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he !obath Concept oday(Talk given at the CSP Congress, October 2000)

Margaret J Mayston, PhD, MCSP 

Bobath Centre London and Lecturer,

Department of Physiology,University College London

Any discussion of the Bobath Concept requires a common understanding of wha

Concept is. In an interview almost twenty years ago, Bobath explained it this w

whole new way of thin!ing, observing, interpreting what the patient is doing, thwe do in the way of techniques# to see and feel what is necessary, possible for

$e do not teach movements, we ma!e them possible......... %Bobath, &'(&). I

clear that Bobath was not a method or technique, not limiting, but fluid* was nochanging, and still changing. +he Concept can be summarised as follows: It is p

observing, analysing and interpreting tas! performance. +his also includes the clients potential, which was considered to be that tas! or those activities which

performed by the person with a little help, and therefore possible for that persoindependently where possible. -f course the Concept also involves the use of v

and Bobath always advocated that the therapist should# do what wor!s the beIn the present day, this should mean, that therapy is based on sound evidence

available, while recognising that currently much of what therapists do has not b+his does not mean that these therapy strategies should be discarded, but does

require investigation and possibly an alternative explanation of their effect. +hesupport some of what therapists do, but there are still many unanswered quest

Bobath therapist, there is also the dilemma of what it means to be a Bobath the0avidson and $aters %1222) showed that ((3 of neurological physiotherapists

Bobath approach. But, it depends on when you trained, where and who with. I that those ((3 of the therapists surveyed would explain or clinically apply the

with any degree of similarity.

$hen therapists attending the paediatric course at the Bobath Centre are as!ed

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reply usually concerns the use of techniques of inhibition of abnormal tone and

patterns, facilitation of more normal movement, and possibly stimulation in cas

muscle inactivity. +hese techniques should not be considered to be Bobath, andtherapists Bobath these techniques are Bobath. 6iven the diverse understandin

Concept, it seems important to as! this question: Is Bobath a relevant therapy

year 12227 It might be, but only if it is based on current scientific evidence, is ways to produce such evidence, and additionally an agreement to leave old idea

inhibition of spasticity, in the past. $e need to have the courage to challenge oand clinical reasoning. $ith this in mind, several of the assumptions underlying

Concept need to be re#evaluated. +he following questions are intended in part tthe current issues facing therapists.

*+ Is tone relevant7 Bobath proposed that the main reason for reduced functionfrom abnormalities of tone e.g. spasticity was thought to be due to abnormally

reflex activity and therefore could be inhibited. It is necessary to define what norder to understand any deviation from that norm.

one is the resistance o,,ered by m$scles to contin$o$s stretch -!rook

+++++++++ at complete rest a m$scle has not lost its tone altho$gh there is ne$rom$sc$lar acti3ity in it -!asma4an % De L$ca. */052

(ormal tone can be de,ined as a slight constant tension o, healthy m$sSch)ar7 % 8essell. *//*2

" state o, readiness -!ernstien. */192

+hese definitions suggest that tone comprises both neural %eg. 8roprioceptive r

arousal level of the C9) and non#neural %eg. visco#elastic properties of muscleCommensurate with this idea, any abnormal tone will also demonstrate neural

changes. /or many years, spasticity has been clearly defined by ;ance %&'(2) adependent increase in stretch reflexes with exaggerated tendon "er!s, resulting

hyperexcitability of the stretch reflex, as one component of the upper motor ne+he 4<9 which consists of positive symptoms %exaggeration phenomena such

extensor plantar response) and negative symptoms %functional deficits such as dexterity) was described by =ughlings#>ac!son %&'?@), and subsequently expla

