The evidence for the use of Bobath methods is reviewed. The reasons for the continued popularity of this approach despite its poor objective evidence base are then discussed.

1. Bobath
Physiotherapy
Evidence Based or Habit Based?
Roger Mepsted.
MCSP. PhD
roger_mepsted@hotmail.com

2. Key points
• UK Neurophysiotherapy is dominated
by the Bobath (BB) approach.
• Many very experienced UK therapists
have spent a lot of time learning &
using BB techniques and are
convinced that it is effective
• Yet BB is only recommended in one
national guideline and no reviews of
neuro rehabilitation.

3. Key points cont’d
• There is now strong evidence that other
techniques are more effective than BB.
• Several basic teachings/practices of BB
are now known to be incorrect.
• It is not possible to “evolve” BB by
adopting the ideas of others and calling
it BB.

4. Key Points cont’d
• How did this happen?
• What of the future?

5. Bobath in the UK
• Most methods used by UK therapists
are BB based, even when therapist
describe themselves as “eclectic” rather
than wholly BB. (Tyson & Shelly 2007).
• Fifty+ year tradition.

6. National Guidelines & Reviews.
• Not recommended by the following
national guidelines:-
– England, NZ, Canada, Australia &
Netherlands.
• But these guidelines DO recommend many
other rehab techniques.

7. AHA / ASA 2016
(the only guideline to recommend BB / NDT)
• The effectiveness of NDT/Bobath has not been
established but it “may be considered” as a
treatment option for mobility.
• This is their lowest classification of an acceptable
treatment. Their two highest recommendation
groups (“should be performed” and “reasonable to
perform”) contained many treatments for which
there is much better evidence.
• NDT/Bobath was not listed as an option for
arm/hand rehabilitation.

8. RCP 2016 Stroke Guidelines
• As with most guidelines, does not mention Bobath
at all.
• But they say:-
• If a treatment is not mentioned, then it was not
recommended and need not be funded.
• Therapists using unrecommended methods must
objectively review their options in the light of the
evidence supporting the recommended alternatives.
• Patients receiving such interventions should be
informed that it was outside mainstream practice.

9. The Effectiveness of the Bobath Concept in
Stroke Rehabilitation. What is the
Evidence? (Kollen et al. 2009)
N +VE for BB +VE Other
UL 7 0 3
LL 4 1 1
Balance 4 1 0
Dexterity 6 0 2
Mobility 5 1 3
ADLs 4 0 1
LoS 1 0 1
31 3 11

10. Conclusions
• Therapist should base their treatment
methods on evidence-based guidelines
rather than any named approach.
• Netherlands & Denmark Bobath no longer
taught.
• UK Bobath constantly evolving / compromise

11. NHS Annual Evidence Update on Stroke
Rehabilitation, Mobility (Tyson, 2009)
• “The strength of evidence that exercise and task-
specific functional training are effective while Bobath
is not indicates that a paradigm shift is needed within
UK Stroke physiotherapy if evidence based practice is
to be implemented; as has occurred in other countries
in Europe.”
• “It is increasingly difficult to justify the continued use
of the Bobath Concept and its associated treatment
techniques.”

12. Not just stroke.
Novak et al.(2013) A systematic review of interventions
for children with cerebral palsy: state of the evidence
• “no circumstances were the aims of Bobath could
not be more effectively achieved by other
techniques”
• “in the interests of doing the best for our patients
we need to stop permissive endorsement of
ineffective techniques and therefore cease all
provision of Bobath within traditional care”

13. Things said in defence of BB
• Patient centred problem solving approach.
• No approach is superior to any other.
• RCTs not appropriate.
• The “knowledge of the profession”.
• Constantly evolving / new books.
• Quality of movement

14. “Patient centred problem solving approach”
• But.
• So is respiratory / orthopaedic physio, OT, nursing
etc. They all involve holistic problem solving with an
individualised treatment plan. BB has no monopoly on
this
“No approach has been shown to superior to any other”
• But
• Research comparing treatment “concepts” or
“approaches” has indeed failed to distinguish between
them, but the notion of basing professional practice
on any concept or approach has been superseded by
the use of more effective specific interventions (as in
national guidelines).

