Research

Interactive-dialogue
in the Bobath concept:
A mixed methods study
Gabriele Eckhardt, Gerlinde Haase, Kim Brock, Horst Hummelsheim

Background/Aims: This study investigated whether treatment using the Bobath concept is
characterised by an identifiable, specific approach to the interaction between therapist and patient,
known as the interactive-dialogue.
Methods: Three studies were conducted. The opinions of a Bobath expert group on the interactive-
dialogue approach were evaluated in a Delphi survey, in which 57 members participated. The data
generated were used to develop a model focused on key aspects of the interactive-dialogue. In a
second survey, perceptions of the interactive-dialogue approach were compared between experienced
therapists with and without training in the Bobath concept, with 73 therapists participating. The third
study investigated whether these aspects of the interactive-dialogue approach could be identified
in videotaped examples of clinical care using the Bobath concept. Ten independent raters, five with
Bobath training and five without, viewed videotapes of a single treatment session.
Results: A high level of agreement (98.2%) was identified in the expert group regarding the
importance of the interactive-dialogue approach. The model developed described the interactive-
dialogue approach in five domains; ‘relationship’, ‘sense/perceive’, ‘reflect’, ‘adapt/react’ and
‘carryover’. The comparison between Bobath-trained and non-Bobath-trained therapists revealed areas
in common, such as goal setting, but also areas of difference, including non-verbal components and
the role of reflection in the learning process. In the videotaped case examples, the raters identified the
domains of the model as being ‘very strongly’ or ‘strongly’ represented in 68.2% of ratings.
Conclusions: The interactive-dialogue approach has been verified as an observable feature of clinical
practice in the Bobath concept.

Key words: ■ Bobath concept ■ Learning process ■ Interactive-dialogue approach

Submitted 4 September 2015; accepted for publication following double-blind peer review 29 October 2015

T
Gabriele Eckhardt,
he Bobath concept is the therapeutic verbal—between the patient and therapist is a Physiotherapist, Centre
approach used most often in crucial factor (Raine, 2007; Graham et al, 2009; for Physiotherapy and
neurorehabilitation worldwide (Van Viebrock et al, 2010; Eckhardt, 2013). In 2011, Rehabilitation, Haan,
Germany;
Peppen et al, 2004; Graham et al, the second author (GH), a senior Bobath tutor,
Gerlinde Haase,
2009; Levin and Panturin, 2011). Despite its presented a model entitled the interactive- Physiotherapist, Centre
high use, there is a lack of research exploring dialogue learning process at the International for Physiotherapy and
the various components of the Bobath concept, Bobath Instructor Training Association (IBITA) Rehabilitation, Haan,
and how it is applied in the clinical situation. Conference in Vienna. This model considers Germany;
Kim Brock,
The holistic nature of the concept makes Bobath therapy from the perspectives of both
Physiotherapist,
it difficult to identify, examine, describe and therapist and patient, outlining the involvement Rehabilitation Unit,
measure specific aspects in a transparent and of each as partners in the learning process. St Vincent’s Health,
comprehensive manner (Viebrock et al, 2010). The purpose of this study is to investigate Melbourne, Australia;
This is a strong limiting factor to research the importance of the interactive-dialogue Horst Hummelsheim,
Professor and Medical
considering potential effective factors or approach in the Bobath concept and describe
Doctor, Neurological
context-specific explanations for therapeutic forms of the interactive-dialogue approach that Rehabilitation Centre,
activities. In response to these limitations, can be identified and objectively verified in a University of Leipzig,
theoretical models have been developed Bobath treatment. Muldentalweg Benewitz,
© 2016 MA Healthcare Ltd

to explore different aspects of the Bobath
concept. A key component identified in several
theoretical publications is the interactive nature
of clinical practice in the Bobath concept,
whereby the dialogue—both verbal and non-
Previous research considering the clinical Germany.
relationship have focused on interactive and
Correspondence to:
narrative clinical reasoning (Feiler, 2003; Gabriele Eckhardt
Jones and Rivett, 2004). Interactive clinical Email:
reasoning is about the perception of feelings g.eckhardt@burgerland.de