%&'(() and Carr and hepherd %&''(). $hen viewed in this context, spasticity small component of the movement disorder, and in some cases can even be of

the client, e.g. standing. $e should conclude from the preceding discussion thahypertonia are not the same. pasticity is a part of hypertonia and of course th

velocity dependent hyperreflexia does not usually in itself explain the clients moand therefore simply reducing spasticity is not the solution for providing effectiv

intervention. +herapists can reduce hypertonia, but can they by handling inhibiterm inhibition was introduced by Bobath as a physiological explanation for the

on spasticity, based on the assumption that spasticity resulted from exaggerate

abnormal tonic reflexes and subsequently abnormal tonic reflex activity %<aystoAlthough on passive movement spasticity is shown to be present by evidence o

voluntary movement there is usually an inability to generate sufficient electrica

muscle %Ibrahim et al &''). Inhibition physiologically is defined as a decrease release, a way of moulding excitation and shaping the firing of action potentials

all levels of the C9. But suggesting inhibition is a physiological explanation for

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achieve by handling is not scientifically correct. +herapists are effecting change

and excitatory synapses simultaneously, but their inhibition also affects visco#

of muscle and by improving muscle length can gain a better biomechanical advefficient muscle action for the performance of functional tas!s. =andling via str

affect and reduce muscle spindle firing and resultant abnormal reflex activity, b

effect of spasticity to be obtained the therapist must enable the client to perforefficient functional activity. 

:+ <uscle wea!ness is secondary to the problems of abnormal tone. /or all theiBobaths considered that muscle wea!ness was a secondary problem to that of

the management of the neurologically impaired person. +hey assumed that whereduced the client would have near normal activity with which to function. +his

true, but any person will !now that disuse and lac! of opportunity to activate matrophy and wea!ness. <ore significantly, the person with an 4<9 lesion will m

some of their voluntary drive onto the motoneurone pools in the spinal cord resactivation of muscles for action, despite exhibiting hyperreflexia at rest. ven th

significant velocity dependent hyperreflexia encounter difficulty in generating su

activity, rather than being limited by an exaggeration of abnormal muscle activself#generated activity.

Decent evidence suggests that wea!ness is a problem for the neurologically imp

child %Bourbonnais E van der 9oven &'('* 6iuliani &''1). $hile therapists can

strength by the use of activity, repetition and weight bearing, it has been showappropriately, strengthening can improve function and does not increase spasti

;ight &''* 0amiano and Abel &''(). +his evidence suggests that therapists m

attention to the role of muscle strength and ways of improving it, for the rehabhabilitation of the neurologically impaired person, of course with the proviso tha

has sufficient muscle activity to participate in a strengthening regime.

;+ Bobath proposed that wor!ing for normal movement patterns would lead to

has been misinterpreted by some to the extent that it is thought that the persoimpairment can become normal if only they receive the right therapy and do

themselves spastic by overactivity or activity too early. /irstly, the C9 is highlyits organisation %/lament et al &''* hrsson et al 1222), therefore movement

automatically lead to function# the function must be practised in the correct conthere is no evidence to suggest that stopping a client from moving will stop the

spasticity. <y experience of wor!ing with <rs Bobath was that the therapists roperson function in the best way possible, helping them to counteract any unwa

tone, not to stop them moving. $hile certain activities are not encouraged in soof stopping a client from moving, especially if they are motivated to do so, cann

on financial, moral or scientific grounds.

Although learning movement patterns might be a part of the re#learning procesopportunity to practise functional, meaningful tas!s if therapy is to be effective

<+ Delated to this is the question of compensation. If the C9 is damaged, ther

be a compensation by other parts of the system, which can be either positive obe shaped by experience. Compensation means to ta!e the place of that which

understood in a variety of ways. /or example, the person with hemiplegia will hwith the sound side for the loss of function on the affected side if recovery is le

