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The Bobath Concept Today Re-printed with permission Margaret J. Mayston PhD,
MCSP Any discussion of the Bobath Concept requires a common
understanding of what the Bobath Concept is. In an interview almost
twenty years ago, Bobath explained it this way: '... A whole new way
of thinking, observing, interpreting what the patient is doing, then
adjusting what we do in the way of techniques - to see and feel what
is necessary, possible for them to achieve. We do not teach movvements,
we make them possible ...' (Bobath, 1981). It was also made clear that
Bobath was not a method or technique, not limiting, but fluid; was not
rigid but changing, and still changing. The Concept can be summarised
as follows: It is primarily a way of observing, analysing and interpreting
task performance. This also includes the assessment of the client's
potential, which was considered to be that task or those activities
which could be performed by the person with a little help, and therefore
possible for that person to achieve independently where possible. Of
course the Concept also involves the use of various techniques, and
Bobath always advocated that the therapist should 'do what works the
best' (Bobath, 1978). In the present day, this should mean, that therapy
is When therapists attending the paediatric course at the
Bobath Centre are asked what Bobath is, the reply usually concerns the use of
techniques of inhibition of abnormal tone and movement patterns, facilitation
of more normal movement, and possibly stimulation in cases of hypotonia or
muscle inactivity. These techniques should not be considered to be Bobath, and
yet for most therapists these techniques are Bobath. Given the diverse
understanding of the Bobath Concept, it seems important to ask this question:
Is Bobath a relevant therapy approach in the year 2000? It might be: but only
if it is based on current scientific evidence; is actively finding ways to
produce such evidence; and additionally an agreement to leave old ideas, such
as the inhibition of spasticity, in the past. We need to have the courage to
challenge our current practice and clinical reasoning. With this in mind,
several of the assumptions underlying the Bobath Concept need to be
re-evaluated. The following questions are intended in part to address some of
the current issues facing therapists. Is tone relevant? Bobath proposed that the main reason
for reduced functional ability resulted from abnorma-lities of tone e.g.
spasticity was thought to be due to abnormally increased tonic reflex activity
and therefore could be inhibited. It is necessary to define what normal tone is
in order to understand any deviation from that norm. 'Tone is the resistance
offered by muscles to continuous stretch' (Brooks 1986) '...at complete rest a
muscle has not lost its tone although there is no neuromuscular activity in if
(Basmajan & De Luca, 1985). Normal tone can be defined as a slight constant
tension of healthy muscles (Kandel, Schwarz and Jessell, 1991). "A state
of readiness' (Bemstien 1967). These definitions suggest that tone comprises both
neural (e.g. Proprioceptive reflexes, and arousal level of the CNS) and
non-neural (e.g. visco-elastic properties of muscle) components. Commensurate
with this idea, any abnormal tone will also demonstrate neural and non-neural
changes. For many years, spasticity has been clearly defined by Lance (1980) as
a velocity-dependent increase in stretch reflexes with exaggerated tendon
jerks, resulting from hyperexcitability of the stretch reflex, as one component
of the upper motor neurone syndrome. The UMN which consists of positive
symptoms (exaggeration phenomena such as hyperreflexia, extensor plantar
response) and negative symptoms (functional deficits such as weakness, loss of
dexterity) was described by Hughlings-Jackson (1954), and subsequently
explained by Burke (1988) and Carr and Shepherd (1998). When viewed in this
context, spasticity is often only a small component of the movement disorder,
and in some cases can even be of functional value to the client, e.g. standing.
We should conclude from the preceding discussion that spasticity and bypertonia
are not the same. Spasticity is a part of hypertonia and of course they
co-exist, but velocity dependent hyperreflexia does not usually in itself
explain the clients movement disorder, and therefore simply reducing spasticity
is not the solution for providing effective, evidence-based intervention. Therapists can reduce hypertonia, but can they by handling
inhibit spasticity? The term inhibition was intro-duced by Bobath as
a physiological explanation for the effect of handling on spasticity,
based on the assump-tion that spasticity resulted from exaggerated/released,
abnormal tonic reflexes and subsequently abnormal tonic reflex activity
(Mayston 2001a). Although on passive movement spasticity is shown to
be present by evidence of hyperreflexia, on voluntary movement there
is usually an inability to generate sufficient electri-cal activity
in the muscle (lbrahim et al 1993). Inhibition physiologically is defined
as a decrease in transmit-ter release, a way of moulding excitation
and shaping the firing of action potentials, and is present at all Muscle weakness is secondary to the problems of
abnormal tone. For all their working life, the Bobaths considered
that muscle weakness was a secondary problem to that of abnormal tone in the
management of the neurologically impaired person. They assumed that when
hyper-tonia was reduced the client would have near normal activity with which
to function. This may be potentially true, but any person will know that disuse
and lack of opportunity to activate muscles results in atrophy and weakness.
