THE HISTORY OF THE BOBATH CONCEPT THE HISTORY OF THE

The Bobath Concept • The aim of this talk………. ‐ To look at the history of the Bobath Concept and how it has developed ‐ To review how current evidence supports our clinical practice of the Bobath Concept ‐ To look at what the future may hold

The Bobath Concept – The Past , Present and the Future Janice Champion

The History of the Bobath Concept o Karel born Berlin 1906, Berta born Berlin 1907 o Karel studied medicine – a family tradition. o Berta trained at the Anna Hermann School of Gymnastics and Dance, learning about Normal Movement, exercise and relaxation o Came to London in 1930`s and married in 1941 o Concept “started” in 1945 when asked to see a patient in the Homeopathic Hospital.

Janice Champion 2010


The History of the Bobath Concept • In 1945, Simon Elwes, a famous portrait painter suffered a near‐death stroke which paralyzed the right half of both his face and body, including his painting hand. He spent two years in hospital recuperating and receiving treatment from renowned physiotherapist Berta Bobath Ref Wikipedia 2010


The History of the Bobath Concept

The History of the Bobath Concept

o Together they developed the Bobath Concept for the treatment of Children with Cerebral Palsy and adults with neurological conditions. o From 1958, they travelled extensively, teaching and training tutors throughout the world. They both received many honours for their pioneering and innovative work. o Their clinical practice was the basis for the development of the Concept which represented a fundamental change in the treatments of the time

• 1948 – British Journal of Physical Medicine published “A new treatment of lesions of the upper motor neurone”‐ Berta’s first publication • 1957 – the Western Cerebral Palsy Centre opened in London • The Bobath Centre in Netherhall Gardens opened in 1975. Now based in East Finchley treating children and adults • They died 20th January 1991 just before their 50th Wedding Anniversary



Clinical Observations

The Bobath Concept

• movement or change in position of proximal limb regions leads to alteration of tone • treating the leg affects the arm • automatic postural adjustments precede and form the basis for volitional movement

..is an holistic approach to the treatment of damage to the CNS which has caused a deviation from the “normal” based on:‐ # analysis of normal movement # analysis of the deviation from normal # appropriate use of treatment techniques

These observations were explained on the basis of the animal neurophysiology available ( Magnus, Sherrington, Walshe) Janice Champion 2010


IBITA

What is the Bobath Concept?

• In 1983 a small group of experienced Bobath Instructors proposed establishing an International Association to facilitate the development of the Bobath Concept and the delivery of standardized Bobath courses. • With the approval of the Bobaths the first meeting took place in London in 1984. • Since 1996 it has been known as IBITA ‐ International Bobath Instructors Training Association www.ibita.org

IBITA 2004 Raine 2006



The Bobath Concept

The Present • Developments in the Bobath Concept since the death of Dr and Mrs Bobath have been disseminated through teaching of postgraduate courses worldwide …..BUT little information has been published on the evolving theoretical framework and the subsequent influence on clinical practice (Graham 2009) ……This has resulted in lack of clarity regarding the theory behind the concept (Lennon 1996) ……and in clinical studies not reflecting the current practice (Brock 2002)



The Past and the Future

The Bobath Concept of Today

Mrs Bobath stated “the Bobath Concept is farreaching and open, it enables us to go on learning and to follow continuous scientific development” Bobath 1984 It can be used with individuals of any age, regardless of the severity of the CNS lesion Janice Champion 2010

The Bobath Concept of Today The integration of many systems and subsystems produce the required output to achieve the desired function. Knowledge of how different areas communicate helps our understanding of the control of movement


Systems model of motor control


Multiple Systems Musculoskeletal

Neurological

Tone Co-ordination Weakness Patterns

Attention Orientation Judgement Planning

Cognitive

Sensory

Proprioception Cutaneous sensitivity (discrimination) Visual Vestibular Visuospatial Body schema Midline orientation


Perceptual

Systems Model of Motor Control

Originally developed by Nikolai Bernstein – The nervous system groups together “degrees of freedom” Movement is not purely due to neural activity, but the biomechanics of the body and inter‐actions with the environment (Bernstein1967) Chiel,H J. 2009


Muscle length Joint range Strength Age related changes


Ref: Shumway Cook and Woollacott 2007

Ref: Shumway Cook and Woollacott 2007

Task

This can be linked with the International Classification of Functioning (ICF)

