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A critical review of the current evidence about the Bobath Concept

Kostas Kypriotis

Physiotherapist MSc

Bobath (IBITA) Instructor

IBITA Research committee member

Orit Elion: PT, PhD

Ariel University

Advanced Bobath (IBITA) Instructor

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Prepared by:

Kostas Kypriotis,

Agnieszka Śliwka

Supported by:

The Research Com

& Hanna Aviv

Presenter:

Mika Ben-David Bauch

Contributor & courier:

Orit Elion

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For course participants

For instructors

Standard framework for courses

Know what to answer

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“The Bobath concept is not superior to other approaches for regaining mobility, motor control of the lower limb and gait, balance and activities of daily living of patients after stroke.

There is moderate evidence regarding the superior results of other approaches in terms of the motor control and dexterity of the upper limb”.

Kostas Kypriotis PT, MSc 2024

Díaz-Arribas MJ. Disabil Rehabil. 2020 Jun;42(12):1636-1649.

Bobath therapy was inferior to task-specific training and not superior to other interventions for improving lower limb activities, with the exception of proprioceptive neuromuscular facilitation.

Scrivener K. J Physiother. 2020 Oct;66(4):225-235.

“This study is inconclusive in determining the effectiveness of the Bobath approach for the movement rehabilitation of stroke patients. These results are similar to the results of previous reviews done on the same topic.”

Pathak A. 2021 Nov;10(11):3983-3990.

Outcomes of recent systematic reviews

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Missing from this analysis

Kostas Kypriotis PT, MSc 2024

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Patient groups included

Kostas Kypriotis PT, MSc 2024

Mainly Randomized Controlled Trials (RCT’s)

Vast majority in Stoke Patients

Usually after First Stroke

Cognitive, perceptual, and sensory impairments very often in the exclusion criteria

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Definition of the Bobath Concept

Kostas Kypriotis PT, MSc 2024

Great variety of how the Bobath Concept is defined

The validity of the term “Bobath” is questionable

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Variability of definition regarding the BC�Diaz Arribas et al., 2020

EXCLUDED: 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 and 1978 and/or whose intervention methodology 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, which rules out any scientific contributions that are not updated with regards to the evolution of the concept.

Kostas Kypriotis PT, MSc 2024

(Summary made by IBITA member Agnieszka Sliwka)

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Variability of definition regarding the BC�Scrivener et al., 2020

Kostas Kypriotis PT, MSc 2024

(Summary made by IBITA member Agnieszka Sliwka)

Trials that included physiotherapy based on Bobath therapy were included.

To determine whether Bobath therapy was used, trials had to meet one of the

following criteria:

The authors explicitly stated that the intervention was based on Bobath or neuro-developmental training;
The authors referenced a Bobath textbook or publication when describing the intervention;
The intervention description suggested that it was based on Bobath therapy.

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Variability of definition regarding the BC�Pathak et al., 2021

Kostas Kypriotis PT, MSc 2024

(Summary made by IBITA member Agnieszka Sliwka)

Karl Bobath developed this technique in 1990, and he described how motor dysfunctions take place in patients with hemiplegia.
Stroke patients shall actively participate in exercises assisted by the therapist.
Therapists use key points of handling and reflex inhibiting patterns for performing exercises
Bobath approach works on the different types of movement dysfunctions and is based on the active involvement of the patients so that they can develop motor control.
Manual handling is holding the patient at specific proprioceptive points, for example, joint compression and distraction, so that patients can respond actively to perform functions.

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Variability of studies included

Kostas Kypriotis PT, MSc 2024

Scrivener (N = 22)

Diaz Arribas (N = 15)

Pathak (N = 19)

(Summary made by

IBITA member Hanna Aviv)

Blue: Articles presented in

only one of the three studies

Green: Number of articles shared by only 2 out of three studies

Red: Number of articles shared by all three studies

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Studies missing up to date description of the BC

E.g., out of 21 studies included in Scrivener et al., 2020:

8 studies referenced Bobath 1990
2 studiesreferenced Bobath 1978
1 study referenced Bobath 1960.
5 studies provided no reference to Bobath.

Only 2 studies used a contemporary description of the Bobath concept.

Kostas Kypriotis PT, MSc 2024

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Even recent studies are ignoring the advances of the concept!!!

Publications range over a period of 30 years from 1986 to 2016.

Kostas Kypriotis PT, MSc 2024

(Summary of all 3 systematic reviews conducted by IBITA member Hanna Aviv)

In total, 31 studies were included in these three recent systematic reviews.