More significantly, the person with an UMN lesion will most likely lose some of
their voluntary drive onto the motoneurone pools in the spinal cord resulting
in a lack of activation of muscles for action, despite exhibiting hyperreflexia
at rest. Even those with significant velocity dependent hyperreflexia
encoun-ter difficulty in generating sufficient voluntary activity, rather than
being limited by an exaggeration of abnormal muscle activity on attempts at
self-generated activity. Recent evidence suggests that weakness is a problem for
the neurologically impaired adult and child (Bourbonnais & van der
Noven 1989; Oiuliani 1992). While therapists can work to increase strength
by the use of activity, repetition and weight bearing, it has been shown
that when used appropriately, strengthening can improve function and
does not increase spasticity (Miller and Light 1997; Damiano and Abel
1998). This Bobath proposed that working for normal movement
patterns would lead to function. "This idea has been misinterpreted by
some to the extent that it is thought that the person with neurological
impairment can become normal if only they receive the 'right' therapy and do
not make themselves spastic by overactivity or activity too early. Firstly, the
CNS is highly task oriented in its organisation (Flament et al 1993; Ehrsson et
al 2000), therefore movement patterns will not automatically lead to function –
the function must be practised in the correct context. Secondly, there is no
evidence to suggest that stopping a client from moving will stop the
development of spasticity. My experience of working with Mrs. Bobath was that
the therapists role was to help the person function in the best way possible,
helping them to counteract any unwanted increase in tone, not to stop them
moving. While certain activities are not encouraged in some cases, the idea of
stopping a client from moving, especially if they are motivated to do so,
cannot be supported on financial, moral or scientific grounds. Although learning
movement patterns might be a part of the re-learning process, clients need the
opportunity to practise functional, meaningful tasks if therapy is to be
effective. Related to this question of compensation. If the CNS
is damaged, there will of necessity be a compensation by other parts
of the system, which can be either positive or negative, and can be
shaped by experience. Compensation means to take the place of that which
is lost, but is understood in a variety of ways. For example, the person
With hemiplegia will have to compensate with the sound side for the
loss of function on the affected side if recovery is less than optimal.
The person with spastic diplegia will ovenise their upper body and limbs
to compensate for the lack of useful activity of their lower limbs.
The critical questions to ask are the following: how much of that compensation
is necessary and how much can be avoided by training the affected body
parts to function more effectively. It has long been part of the Bobath
approach to restrain use of the less affected body parts manually during
a therapy session to try and activate the affected body parts, e.g.
hold back the sound arm to force the use of the affected arm, providing
there is activity for the person to work with. For the person with diplegia,
it might mean activating the legs without overuse of the upper body
and arms e.g. to sit to stand without pushing on the arms. Support for
this idea is found in the recent work of Taub (Taub et aJ 1993; Taub
and Wolf 1997), described as Constraint Induced Therapy, or forced use.
One of the basic ideas underlying the Bobath Concept is that each person
with a neurological lesion has the potential for improved functional
performance - this is one way that it might be "These are only a few of the considerations for
the Bobath therapist in the light of changes in our understan-ding of the
control of movement and changes in the clinical presentation of clients. It is
essential to continuously read the available literature and to review our mode
and frequency of therapy intervention. Carr and Shepherd (1998) have
contributed much by their aggressive encouragement that we read the literature
and act upon it. Their motor learning approach to optimise functional
performance is of value in clients with a reasonable level of ability. But what
about the less able client, and is the emphasis on training and bio-mechanics
sufficient? It should be noted thattheir ideas for motor re-learning are
predominantly based on data from healthy individuals. It is not known if those
same principles can be directly applied to the neurolo-gically impaired person. I would like to propose some factors that we might
take into account when planning an intervention programme: ·
Muscles need to
be at the best length for activation. It is known that muscles generate the
most efficient active force at a mid-length. For this reason alone it would
seem important to gain alignment. This may involve muscle stretching to achieve
length, perhaps we could call it tone reduction, the judicious use of equipment
and/or orthoses. Sustained muscle stretch may also prepare for more efficient
muscle activity by reducing the effect of hyper-sensitive muscle spindles. ·
The muscle needs
sufficient activity to generate force for action. In the case of reduced drive
onto the motoneurone pool, there might need to be stimulation of muscle
activity through the use of weight bearing, resistance, sensory stimulation in
appropriate postures and patterns to enable the person to have a sufficient
basis for the training of functional tasks. Splinting and orthoses may also be
indicated to gain alignment, or a good weight-bearing base for improved
proximal and truncal activity (Mayston 2001b). ·
This activity
needs to be translated into functional, meaningful goals for that person.
Bobath advocated specific preparation for specific function, which is another
way of staling this principle of translating activity into function. There
needs to be opportunity for practise for leaming/re-leaming to occur, either by
the individual or with the help of carers. ·
Goals need to be
realistic according to the client's potential and appropriate to the
environment encountered during daily life. These principles integrate with the main ideas of
motor learning theory, which requires the active participa-tion of the client.