Task

M

Individual

Environment

Movement

Individual

Environment

Cognition I

WHO 2002 Perception


The Bobath Concept

Action


The Bobath Concept o “Without information, (sensory input) there is no control, no learning, no change, no improvement.” Mulder and Hostenbach 2003 o Therapy aims to “utilize afferent input to re-

educate the individual’s internal reference systems to enable the person to have more movement choices and greater efficiency of movement” Graham 2009 Gjelsvik 2008




Neuromuscular plasticity • Occurs in response ‐ to trauma ‐ to changes in the internal and external environment ‐ to sensorimotor learning and experience ….is the reason we treat patients!!!!



Cortical Plasticity

Effects of Environment on Dendritic Branching Johansson 2000

• Animals reared or housed as adults in enriched environments develop more dendritic branching and more synapses / neurons and have higher gene

• Increased dendritic branching

expression for trophic factors than animals housed individually or in small groups in standard cages Johansson 2000

• Similar changes can be induced during learning

• Increased number of synapses / neuron A = Standard environment B = Enriched environment



Neuromuscular plasticity

Muscular Plasticity

• Recovery is an active time‐dependent process that includes plasticity and reorganization of brain structures, as well as adaptive changes in musculoskeletal, cardiovascular and respiratory systems

oOccurs in response to ‐ Neural pathology ‐ Changes in muscle length ‐ Changes in muscle use

Gordon 2005




Motor Learning • Motor learning refers to the permanent change in an individual’s motor performance resulting from practice or intervention Wishart 2000 • Motor learning principles help therapists identify how to manipulate the individual, the task and the environment to influence the long term neuroplastic changes that will promote motor performance Raine 2009



Motor Learning • Practice and variability becomes very important • Motor skill training as opposed to motor activity promotes motor learning‐induced structural plasticity, which is reflected by improved functional outcome.

Mrs Bobath said…… • A passive recipient will never be an active learner and will never get the most out of rehabilitation . The active learner needs to be engaged, challenged and involved in meaningful task practice Bobath 1990

(Biernaskie and Corbett 2001) Janice Champion 2010



Clinical Reasoning in Neurorehabilitation In order to use a problem solving approach for the treatment of people with neurological disability, it is necessary to have an understanding of the control of movement, the result of damage to different areas of the CNS, neuroplasticity and ways to promote skill learning. (Mayston 2002)



Human Movement

Berta Bobath said

• The impact of the movement dysfunction is unique to the individual and influenced by experiences prior as well as post lesion Graham 2009

‘See what you see , and not what you think you see” Cited in Schleichkorn 1992 p48



Human Movement • Postural control – the ability to control the body’s position in space for the dual purposes of stability and orientation. Shumway‐Cook and Woollacott 2007 • Postural control and selective movement allow the co‐ordination of patterns of movement. Gjelsvik 2008 • Patterns such as walking, reach to grasp, sit to stand etc. give human movement its efficiency and although similar between individuals, are dynamic, changeable and vary in relation to the individual, the environment and the goal. Janice Champion 2010

Movement dysfunction (Problems)

Intervention

Outcome

Clinical Reasoning The Bobath Concept Janice Champion 2010

The Past, Present and the Future Movement dysfunction (Problems)

CNS pathology Musculoskeletal changes Learned movement strategies

Clinical Reasoning

• The development of sound clinical reasoning skills & the use of facilitation techniques is fundamental to the Bobath concept & is based on growing knowledge & experience Bobath, 1990

The Bobath Concept Janice Champion 2010

What is facilitation? o “the use of afferent information to effect improvements in motor performance” Graham 2009 o ‐ part of an active learning process in which the individual is enabled to actively overcome inertia and initiate, continue or complete a functional task o It allows the patient to experience more efficient movement and success in task achievement – success is required for motor learning


Clinical Practice • Make it possible ( realignment, information)

• Make it necessary (demands)

• Let it happen ( activity)

Facilitation

Lynne Fletcher – personal communication / IBITA website. Gjelsvik 2008 Janice Champion 2010


Clinical Practice • "......... 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 movements, we make them possible......." (Bobath, 1981)

The Future…… • We need to be aware of new technologies and adjuncts to treatment ‐ ‐ ‐ ‐