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Application of treatment

Kostas Kypriotis PT, MSc 2024

In most studies “Bobath Techniques” serve as the control group intervention (“Standard care”), implicating “control group bias”

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CIMT vs Bobath Intervention - Variability in intervention protocols between intervention groups or between studies

Kostas Kypriotis PT, MSc 2024

Publication	Van der Lee et al., 1999	Suputtitada et al., 2004	Huseyinsinoglu et al., 2012
Pedro	7/10	6/10	7/10
Protocol	CIMT or Bobath Intervention for 6 hours daily	Not clear description of Intervention protocol and dosage	CIMT 80% of the day combined resulting in �3 hours of intervention vs. 1 h of Bobath Intervention daily

(Díaz-Arribas MJ. Effectiveness of the Bobath concept in the treatment of stroke: a systematic review. Disabil Rehabil. 2020 Jun;42(12):1636-1649)

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Treatment Fidelity bias

Kostas Kypriotis PT, MSc 2024

No studies identified clinical adherence.

Causality determinations depend on aspects of treatment fidelity including intervention description, therapist adherence and expertise.

Out of 21 included studies in Scrivener et al., 2020�- 7 studies the intervention was not described�- 11 studies provided no description of the therapists’ background

Thus, 17/21 studies included in this review failed to provide sufficient detail to determine causality.

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Interestingly, of the 4 studies that identified the skill level of the Bobath therapist, the Bobath concept demonstrated superiority compared with other approaches.

(Mudie et al., 2002, Wang et al., 2005, Brock et al., 2011, Kilinc et al., 2016)

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Authors Response

Kostas Kypriotis PT, MSc 2024

“If, as suggested, an intervention such as Bobath therapy requires significant postgraduate training to be implemented successfully, then its application to a wider clinical setting is likely to be limited.
We are fortunate to have high levels of evidence for many interventions in stroke rehabilitation that do not require additional postgraduate training and can therefore be implemented broadly”.

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Cost / Benefit

Kostas Kypriotis PT, MSc 2024

Cost / Benefit ratio research should be performed.
There are several recent examples in neurorehabilitation where more costly, training and resource demanding solutions can result in substantially greater results (e.g. thrombolysis, increased treatment time after stroke, treatment focusing on movement patterns (E.g., Bernhardt et al., 2017, Krakauer and Cortès, 2018, Ward et al., 2019, Kelly et al., 2020).

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Kostas Kypriotis PT, MSc 2024

Other Concerns

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Other Concerns

Kostas Kypriotis PT, MSc 2024

Inherent methodological constrain to provide a specific treatment protocol for an individualized treatment approach such as the Bobath Concept (Bartlett et all., 2006, Vaughan – Graham et al., 2014).

Often the Bobath Concept is compared to complementary rehabilitation approaches (e.g. electrotherapy) or approaches concerning the rehabilitation of specific body parts or areas of functionality (e.g. CIMT).

Moreover, other rehabilitation approaches account to a small portion of the stroke population (e.g. in CIMT around 10% of stroke patients are eligible (Kwakkel et al., 2015).

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Future Suggestions

Kostas Kypriotis PT, MSc 2024

Outcome measures for quality of movement

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True recovery after stroke�

Kinematic patterns dissociate true recovery from learning compensatory strategies, potentially reducing the expectation of reparative plasticity (Bernhardt et al., 2017, Kwakkel et al., 2017 Krakauer and Cortéz, 2018, Ward et al., 2019, Bernhardt et al., 2019)

Kostas Kypriotis PT, MSc 2024

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Recovery: quality of movement

Kostas Kypriotis PT, MSc 2024

Quality of movement is a core element in the Bobath assessment and treatment.

Quality improvement may not be reflected in activity level outcome measures, especially in the short time period (often around 2 weeks) (Vaughan – Graham et al., 2014).

Recent consensus dictates to carry out novel research that will include the evaluation of the quality of movement in the outcome measures (Bernhardt et al., 2017 ).

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Conclusions: This review provides an updated Bobath clinical framework that gathers the theoretical foundations and clinical practice principles that require careful consideration in the design of future intervention studies. �

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Take home message�

Face the current literature with knowledge.
An updated version of the ResCom review should be added to the basic course curriculum.
Empowering IBITA for the future.
Further research of the different aspects of the Bobath Concept is essential
Knowledge is strength!

Kostas Kypriotis PT, MSc 2024

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