85:
1020–1033.
[71] Dias D, La
ıns J, Pereira A, et al. Can we improve gait skills
in chronic hemiplegics? A randomised control trial with
gait trainer. Eura Medicophys. 2007;43:499–504.
[72] Krukowska J, Bugajski M, Sienkiewicz M, et al. The influence
of NDT-Bobath and PNF methods on the field support and
total path length measure foot pressure (COP) in patients
after stroke. Neurol Neurochir Pol. 2016;50:449–454.
[73] Suputtitada A, Suwanwela NC, Tumvitee S. Effectiveness of
constraint-induced movement therapy in chronic stroke
patients. J Med Assoc Thai. 2004;87:1482–1490.
[74] Lum PS, Burgar CG, Shor PC, et al. Robot-assisted move-
ment training compared with conventional therapy techni-
ques for the rehabilitation of upper-limb motor function
after stroke. Arch Phys Med Rehabil. 2002;83:952–959.
[75] Lum PS, Burgar CG, Van der Loos M, et al. MIME robotic
device for upper-limb neurorehabilitation in subacute
stroke subjects: a follow-up study. J Rehabil Res Dev. 2006;
43:631–642.
[76] Van Vliet PM, Lincoln NB, Foxall A. Comparison of Bobath
based and movement science based treatment for stroke: a
randomised controlled trial. J Neurol Neurosurg Psychiatry.
2005;76:503–508.
[77] Wang RY, Chen HI, Chen CY, et al. Efficacy of Bobath versus
orthopaedic approach on impairment and function at dif-
ferent motor recovery stages after stroke: a randomized
controlled study. Clin Rehabil. 2005;19:155–164.
14 M. J. D
IAZ-ARRIBAS ET AL.
[78] Huseyinsinoglu BE, Ozdincler AR, Krespi Y. Bobath concept
versus constraint-induced movement therapy to improve
arm functional recovery in stroke patients: a randomized
controlled trial. Clin Rehabil. 2012;26:705–715.
[79] Kılınç M, Avcu F, Onursal O, et al. The effects of Bobath-
based trunk exercises on trunk control, functional capacity,
balance, and gait: a pilot randomized controlled trial. Top
Stroke Rehabil. 2016;23:50–58.
[80] Keser I, Kirdi N, Meric A, et al. Comparing routine neurore-
habilitation program with trunk exercises based on Bobath
concept in multiple sclerosis: pilot study. J Rehabil Res Dev.
2013;50:133–140.
[81] Fazekas G, Horvath M, Troznai T, et al. Robot-mediated
upper limb physiotherapy for patients with spastic hemi-
paresis: a preliminary study. Acta Derm Venereol. 2007;39:
580–582.
[82] Mudie MH, Winzeler-Mercay U, Radwan S, et al. Training
symmetry of weight distribution after stroke: a randomized
controlled pilot study comparing task-related reach, Bobath
and feedback training approaches. Clin Rehabil. 2002;16:
582–592.
[83] Pollock AS, Durward BR, Rowe PJ, et al. The effect of inde-
pendent practice of motor tasks by stroke patients: a pilot
randomized controlled trial. Clin Rehabil. 2002;16:473–480.
[84] Brock K, Haase G, Rothacher G, et al. Does physiotherapy
based on the Bobath concept, in conjunction with a task
practice, achieve greater improvement in walking ability in
people with stroke compared to physiotherapy focused on
structured task practice alone?: a pilot randomized con-
trolled trial. Clin Rehabil. 2011;25:903–912.
[85] Ilett P, Lythgo N, Martin C, et al. Balance and gait in people
with multiple sclerosis: a comparison with healthy controls
and the immediate change after an intervention based on
the Bobath concept. Physiother Res Int. 2016;21:91–101.
[86] Hafsteinsdo
ttir TB, Kappelle J, Grypdonck MH, et al. Effects
of Bobath-based therapy on depression, shoulder pain and
health-related quality of life in patients after stroke. Acta
Derm Venereol. 2007;39:627–632.
[87] Mikołajewska E. Associations between results of post-stroke
NDT-Bobath rehabilitation in gait parameters, ADL and
hand functions. Adv Clin Exp Med. 2013;22:731–738.
[88] Medical Advisory Secretariat, Health Quality Ontario.
Constraint-induced movement therapy for rehabilitation of
arm dysfunction after stroke in adults: an evidence-based
analysis. Ont Health Technol Assess Ser. 2011;11:1–58.
[89] Veerbeek JM, van Wegen E, van Peppen R, et al. What is
the evidence for physical therapy poststroke? A systematic
review and meta-analysis. PLoS One. 2014;9:e87987.
[90] Corbetta D, Sirtori V, Castellini G, et al. Constraint-induced
movement therapy for upper extremities in people with
stroke. Cochrane Database Syst Rev. 2015;(10):CD004433.
[91] Liepert J, Bauder H, Wolfgang HR, et al. Treatment-induced
cortical reorganization after stroke in humans. Stroke. 2000;
31:1210–1216.
[92] Prange GB, Jannink MJ, Groothuis-Oudshoorn CG, et al.
Systematic review of the effect of robot-aided therapy on
recovery of the hemiparetic arm after stroke. J Rehabil Res
Dev. 2006;43:171–184.
[93] Norouzi-Gheidari N, Archambault PS, Fung J. Effects of
robot-assisted therapy on stroke rehabilitation in upper
limbs: systematic review and meta-analysis of the literature.
J Rehabil Res Dev. 2012;49:479–496.
[94] Veerbeek JM, Langbroek-Amersfoort AC, van Wegen EE,
et al. Effects of robot-assisted therapy for the upper limb
after stroke. Neurorehabil Neural Repair. 2017;31:107–121.
[95] Kamphuis JF, de Kam D, Geurts AC, et al. Is weight-bearing
asymmetry associated with postural instability after stroke?
A systematic review. Stroke Res Treat. 2013;2013:692137.
[96] van Peppen RP, Hendriks HJ, van Meeteren NL, et al. The
development of a clinical practice stroke guideline for
physiotherapists in The Netherlands: a systematic review of
available evidence. Disabil Rehabil. 2007;29:767–783.