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 Research
during the therapy—the conscious shaping of
the therapeutic relationship and communication.
Narrative reasoning includes communication
and interaction with the patient in order to
understand his or her situation, and be able to
initiate changes. This study explores how these
aspects of the clinical relationship occur within
the Bobath concept.
To better understand the role of the
interactive-dialogue in the clinical relationship
within the practice driven from the Bobath
concept, the following questions were posed in
this study:
■■ How do experts in the Bobath concept
describe the interactive-dialogue approach in
the practice of the Bobath concept?
■■ Do therapists with training in the Bobath
concept have a different understanding of
the interactive-dialogue approach compared
with therapists who have not received formal
training in the Bobath concept?
■■ Can aspects of the interactive-dialogue
approach be identified when observing
therapy based on the Bobath concept,
by experts in the Bobath concept and by
clinicians without expertise in the Bobath
concept?
■■ Is there a correlation between participation
by therapists and patients in the interactive-
dialogue approach?
MATERIALS AND METHODS
Study design
A multi-method approach was used, including
the following:
■■ Delphi studies
■■ Comparative correlational measurement
■■ Qualitative observation and analysis.
The inductive approach of qualitative
research was used as it offers a model that
can adequately describe a topic or content
area on the basis of empirical data. It can
explore and illuminate individually significant
processes (Wirtz et al, 2007). The development
of a theory based on empirical data in the
qualitative paradigm can be further investigated
with regard to validity and scope, using
quantitative study designs. A combination of
these methodical approaches, in triangulation,
is therefore useful for the study of contents of
therapeutic intervention.
Firstly, a two-phase Delphi survey was
conducted with experts in the Bobath concept.
Secondly, similar questions to those developed
for the Delphi survey were addressed to
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therapists working in neurorehabilitation
with and without formal training in Bobath.
The third component of the study used
video-recorded therapy sessions, whereby
experienced Bobath therapists and clinicians
without Bobath training rated elements of
the interactive-dialogue for the therapist and
patient. The methods and results of each of
these studies will be presented sequentially to
enhance readability. Ethical approval for this
study was not required, in accordance with
ethics guidelines in Germany. Written informed
consent was obtained from all participants.
Study 1: Delphi survey of Bobath
experts
Method
All members of the International Bobath
Instructor Training Association (IBITA) from
27 countries were asked to provide a description
of the interactive-dialogical approach of the
Bobath concept (n=267). Members of IBITA
have achieved qualification to lead Bobath
courses. The questions posed in the initial
Delphi round are listed below:
■■ Question 1: Is the ‘interactive-dialogue
approach’ an important principle (a primary
course of action) of the Bobath concept?
■■ Question 2: What do you understand by
the interactive-dialogue approach of the
Bobath concept?
■■ Question 3: What makes this approach an
important (or unimportant) aspect of the
work of a Bobath therapist?
■■ Question 4: Can you name some criteria
by means of which it is possible to judge
‘from the outside’ whether a therapy matches
the interactive-dialogue approach of a
Bobath therapist?
All responses received in this round
were used to structure the content analysis
according to the methods of Kuckartz (2012)
and Schreier (2012) to develop the quantitative
evaluation. Encoding was done with two raters,
and diverging points of view were discussed
between the raters. The MAXQDA-2 software
was used to process the data. The responses
from Questions 2 and 3 were encoded and used
to create statements to define the interactive-
dialogue in the Bobath concept. These
statements were then checked and validated
in a second Delphi round using a five-point
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Likert scale.
Results
Fifty-seven members of IBITA (21% of those
invited to participate) from 20  countries
 responded to the first round of the Delphi Table 1. Demographic data for participants
survey. The countries with the highest levels Study 1 Study 2 Study 3
of response were Germany (15 responses), Group IBITA IBITA Bobath Non- Bobath Non-Bobath
Switzerland (seven responses), and five Dephi 1 Dephi 2 therapists Bobath therapists therapists
responses were received from both Brazil and therapists
the UK. Demographic data are listed in Table 1. n 57 35 34 39 5 5
Thirty-five members responded to the second Gender 13 m, 8 m, 5m 8m 3 m, 5f
Delphi study. 44 f 27 f 2f
A high level of agreement was reached PT/OT 57 PT 35 PT 28 PT, 30 PT, 3 PT, 1PT,
for Question 1 regarding the importance 6 OT 9 OT 2 OT 1 Neurol,
of the interactive-dialogue, with 98.2% of 1Psychol,
respondents answering ‘yes’. For Question 2, 2 OT
the following statement was developed from Other 41BC 25 BC,
the encoded responses, reaching a high level info 5 AC, 4 AC,
6 SI, 2 SI,
of consensus in the second Delphi round, with
4 Cand. 4 Cand
71.5 % responding ‘strongly agree’ and 22.2% 1 RM
as ‘agree: from 20
‘The interactive-dialogue (verbal and non- countries
verbal) therapeutic approach is defined as an PT: physiotherapist; OT: occupational therapist; m: male / f: female; n: number
empathetic and respectful therapist-patient BC: Basic Course Instructor IBITA; AC: Advanced Course Instructor IBITA;
relationship, which allows for working out SI: Senior Course Instructor IBITA; Cand: Bobath Instructor Candidate IBITA;
RM: Retired Member of IBITA
together solutions to restricting functional
disorders in the individual daily routine of the of the interactive-dialogue approach, with
patient. The interactive-dialogue approach is corresponding therapist and patient perception,
an integrated part of the clinical reasoning of and action processes related to the five key
a Bobath therapist and supports the learning items.
process of the patient.’
The following three statements were Study 2: Comparison of therapists’
developed from Question 3 and all statements perceptions of interactive-dialogue
were rated as ‘agree’ or ‘strongly agree’ Method
by more than 85% of raters in the second Two groups of therapists were recruited to
Delphi round. this study. Physiotherapists and occupational
■■ ‘The interactive-dialogue approach of the therapists who had previously completed the
Bobath concept looks upon the human being 3-week basic Bobath course were recruited
as a whole (biopsychosocial)’ from 12  rehabilitation centres in Germany.
■■ ‘The interactive-dialogue approach of the The non-Bobath-trained therapists were
Bobath concept supports the learning process recruited from participants about to commence
of the patient’ a basic Bobath course. The instructors of the
■■ ‘The interactive-dialogue approach of Association of German and Austrian Bobath
the Bobath concept is a component of the Instructors (VEBID) were asked to hand out the
clinical reasoning process’. questionnaire to the participants of their courses
The encoded answers of the Bobath experts and have them fill them in prior to the course.
to Question 4 are shown in Table  2. They The questionnaire used for this survey was not
were clustered into the codes (items 1–5) related exclusively to the Bobath therapy, but
‘relationship’, ‘sense/perceive’, ‘reflect’, ‘adapt/ to physiotherapy and occupational therapy in
react’ and ‘carryover’. All of these categories general. Three questions were posed, as follows:
were well represented in the responses. The ■■ Question 1: Is the ‘interactive-dialogue
data generated in this study were integrated approach’ an important principle (a primary
with the literature discussed in the introduction, course of action) within the rehabilitation of
pertaining to both the clinical relationship patients with neurological disorders?
generally (Jones et al, 2008; Skjaerven et al, ■■ Question 2: What do you understand
2008; Holdar et al, 2013), and the Bobath by the interactive-dialogue approach in
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concept (Bobath, 1990; Raine, 2007; Viebrock
et al, 2010; Eckhardt, 2013), as well as the
model developed and presented at IBITA by
the second author (GH). Table  3 shows the
resultant model, focusing on five key aspects
physiotherapy and occupational therapy?
■■ Question 3: What makes this approach an
important (or unimportant) aspect of the
work of a therapist?
The data-coding processes used in study  1