15. RCTs not appropriate to physio
• BB is too complex and highly tuned to each patient.
• RCTs too simplistic to measure complex
interventions.
• BUT
• BBTA quote RCTs (some) on their website.
• RCTs do not measure the complexity of an
intervention, they only measures the significance of
change in outcomes. Lack of RCTs is the problem.
• Why do RCT with BB show the alternative are better?
If BB produced the best outcome they would show
that. It is all BB research.
• NICE & NHS demand best evidence.

16. The Knowledge of the Profession
• People would not do it if it did not work.
• Do not denigrate decades of experience and
knowledge.
• BUT
• How do we know what would happen if we
did a different Rx to Mrs Brown?
• Homeopaths and their patients know it
works.
• Hence need for RCTs.

17. Constantly Evolving
• Mayston (2006) (Chair ACPIN)
•
• “The Bobath Concept is now so diverse that it
can be difficult to know where it came from
and what it is”
• BB dilemma, stick to the original teachings or
evolve.
• “I do not support the idea that the Bobath
Concept can be developed and changed and
go under the name of Bobath.”

18. Constantly Evolving
• Damiano (2007) Pass the torch please!
• “..therapy principles and programs developed by
other innovative clinical researchers or scientists are
now considered an integral part of NDT or Bobath.
Why does this method have the right to pull in
everything that comes into its path like a supernova
that becomes a black hole?”
• “This may serve the therapists who have invested
their careers in this method, but it does not serve
the broader scientific community, the new generation
of therapists, or the parents.”

19. New Books
• The Bobath Concept in Adult Neurology.
Gjelsvik B. (2007).
• The Bobath Concept: Theory and
clinical practice in neurological
rehabilitation. Raine, Meadows, Lynch-
Ellerington. (2009).

21. Amanda Connell (2010) reviews
The Bobath Concept in Adult Neurology.
• "reads as a philosophical treatise as opposed to an
evidence based approach”
• "the use of research to support the discussion is
limited and biased"
• "reflecting the authors views that, in places,
contradicts research findings”
• "prescriptive in its approach with limited exploration of
clinical reasoning"

23. Review
• Mayston (2010) (president of ACPIN, 2010)
• “ I am not really sure that it is clear from the
book what the Bobath approach actually is”
• “often the prose turns into jargon”
• “leaving the reader with the impression that
Bobath is all about having the therapists
hands on the patient”
• "this book will do little to quell the critics; in
fact it will no doubt give them more fuel for
the fire".

24. Quality of movement
• Lennon (2006). Gait outcome following
outpatient physiotherapy based on the
Bobath concept in people post stroke.
• Only 9 (but cherry picked) stroke patients.
• Walk >10m + c 1.
• Advanced ++ BB trained Physios.
• Mean treatment daily or 2-3 /week for 17.5 weeks.
• Stop only when physio wanted.
• Motor analysis lab.

25. • Small trial but patients very
carefully picked for max. rehab
potential
• Optimise chances of showing
benefit.
• Main aim is to retrain gait.

26. Effect of BB therapy on Gait Quality
-10
0
10
20
30
40
50
60
70
Pelvic Tilt Hip ext. Hip flex. Knee flex. Dorsiflexion Plantarflexion
PeakDegrees
Pre Post

27. Effect of BB therapy on Gait Quality
-10
0
10
20
30
40
50
60
70
Pelvic Tilt Hip ext. Hip flex. Knee flex. Dorsiflexion Plantarflexion
PeakDegrees
Pre
Post
Normal

28. Conclusion
• Even under idealised conditions Bobath
does not effect the quality of gait.
• Even when gait was the main objective
these patients averaged less than 10%
of therapy time actually walking.

29. Some things that BB tutors teach
/ taught
• Tone is the main problem not strength.
• “proximal hamstrings”. Hamstrings can
pull more at one end than the other.
• Core stability, proximal before distal.

30. Core stability
• Big emphasis in BB, Based on their
neurodevelopmental model?
• BUT
• Certainly for stroke not appropriate as core
stability is the least effected.
• Trunk before arm in sitting, yet….

31. • In standing tasks it is the distal muscles that
are activated first. (Le Bozec & Bouisset 2004;
Misiaszek 2003; Mercer & Sahrmann 1999).
• This makes sense as they are the base of
support.
• Cannot get further away from the trunk. So
why spend so much time on core stability?
• Carr & Shepherd (2008). “ the BB tutors
have a poor understanding of biomechanics
and neuro-anatomy”.

