The BOBATH Concept - Theoretical Assumptions

Preamble

The need to develop a set of statements which would clarify the current theoretical assumptions underlying the Bobath concept was expressed at the 12th Annual General Meeting of IBITA in 1996. At the 14th Annual General Meeting of IBITA, held in September 1998, the members established a working group which was charged with this task - specifically as related to the rehabilitation of adults with neurological disorders. The group was centered in the Netherlands, where a theoretical framework was already being developed 1. Whilst the group was working towards this goal, they became aware that the Theory Committee of the Neurodevelopmental Treatment Association in North America had been working towards the same goal, and had already put forward provisional statements 2,3 which were very similar to ours. The IBITA working group felt that it would be to the advantage of the Bobath/NDT approach worldwide if the two sets of statements agreed in their main principles, whilst still allowing scope for the inclusion of additional statements more specific to the goals of IBITA. At the 15th Annual General Meeting of IBITA, in 1999, the members adopted the proposed statements as a working document, with a similar format to that of the NDTA 2,3.

IBITA is most grateful to the NDTA for their permission to incorporate several clauses which are clearly recognizable as having been derived from the original NDTA document, and which have been fully referenced below. The work of the NDTA working group is acknowledged and appreciated. Other clauses reflect the work of the IBITA working group and are felt to be specifically relevant to the rehabilitation of adults with neurological disorders.

THE BOBATH CONCEPT

A Theoretical Framework

The Bobath concept is an approach to therapy and rehabilitation which was developed for individuals with pathophysiology of the central nervous system. The approach is used in the treatment of adults, children and infants. Originating in the work of Berta and Karel Bobath and initially developed upon clinical experience, the concept was based upon models of motor control and neuroscience available at that time. This bio-psycho- social approach has evolved over more than fifty years and modern movement science underpins the rationale for current practice.

The theoretical framework of the approach continues to evolve and be enriched as new information in neuroscience and movement science emerges.

Statement of philosophy

The Bobath concept is a problem-solving approach to the assessment and treatment of individuals with disturbances of function, movement and tone due to a lesion of the central nervous system.

The person is evaluated in terms of total function within changing environments. The intervention process is individualised to address bio-psycho-social needs, including the preventive and promotive aspects. An interactive process between the involved individual, the interdisciplinary team and relevant family and/or caregivers leads to appropriate intervention throughout the 24-hour day.

The goal of intervention is to optimise function. The ongoing process of assessment and treatment is directed towards those impairments interfering with function as well as towards integrating improved control into participation in daily life. During treatment the therapist tries to optimise postural and movement strategies in order to improve efficiency.

Treatment is characterised by seeking solutions for those aspects of motor behaviour which interfere with the successful performance of an activity. It involves the active participation of the individual, using specific handling by the therapist which is modified and gradually withdrawn according to the individual’s response, in order to achieve independence. The motor task and the environment are structured according to need.

Key theoretical statements

• Organization of motor behaviour

Human motor behaviour is based upon continuous interaction between the individual, the environment and the task 4. The individual comprises many sub-systems which are interactive and interdependent 5,6. These sub-systems are plastic and adaptive to both internal and external changes 6. The individual’s environment includes the immediate and extended family and the society in which the individual lives and functions 2,7. In the acquisition of functional motor skills, the individual focuses on the goal rather than the specific movement components of the task 4.

Proficient human motor function allows the individual to limit and combine movements selectively into the desired functional activity under a wide variety of environmental conditions 8. Learning and adaptation of motor skills involve a process associated with practice and experience 9. Skill acquisition and loss continues across the lifespan 10.

• Movement dysfunction

The effects of disease on human motor behaviour are classified by the World Health Organization"s ICF (22-05-2001) into changes in body structure and function, activities and participation 11.

Individuals with motor control problems resulting from central nervous system pathology present with varying changes in body structure and function. These changes may limit the person’s ability to function. In turn, inability to function and the adoption of poorly adapted or inappropriate behavioural strategies may result in secondary changes and further decreased function 3.

• Intervention

The intervention process begins with the assessment of the individual’s functional performance 3.

The active involvement of the individual is essential in determining needs and expectations. Analytical problem-solving is used in developing a treatment plan 3. Treatment focuses on increasing function by building upon the individual’s strengths whilst addressing underlying factors. Therapeutic handling is one of many strategies which are utilised to help the individual achieve his/her functional goals 2.

In assisting the individual to re-acquire functional motor skills following central nervous system pathology, Bobath-trained therapists address both the specific movement components of the task and the functional activity in order to achieve goals 3.

Clinical decision making is a process which involves assessment, analysis and interpretation of assessment data, formulation of short- and long-term goals, development of a treatment plan, implementation of this plan and re-evaluation of the individual in order to establish the outcome of treatment. Reassessment takes place throughout the treatment programme to enable the therapist and the individual to evaluate the response to treatment and adjust goals and treatment strategies accordingly.

These statements each represent a larger group of theoretical assumptions underlying the Bobath Concept. The concept will continue to evolve as these assumptions are modified over time 3. The current statements represent current theories, the validity of which must be evaluated through research and experience.

Notes:

The term neurodevelopmental treatment (NDT) may be used as a synonym for the Bobath concept. Developmental aspects play a lesser role in understanding normal adult movement.

This is a working document and will be reviewed from time to time as new knowledge becomes available.

References

BaumGarten Advies Begeleiding en Management (1999) Functie- Opleidingsprofiel Therapeut met NDT-aantekening

Neurodevelopmental treatment philosophy (draft document), NDTA Inc. 1998.

NDT - Theoretical Overview. NDTA Inc. 1998

Shumway-Cook A, Woollacott MH (2nd edition, 2001) Motor control, theory and practical applications. Baltimore, Williams and Wilkins, , 40.pp. 1-2, 24-25

Horak FB (1991) Assumptions underlying motor control for neurologic rehabilitation, in: Contemporary management of motor control problems, Proceedings of the II Step Conference, Alexandria VA, APTA (Foundation for Physical Therapy).

Giuliani CA (1991) Theories of motor control: new concepts for physical therapists, in: Contemporary management of motor control problems, Proceedings of the II Step Conference, Alexandria VA, APTA (Foundation for Physical Therapy).

World Health Organisation (1981) Disability, prevention and rehabilitation, Report of the WHO Expert Committee on Disability Prevention and Rehabilitation, WHO Technical Report No. 668, Geneva, WHO.

Schmidt RA (1991) Motor learning principles for physical therapy, in: Contemporary management of motor control problems, Proceedings of the II Step Conference, Alexandria VA, APTA (Foundation for Physical Therapy).

Schmidt RA (1988) Motor control and learning: a behavioural emphasis (2nd ed), Champaign ILL, Human Kinetics Publishers Inc. p. 346.

VanSant AF (1991) Life-span motor development, in: Contemporary management of motor control problems, Proceedings of the II Step Conference, Alexandria VA, APTA (Foundation for Physical Therapy).

World Health Organisation, Geneva (2001) ICF - International Classification of Functioning, Disability and Health. Endorsed by the fifty-fourth World Health Assembly for international use on 22 May 2001. (Resolution WHA54,21)

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Dr Karel Bobath, a physician, and Berta Bobath, a physiotherapist, were born in Berlin and moved to England during World War 2. There they developed their approach to the evaluation and treatment of children and adults with lesions of the central nervous system. The first centre opened in 1951 and there the first course was conducted. Since then many thousands of therapists and doctors have been trained worldwide. The Bobaths died in 1991.