Neurological Physiotherapy: The Bobath Concept
Updated: Jan 15, 2020
The Bobath concept has been updated and added to since its inception. Currently, it is based on the international classification of functioning and health and has client centered, evidence based practice at its core. I was wondering why then, were there questions regarding its suitability as a treatment approach?
The Bobath concept has been somewhat of a mystery over the years. No one has been able to be as definitive with neurophysiology up until the recent past. With our current improvements with objective neurological assessments such as fMRI and radioactive dying etc, researchers are able to make more definitive statements about the CNS. This allows clinicians to make more definitive relationships within the literature to inform their practice. So for Bobath, this means the teaching has gone from, “we think”, to “we know”. So with more neurophysiological ‘truths’, there can be more evidence-based education. Initially, Berta Bobath found that individuals with strokes could recover some of their lost function. The reasons she thought for why this was have been disproven, but that doesn’t change the fact that she was able to help people regain function through her bare hands. What we needed was for the science to catch up to the practice. This is an issue that exists in every aspect of therapy. Now that the science around how movement is organized and planned for within the CNS is more solid, approaches that utilize this knowledge base are now able to be validated, where as before this simply was not possible.
A key element of many people’s complaints and the discussions around the Bobath concept are that randomized control trials, (RCTs), don’t show that the Bobath concept is better than any other. So why then study it, use it, and have it as a current method of practice at all? And thus the debate. The challenge here is that RCTs require controlling all the variables to explore the impact of one variable. This is how drugs are studied – one person gets the drug and one person doesn’t. If everything else is pretty much equal, they can then assess the impact of the drug. As long as they have enough participants, trends will emerge and a conclusion can be made. The RCT design can not accurately capture the individualized nature of an interpersonal relationship of therapist – client as in the Bobath concept. There are too many variables to control for to actually have a randomized controlled trial.
The International Bobath Instructor Training Association, IBITA, has been conducting research to look at the Bobath Concept with more objectivity and to learn how to study it in a manner that can answer questions as to its efficacy as a treatment approach. Alternative study designs have been proposed and over the next decade as more data is gathered, there will be a body of new evidence regarding the Bobath concept.
One of the reasons it is hard to determine the impact of the Bobath concept at present, is that there is no one Bobath concept, delivered in the same way by every practitioner. It is a problem-solving framework that is clinician-client driven, and does take time to learn. The goal of the therapist is to ascertain which systems/areas have sparring and how to go about creating remediation whilst reconciling this with necessary compensations for function. Bobath therapists do this by observing, feeling and moving with the person they are treating, and through skilled facilitation – to make movements easier through handling/help to give the sensory information that would create a demand for a specific muscle activation and thus movement.
Knowledge through studying and time is the only way someone can do this. It is not something that a weekend or even several weeks of course work can teach fully. The concept needs to become somewhat second nature to the therapist for them to attend to the myriad of information they are receiving from moment to moment. The Bobath concept is science based, using the latest neuro-scientific research to inform practice, and uses the scientific method in its clinical reasoning approach.
There are musings that we as therapists should engage more in research. A single case study design has been suggested as a potential way to build the body of evidence. Trends would undoubtedly appear with enough data. The level of evidence would not be the same as an RCT, but we have to look at what we are studying and critically think about how we can capture the information we are trying to capture: Does this work? For whom? When? What is the best dosage?
With enough reports containing information about how the Bobath concept was applied, the reasoning behind its application in that specific setting with that particular client, and the results, hopefully trends will emerge to either support or refute the Bobath concept in neurological rehabilitation.
From first muscle twitches to first steps, I have witnessed the meaningful impact the Bobath concept has been able to make along the continuum of care. Over years of study I have seen how far one can go with their learning and practice. It is a never-ending journey that, for me, has been a pathway to helping my patients grow and recover from traumatic events and challenging Life situations.