32. Summary
• Some very important Neurophysios are highly critical
of Bobath.
• Very popular “approach”, but not supported by
guidelines or reviews.
• Where is the independent/objective support for BB?
• The BB dilemma. (evolve or remain)
• Senior staff are most likely to have had no
alternative training and will influence junior staff.
• Sometimes strong peer pressure to attend Bobath
courses.

33. Why do physios follow BB
• The Guru effect.
• Want to learn complex techniques.
• Want to be hands on.
• Traditionally little understanding or training in
research.
• We happily learn the technique but don’t ask
for the evidence that it works.

34. The Future
• The Netherlands model?
• Let tutors evolve BB and be the main source
of training.
• BB should just stick to traditional BB.
• We need to be brave in our review of what
we do. (Passive manual stretching:- Cochrane, NICE)
• We need some better options, eg. Courses
on the things that ARE recommended in
guidelines.

35. Final thought
• ”It's important to remember we were all
physiotherapists first before we studied
Bobath and it should be used or discarded in
line with the evidence base like any other
treatment modality.” Chris, iCSP 2015.
• See iCSP 2015a & 2015b discussions.
• See Sarah Tyson’s Bobath blog. There is a
very good section with links to therapy
options with a good evidence base.

36. References
AHA / ASA (2016) Guidelines for Adult Stroke Rehabilitation and Recovery. A Guideline
for Healthcare Professionals, 2016. Available at :-
http://stroke.ahajournals.org/content/early/2016/05/04/STR.0000000000000098.full.
pdf+html.
Bozec & Bouisset (2004) Does postural chain mobility influence muscular control in
sitting ramp pushed? Exp Brain Res 158 427-437.
Damiano (2007) Pass the torch, please! Developmental Medicine & Child Neurology 49
723–723.
Carr & Shepherd (2008) Science-Based Neurological Rehabilitation. St James’ Hospital,
Dublin.
Connell (2010) Review of the Bobath Concept in Adult Neurology. Physiotherapy 97
p360.

37. iCSP (2015a) Novak casts doubt on efficacy of Bobath. Should we embrace or ignore
it? Available at:- http://www.csp.org.uk/icsp/topics/novak-review-casts-doubt-
efficacy-bobath-should-we-embrace-or-ignore-it
iCSP (2015b) The rationale and evidence for Bobath and neurological physio. Available
at:- http://www.csp.org.uk/icsp/topics/rationale-evidence-bobath-neurological-physio
Kollen et al. (2009) The Effectiveness of the Bobath Concept in
Stroke Rehabilitation. What is the Evidence? Stroke 40 (4) e89-97. Available at-
http://stroke.ahajournals.org/content/strokeaha/early/2009/01/29/STROKEAHA.108.5
33828.full.pdf
Lennon et al. (2006) Gait outcome following outpatient physiotherapy based on the
Bobath concept in people post stroke. Disability and Rehabilitation 28 873-881.
Mayston (2006) Letter to the editor RAINE: A RESPONSE. Physiotherapy Research
International 11 183-186.
Mayston (2010) Review of The Bobath Concept: Theory and clinical practice in
neurological rehabilitation. Synapse Spring 2010.
Mercer & Sahrmann (1999) Postural synergies associated with a stepping
task. Physical Therapy 79 1142-1152.
Misiaszek (2003) Early activation of arm and leg muscles following pulls to
the waist during walking. Exp Brain Res. 151 318-329.

38. Novak et al. (2013) A systematic review of interventions for children with
cerebral palsy: state of the evidence. Developmental Medicine & Child
Neurology 2013, 55: 885–910. Available at :-
http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pdf
RCP (2016) National Clinical Guideline for Stroke, fifth edition. 1.8 Treatments
not mentioned in this guideline. Available at:-
https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-
National-Clinical-Guideline-for-Stroke-5t-(1).aspx
Tyson, Selley (2007) The effect of perceived adherence to the Bobath concept
on physiotherapists' choice of intervention used to treat postural control after
stroke Disabil Rehabil. 29(5):395-401.
Tyson (2009) 2009 Annual Evidence Update on Stroke rehabilitation – Mobility,
NHS Evidence. Available at :-http://usir.salford.ac.uk/2740/
Tyson (2016) When EBP meets neurological physiotherapy… Available at :-
https://sarahtphysioblog.wordpress.com/author/sarahtysonblog/