+he person with spastic diplegia will overuse their upper body and limbs to com

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lac! of useful activity of their lower limbs. +he critical questions to as! are the f

much of that compensation is necessary and how much can be avoided by train

body parts to function more effectively. It has long been part of the Bobath appuse of the less affected body parts manually during a therapy session to try and

affected body parts, e.g. =old bac! the sound arm to force the use of the affect

there is activity for the person to wor! with. /or the person with diplegia, it migactivating the legs without overuse of the upper body and arms e.g. to sit to st

pushing on the arms. upport for this idea is found in the recent wor! of +aub %+aub E $olf, &''), described as Constraint Induced +herapy, or forced use. -n

ideas underlying the Bobath Concept is that each person with a neurological lespotential for improved functional performance# this is one way that it might be

who meet the criteria for inclusion in such a regime. I very much doubt that theperson normal# if so, their C9 had the potential for recovery and they would h

anyway %whatever normal isF). +he C9 if damaged has to compensate, it is thguide the persons recovery so that they can achieve their maximal functional p

constraints of the damaged C9. =ow soon and how much is unclear, but +ardiethat a muscle must be stretched for G hours a day in order for length to be mai

receiving forced use therapy were trained for at least three hours a day. +he woand colleagues indicates that specifically training activity can enhance behaviou

reduce the loss of secondary areas around the infarct. /orced use of the lower training has also been shown to be effective in improving function for both adul

%=esse et al &''@* chindl et al, 1222). +he caveat is of course, that the persothis !ind of regime if they have sufficient activity to utilise. /orced use in clients

no activity may drive negative changes in the C9 and result in further loss of around the original lesion site.

+hese are only a few of the considerations for the Bobath therapist in the light

understanding of the control of movement and changes in the clinical presentat

essential to continuously read the available literature and to review our mode atherapy intervention. Carr and hepherd %&''() have contributed much by thei

encouragement that we read the literature and act upon it. +heir motor learninoptimise functional performance is of value in clients with a reasonable level of

about the less able client, and is the emphasis on training and biomechanics sube noted that their ideas for motor re#learning are predominantly based on dat

individuals. It is not !nown if those same principles can be directly applied to thimpaired person.

I would li!e to propose some factors that we might ta!e into account when planintervention programme.

<uscles need to be at the best length for activation. It is !nown that mugenerate the most efficient active force at a mid#length. /or this reason

would seem important to gain alignment %see /ig. &., <ayston 122&a). +involve muscle stretching to achieve length, perhaps we could call it ton

the "udicious use of equipment and or orthoses. ustained muscle stret

prepare for more efficient muscle activity by reducing the effect of hypemuscle spindles.

+he muscle needs sufficient activity to generate force for action. In the creduced drive onto the motoneurone pool, there might need to be stimu

muscle activity through the use of weight bearing, resistance, sensory s

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appropriate postures and patterns to enable the person to have a suffici

the training of functional tas!s. plinting and orthoses may also be indic

alignment, or a good weight#bearing base for improved proximal and tru%<ayston 122&b).

+his activity needs to be translated into functional, meaningful goals for person. Bobath advocated specific preparation for specific function, whic

way of stating this principle of translating activity into function.

+here needs to be opportunity for practise for learning re#learning to ocby the individual or with the help of carers.

6oals need to be realistic according to the clients potential and appropr

environment encountered during daily life.

+hese principles integrate with the main ideas of motor learning theory, which r

participation of the client. +his is not new. Bobath in the &'G2s stated that unl

or activate your patient in the way in which new activities are possible, you havall. o the handling techniques as such are only the very first step in treatmentvery important %Bobath, &'G?).

econdly, motor learning emphasises the need for practise, also advocated by B

perhaps less rigorously, by stressing the importance of home activities for the clearning requires that there be meaningful goals, relevant to the client. +his asp

learning is now important, and at the Bobath Centre goals are set in collaborat

and their family %at least for each child) and their achievement is monitored usoutcome measures.

In summary, the Bobath Concept states that each client has the potential for imand that we should wor! with our clients doing what wor!s the best. +his req

!nowledge of current scientific motor control and rehabilitation literature, and cideas in the past.