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 Research

Table 2. Question 4 of the Delphi survey of Bobath experts: Can you name some criteria by means of
which it is possible to judge ‘from the outside’ whether a therapy matches the Interactive-Dialogue
approach of a Bobath therapist?
Aspects of the I-D approach Responses of Bobath experts (IBITA) Number of
n=57 responses*

Relationship Talk/listen 23
observing, talking, listening, To be alert 15
be in contact
Observe 9
Feedback 7
Motivation 6
Respectful 3
Positive atmosphere 3
Trust 1
Sensing/perceiving Hands-on/hands-off 19
to be aware, to be conscious of To be attentive, 10
attending to the moment
Less effort 6
Take time 5
Curious—have fun 5
Together, mutual 3
Idea of movement 3
To sense own body 2
Breathing 1
Satisfaction 1
Reflecting Aware of changes 14
Analysis of movement 11
Quality of movement 9
Clinical reasoning 9
Bio/psycho/social situation 6
of the individual
Measurement 5
Theoretical background 3
Reacting/adapting Adapt to the needs of the person 11
Adapt to alignment 11
Aadapt to the environment 6
Try out/explore 5
Adapt to ability 5
Adapt to the task 5
Allow movement 4
React to the sensory motor response 3
To be active 2
Trial and error 1
Carryover Goal-setting/goal achievement 14
Change the movement behaviour 14
Participation (ICF) of person 8
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24-hour/ daily life 7