This is not new. Bobath in the 1960s stated that 'unless you stimulate or
activate your patient in the way in which new activities are possible, you have
done nothing at all. So the handling tech-niques as such are only the very
first step in treatment, though they are very important' (Bobath, 1965). Secondly, motor learning emphasises the need for
practise, also advocated by Bobath though perhaps less rigorously, by stressing
the importance of home activities for the client. Thirdly, learning requires
that there be meaningful goals, relevant to the client. This aspect of motor
learning is now important, and at the Bobath Centre goals are set in
collaboration with the client and their family (at least for each child) and
their achievement is monitored using a variety of outcome measures. ln summary, the
Bobath Concept states that each client has the potential for improved
function and that we should work with our clients doing 'what works
the best'. This requires an ongoing knowledge of current scientific
motor control and rehabilitation literature, and courage to put old
ideas in the past. Of course it is important to have a Centre which
honours the contribution made by Bobath to the progression of the References Basmajan, J.V.
and De Luca, Carlo J. (1985) Muscles Alive. Their Functions Revealed by Etectromyography. Williams and Wilkins Chapter 10 and II. Bernstein, N.
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(1986) Neural Basis of Motor Control.
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M.F. (1998) Functional outcomes of
strength training in spastic cerebral palsy. Archives of Physical Medicine
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stroke patients: A national survey. Physiotherapy 86:69-80. Ehrsson, H.H., Fagergren, A., Jonsson, T„ Westling,
G., Johannsson, R.S., Forssberg, H. (2000) Cortical
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in Children Ed. Forssberg, H., Hirschfeld, H. 247-254. Hesse, S„ Bertelt, C.H.,
Schaffrin, A„ Maiezik, M„ Mauritz, K.H. (1994) Restoration of gait in non-ambulatory patients by treadmill training
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(1993) Stretch-induced electromyographic
activity and torque in spastic elbow muscles. Brain; 116: 971-989. Lance, J.W. (1980) Symposium
synopsis In: Spasticity: disordered motor control. Ed. Feidman, R.G.,
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485-495,1980. Mayston, MJ. (2001 a) Setting the scene In: Edwards, S. Ed.
Neurological Physiotherapy- a Problem Solving Approach 2nd edition. Churchill
Livingstone (in press). Mayston, MJ. (2001b) People with cerebral palsy: effects of and perspectives for therapy.
Neural Plasticity (in press). Miller, GJ.T. and Light,
K.E. (1997) Strength training in spastic
hemiparesis: should it be avoided? Neurorehabilitation, 9, 17-28. Nudo, RJ., Wise, B.M.,
SiFuentes, P., Milliken, G.W. (1996) Neural
substrates for the effects of rehabilitative training on motor recovery after
ischaemic infant. Science 272:1791-1794. Schindi, M.R., Forster,
C., Kern, H., Hesse, S. (1988) Treadmill
training with partial body weight support in nonambulatory patients with
cerebral palsy. Archives of Physical Medicine and Rehabilitation; 81:
301-306. Tardieu, C., Lespargot, A., Tabary, C.,
Bret, MJ). (1988) For how long must the soleus be stretched
each day to prevent contracture? Developmental Medicine Child Neurology
30:31-10. Taub, E., Miller, N.E.,
Novack, T.A. (1993)A technique for
improving chronic motor deficit after stroke. Archives of Physical Medicine
and Rehabilitation, 74, 347-354. Taub, E. and Wolf, S.L.
(1997) Constraint induced techniques to
facilitate upper extremity use in stroke patients. Topics in Stroke
Rehabilitation 3: 38-61. Dr.
Mayston gained her Diploma
in Physiotherapy in Melbourne, Australia in 1973, and following a completion
of a conversion course was awarded a Bachelor of Applied Science (Physiotherapy)
in 1981. She has extensive clinical experience, initially working at
the Royal Children's Hospital, Melbourne and then as a senior Physiotherapist
at the Bobath Centre. In 1990 she gained her Master of Science degree
in Human and Applied Physiology from King's College, London, whilst
continuing to work part-time as a senior clinician at In 1996 she was awarded a Doctor of Philosophy from
University College London. Her PhD focussed on two main areas, that of the
mechanisms underlying mirror movements in development and pathology, and the
mechanisms underlying co-contraction of antagonistic muscle pairs in
development and pathology. Dr. Mayston has two main areas of research currently,
firstly the changes in the control of hand movements during development and in
various pathologies, and secondly the neural control of antagonistic muscles
pairs, both in healthy children and adults and in children with cerebral palsy.
A variety of neurophysiological techniques are used including EMG, transcranial
magnetic stimulation, cutaneomuscular reflex and stretch reflex testing in
addition to cross-correlation analysis of EMG signals. Dr. Mayston's
work has been published extensively. |