Variations 5

ICF: International Classification of Functioning, Disability and Health (www.who.int/classifications/icf/)

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 were also used in this study, including the use Table 3. Summary of Interactive-Dialogue approach in the Bobath concept
of two raters. Therapist Aspects of the Patient
interactive-dialogue
Results approach
Questionnaires were received from Questioning, Observing, talking, Answering, questioning,
73  therapists; 34 Bobath-trained therapists and encouragement, leading listening, be in contact imitating, mimic, gesture,
39  non-Bobath-trained therapists. Question  1 to, mimic, gesture, attention
was answered ‘yes’ by all respondents. attention, breathing
Question  2 revealed some similarities and Assessing, not disturbing, Sensing, perceiving, to be Understanding of
differences between the two groups of giving time, changing aware, to be conscious of movement, identifying
environment and task, mistakes, self-assessment,
therapists (Table  4). Both groups agreed about go into-out of the pattern self-exploration, take time
the importance of interacting with the patient,
Compare, re-evaluation, Reflecting Compare, understanding
and the necessity of collaborative goal- correlation, hypothesis of mistakes and
setting. However, the non-Bobath therapists movement behaviour,
described the interactive-dialogue in terms of accepting the truth
verbal communication, whereas the Bobath Mediating secureness, Reacting/adapting Trial and error, exploration,
therapists emphasised both the verbal and non- making suggestions, time, shaping, without
verbal interaction, the importance of mutual invitations for initiation, fear, realising first results,
understanding of the problem at hand, and the hands-on/hands-off, motivation
shaping, all levels ICF,
role of reflection as part of the dialogue. Thus, learning phases
based on the data, each group would come up
Movement components Carryover Achievements part-task
with a different definition of the interactive- into task, making decision, to whole task, less effort,
dialogue approach. variations, ADL, goal- planning learning steps,
For Question 3 (Table 5), a similar proportion setting, relatives, 24-hour ADL, new goals
of both groups considered the interactive- plan, self-exercises,
dialogue approach to be important for the repetition
‘relationship between therapist and patient’ and The perception and action processes are placed in the centre of the model and the
the ’improvement of motivation’. Additionally, descriptive synonyms are attributed to therapists and patients on the left and right
sides, respectively
the non-Bobath therapists pointed out ‘adapting
to the needs of the patient’ and the ‘possibility Table 4. Question 2 for Bobath-trained and non-Bobath-trained therapists:
of making corrections’. Apart from the points What do you understand under the I-D approach?
already mentioned, the Bobath therapists most Non-Bobath-trained responses* n = 39 Bobath-trained responses* n = 34
often named ‘perceiving and understanding
Verbal communication 49 Verbal and 29
changes’ by both the therapist and patient and non-verbal
the ‘learning process of the patient’. communication
To have a relationship 15 To have a 26
Study 3: Interactive-dialogue in the relationship
Bobath concept in clinical examples Goal-setting together 14 Goal-setting 21
In a further step, the authors investigated together
whether the interactive-dialogue approach in the Communication between 7 To perceive and 19
Bobath concept could be identified by observers professional understand
during clinical interactions. information
Patient and therapist 7 Reflection patient/ 10
Method together therapist
Five single-patient treatment sessions based After dialogue follows 3 Communication 2
on the Bobath concept of 1-hour duration were interaction between
video-recorded, with all sessions conducted professionals
in the German language. The participating Patient and therapist learn 1
treating therapists were drawn from three from each other
groups from Germany, Austria or Switzerland. *Participants may have had more than one statement coded to a single code
These included senior instructors in the Bobath
concept (n=5); therapists formally enrolled Inclusion criteria for patient participants were
© 2016 MA Healthcare Ltd

in the IBITA instructor training programme
(n=6); and participants from four advanced
Bobath training courses (n=50). The choice
of patients was left to the discretion of the
treating therapists.
the presence of a central neurological injury
and informed consent. In addition, an archived
videotape of Berta Bobath herself was used for
the study. Ten  observers were recruited from
seven rehabilitation facilities in North Rhine-

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 Research

Table 5. Question 3. What makes this approach an important Westphalia and Hessen via an email flyer. Two
(or unimportant) aspect of the work of a therapist? groups of observer participants were used:
Non-Bobath-trained responses* Bobath-trained responses* experienced Bobath therapists (completed basic
n=39 n=34 and advanced courses); and clinicians without
Relationship 14 To perceive and understand changes 16 formal Bobath training. All clinicians had a
Adapt to the needs 14 Motivation 11 minimum of 5  years of professional experience,
Goal-oriented 13 Goal-oriented 11 and IBITA instructors and instructor trainees
were excluded.
Correction 9 Relationship therapist/patient 10
The model shown in Table  3 was formatted
Motivation 8 Learning process 8
into an evaluation form using a central
Reflection and 8 Personal responsibility 6 column with the five key items (‘relationship’,
education
‘sense/perceive’, ‘reflect’, ‘adapt/react’ and
Goal-setting 8 Individual bio/psycho/ social 6 ‘carryover’). A five-point Likert scale was
Assessment and 4 Basis for active working 5 included either side to record level of agreement
progression regarding the presence of these aspects from the
Personal 3 Decision-making process 5 perspective of the therapist and patient during
responsibility/ the treatment session. The observer participants
participation
received the video recordings by mail, with
Activate the person 3 Effective 4 accompanying information notes and evaluation
Evidence-based 1 Continuous interplay of assessment 2 forms. They were asked to review all videos and
practice and intervention to score the criteria using the five-point Likert
Interdisciplinary 1 Orientated to daily life 2 scale for each treatment session.
Work on limit of abilities 2 Thus, for each videotape, 100  data were
Oriented to potential 1 collected (ten raters; five items from the point
of view of the therapist, five items from the
point of view of the patient). The data were
Table 6. Comparison of ratings of Bobath-trained observers and non- analysed in three ways. Descriptive statistics
Bobath-trained observers
were used to examine the degree to which items
Item Marginal estimated means F# p of the interactive-dialogue approach could
(standard error)
be identified in the videos. The correlation
Median (IQR)
between patient and therapist for the items
Non-Bobath Bobath-
of the Interactive-Dialogue were calculated
trained trained
using the gamma test. Analysis of co-variance
Relationship therapist 4.32 (.20) 3.60 (.20) 6.29 .04*
(ANCOVA) for repeated measures was used
5 (5,4) 4 (5,2)
to examine whether there were significant
patient 4.08 (.27) 3.48 (.27) 2.42 .16
differences between how Bobath-trained and
4 (5,4) 4 (5,2)
non-Bobath-trained observers rated aspects of
Sense/ therapist 4.28 (.20) 3.80 (.20) 2.80 .13
the interactive-dialogue. The ANCOVA analysis
perceive 5 (5,4) 4 (5,2)
was conducted for each of the five key items for
patient 4.24 (.14) 3.60 (.14) 10.90 .01*
both the therapist and patient, using ‘patient’ as
5 (5,2) 4 (5,2)
a within-subject variable and ‘group’ (Bobath-
Reflect therapist 4.52 (.14) 3.68 (.14) 17.29 <.01*
trained or non-Bobath-trained) as a between-
5 (5,4) 4 (5,2)
subject variable.
patient 3.76 (.28) 3.00 (.28) 3.57 .09
4 (5,3) 3 (4,2)
Results
Adapt/react therapist 4.56 (.24) 4.04 (.24) 2.27 .17
Four therapists provided a video of a treatment
5 (5,4) 5 (5,4)
session: two senior Bobath instructors, one
patient 4.12 (.25) 3.52 (.25) 2.88 .13
trainee instructor and one advanced course-
4 (5,3) 4 (5,2)
trained therapist. Therefore, five videos
Carryover therapist 4.28 (.26) 3.12 (2.6) 9.56 .01*
were viewed by the observers, including
5 (5,4) 2 (5,2)
the historical video by Bertha Bobath. The
patient 3.8 (.21) 2.84 (.21) 10.29 .01*
Bobath-trained observer participants included
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4 (4,3) 2 (4,1)
three physiotherapists and two occupational
strongly agree = 5, Agree = 4, neither agree or disagree = 3, disagree = 2,
therapists. The observers without formal Bobath
strongly disagree = 1;
training were made up of two occupational
# ANCOVA for repeated measures (group: Bobath trained or non Bobath trained); therapists, a neurologist, a psychologist, and
*p<0.05 one physiotherapist.

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 The graph in Figure  1 shows the combined
ratings of the 10  observers for all items for all
videos (100  data per video; n=500). In total,
68.2% (n=341) of the ratings were scored as
‘strongly agree’ and ‘agree’ that the item of
the interactive-dialogue could be identified
in the video. Ratings of ‘neither agree nor
disagree’, ‘disagree’ and ‘strongly disagree’
were recorded for 31.8 % (n=159). Figure  2
and Figure  3 show the proportion of scores
rated as ‘strongly agree’ and ‘agree’ for the
therapist and patient separately, for each of the
five videos. The correlation between ratings
for the therapist and the patient for each item
varied from moderately correlated for ‘adapt/
react’ (0.57), ‘sense/perceive’ (0.72) and
‘relationship’ (0.72), to highly correlated for
‘reflect’ (0.76) and ‘carryover’ (0.94).
In the comparison between Bobath and
non-Bobath clinicians’ ratings for therapists,
significant differences were observed for
the three items ‘relationship’, ‘reflect’ and
‘carryover’ (Table  6). For ratings for patients,
significant differences were observed for the
two items ‘sense/perceive’, and ‘carryover’.
Overall, the non-Bobath trained clinicians
tended to use higher scores than Bobath-trained
therapists. The ratings scored by the Bobath-
trained therapists demonstrate wide interquartile
range for most components (Table  6),
suggesting that raters held different views on
the degree to which these components were
observable in the treatment sessions. A power
analysis was conducted indicating that a sample
of 22  videos viewed by 10  raters would have
sufficient power to provide an accurate estimate
of reliability.
250
200
150
100
72
50
32
0
Strongly Disagree
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disagree
Figure 1. Identification of the five aspects of the interactive-dialogue approach by 10 observers
rating videoed patient treatment sessions: Overall level of agreement
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KEY POINTS
■■ This article helps to better understand the role of the interactive-dialogue
approach in the clinical relationship within the practice driven from the
Bobath concept.
■■ The interactive-dialogue approach is described as a specific aspect of the
Bobath therapy and used to support the learning process of the patient with
a neurological disorder.
■■ This study has demonstrated that the interactive-dialogue approach in the
Bobath concept can be described by experts in the Bobath concept.
■■ The interactive-dialogue approach has both aspects in common with the
views of clinicians that are not expert in the Bobath concept, and aspects
that are specific to, or more strongly represented, in clinicians trained in the
Bobath concept.
DISCUSSION
This study has demonstrated that the
Interactive-Dialogue approach in the Bobath
concept can be described by experts in
the Bobath concept, and also has aspects
in common with the views of clinicians that
are not expert in the Bobath concept. The
Interactive-Dialogue is an integrated part of
the clinical reasoning of a Bobath therapist.
The areas of difference include the Interactive-
Dialogue being part of the clinical reasoning
process; the key role of non-verbal interactions;
the importance of mutual therapist/patient
understanding of the problem; and reflection
by therapist and patient as part of the learning
process. Areas in common include the
importance of goal-setting and the key role of
the therapist/patient relationship for motivation
for the patient. The differences observed
All items
205
136
55
Agree Strongly agree
Neither agree
nor disagree
87
 Research

120

100

80
Video 1

Video 2
60
Video 3

Video 4
40
Video 5

20

0
Item 1 Item 2 Item 3 Item 4 Item 5

Figure 2. Frequency of scores of ‘strongly agree’ or ‘agree’ for the five domains for the therapist
component for each video-recorded treatment session

120

100

80
Video 1

Video 2
60
Video 3

Video 4
40
Video 5

20

0
Item 1 Item 2 Item 3 Item 4 Item 5

Figure 3. Frequency of scores of ‘strongly agree’ or ‘agree’ for the five domains for the patient
component for each video-recorded treatment session
between Bobath-trained and non-Bobath- observed for both the therapist and the patient.
trained therapists indicate that the processes Experts make a distinction between two
of the interactive-dialogue are learned while possibilities of practical realisation: the level
participating in Bobath training courses. of perception and the level of action (Taylor
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The study revealed a structure by which
the interactive-dialogue could be described
in clinical practice, with five domains;
‘relationship’, ‘sense/perceive’, ‘reflect’, ‘adapt/
react’ and ‘carryover’. These domains could be
et al, 2009; Holdar et al, 2013). Processes of
perception and processes of action are not to
be regarded as hierarchical procedures, but as
partial aspects which influence each other and
are interrelated.

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 The responses indicate the interactive-
dialogue demands attention, deeper
understanding, and memory, and requires
concurrent reflecting and anticipatory cognitive
engagement from both the therapist and
the patient.
Using the video-recorded patient treatment
sessions, Bobath clinicians with varying levels
of expertise and clinicians without Bobath
training were able to identify the five domains
of the interactive-dialogue in the clinical
examples for both the therapist and the patient.
Overall, the Bobath clinicians tended to score
the components lower than non-Bobath trained
clinicians. Also, there was variability between
Bobath clinician raters for most items. This is
an interesting observation because it suggests
that, while Bobath clinicians agree on the words
used to describe the interactive-dialogue, there
is less agreement when these terms are applied
to real clinical examples. Further research
should be undertaken to clarify and describe
these components to both improve agreement
between raters and enhance our knowledge of
the interactive-dialogue. After the evaluation
sheet has been further developed, reliability
testing would need to be conducted.
The study also examined the correlation
between therapist and patient in the interactive-
dialogue approach. In other words, what is
the relation between the approach used by the
therapist and the engagement of the patient in
their learning? Does the approach used by the
therapist support the processes of perception
and action of the patient? Moderate-to-high
correlations were demonstrated between
observations for the therapist and patient for the
five domains, indicating the interactive-dialogue
is a partnership, with both players taking an
active role.
In qualitative research, bias on the part of
the study leader (Kuckartz, 2012) can distort
the results and lead to an invalid outcome.
Therefore, a triangulation approach was taken,
whereby both qualitative and quantitative
procedures were used. Encoding for qualitative
components was done with a second rater in
order to minimise subjective interpretations by
the study leader. Another potential source of
distortion was the choice of video recordings;
therefore, participation was invited from a
large pool of therapists to ensure that a broad
© 2016 MA Healthcare Ltd
representation of video material was included.
All videos received that fulfilled study criteria
were included in the study. Similarly, the
observers rating the videos were recruited by
an open e-mail to rehabilitation facilities and
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nal Journal of Therapy and Rehabilitation. Downloaded from magonlinelibrary.com by 144.082.108.120 on June 16, 2016. For personal use only. No other uses without permission. . All rights
clinics in North Rhine-Westphalia and Hessen.
The evaluation form used in this study, based
on Table  3, has potential as a self-assessment
tool for reflecting on treatment sessions in
terms of the interactive-dialogue approach. For
example, some reflections include:
■■ Which forms of perception processes did I
realise as a therapist, which forms of action
processes are comprehensible?
■■ How did the patient react?
■■ Was the patient able to actively influence his
or her learning process?
■■ Did I give the patient enough time for self-
reflection and the exploration of movement
sequences?
■■ Was the patient able to integrate what he or
she had learned into everyday situations?
■■ Are there forms of the interactive-dialogue
approach I feel safe with or which I have to
reassess?
The evaluation form is particularly suited for
use in teaching since the course participants are
enabled, in a structured manner, to reflect on
their own processes of perception and action
and to put the focus of the learning situation on
the patient.
CONCLUSION
The results of the current study suggest that the
interactive-dialogue approach is an identifiable
feature of the clinical practice in the Bobath
concept and is used to support the individual
motor learning of patients with a neurological
disorder. Key aspects of the interactive-dialogue
approach have been identified and can be used to
evaluate and reflect on clinical practice. Further
research is needed to describe and clarify the
components of the interactive-dialogue approach
and investigate inter-rater reliability of the
evaluation forms developed in this study.
Conflict of interest: Gabriele Eckhardt, Gerlinde
Haase and Kim Brock are IBITA members and are
involved in the teaching of the Bobath Concept.
Acknowledgements: For the Delphi survey, the
authors were reliant on the cooperation of the
IBITA members. They would like to express sincere
thanks to everybody involved. A very special thanks
goes out to the raters who offered a great deal of
their leisure time to review and evaluate the video
tapes, and also to the therapists who provided the
tapes, and the patients who agreed to be filmed.
Without their support, this study could not have
been conducted. IJTR
89
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54

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