Robotics and computer assisted therapy Strengthening / treadmills Electrical stimulation / FES. Cortical excitation / Transcranial Magnetic stimulation (TMS)



Mental Imagery / Practice

The Future

Mental practice –the rehearsal of a task without overt physical activity. Has shown to have a positive learning effect. Useful when limitations of time, energy, or when physical practice outside therapy could be detrimental. Raine 2009 # Efficacy of motor imagery in post‐stroke rehabilitation : a systematic review by Andrea Zimmermann‐Schlatter et al 2008 Journal of NeuroEngineering and Rehabilitation 5.8 ( Can be accessed via BioMed Central)

The Bobath Concept is as effective as any other therapy. There is no difference between Bobath and other therapies (Barreca 2003; Lincoln 1999; Luke 2004; Paci 2003; van Peppen 2004; Van Vliet 2005)



The Present and the Future

The Future

• At present, the Bobath Approach, based on neurophysiological principles, remains probably the most widely used approach in Sweden, Australia and the UK. Pollock 2007

BUT…..we must be proactive Janice Champion 2010

• As physiotherapists involved in the

treatment of movement dysfunction we need ... ‐ to be constantly developing our clinical reasoning skills and expanding our knowledge base ‐ sharing ideas and developing these ideas into sound research questions ‐ to be collaborating with researchers Janice Champion 2010

References

“the Bobath Concept is unfinished ‐ we hope that it will grow and develop in the years to come” K Bobath 1986

• Bernstein N (1967) The coordination and regulation of movements. Oxford: Pergamon. • Biernaskie J, Corbett D. (2001) Enriched rehabilitative training promotes improved forelimb motor function and enhanced dendritic growth after focal ischemic injury. J Neurosci. 21:5272–5280. • Bobath B & Bobath K (1981) Interview for NDTA. Baltimore • Bobath, B. (1984) Die Entwicklung und Veranderung des Neuro‐developmental Treatment. Lecture for the Vereinigung der Bobath‐Therapeuten Deutschlands, Bremerhaven • Bobath,B (1990) Adult Hemiplegia: Evaluation and Treatment 3rd Ed. Heinemann Medical Books



References

References

• Brock, K., et al. (2002) The Bobath concept has changed. (Comment on critically appraised paper, Australian Journal of Physiotherapy 48 : 59.). Australian Journal of Physiotherapy, 48 (2), 156‐157 • Chiel,H J. (2009) The Brain in Its Body: Motor Control and Sensing in a Biomechanical Context The Journal of Neuroscience, October 14. 29(41):12807–12814 • Gordon, J. A top‐down model for neurologic rehabilitation. In: Linking Movement Science and Intervention, Proceedings of the III Step Conference. Salt Lake City, Utah: American Physical Therapy Association; 2005:28–33. • Graham, JV. Et al (2009) The Bobath Concept in contempory clinical practice. Topics in Stroke Rehab 16.1(Jan – Feb) :57 (12)


References • Luke, C., Dodd, K.J. & Brock, K. (2004) Outcomes of the Bobath concept on upper limb recovery following stroke. Clinical Rehabilitation, 18 (8), 888‐898. • Mayston M (2002) Problem solving in neurological physiotherapy: setting the scene In Edwards SE (Ed) Neurological Physiotherapy 2nd Ed. Churchill Livingstone • Mulder T, Hostenbach J.(2003) Motor control and learning: Implications for neurological rehabilitation. In: Greenwood RJ, ed. Handbook of Neurological Rehabilitation. New York: Psychology Press; 143–157. • Pollock, A.(2007) Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: a systematic review. Clinical Rehabilitation 21: 395–410


• Gjelsvik BE.(2008) The Bobath Concept in Adult Neurology. Stuttgart, Germany: Thieme;. • IBITA website – www.ibita.org • Johansson,B. (2000) Brain Plasticity and Stroke Rehabilitation. Stroke 31:223‐230 • Lennon, S (1996) The Bobath Concept : a critical review of the theoretical assumptions that guide physiotherapy practice in stroke rehabilitation. Phys ther Rev. 1:35‐45 • Lennon, S. (2001) Gait re‐education based on the Bobath concept in two patients with hemiplegia following stroke. Physical Therapy, 81 (3), 924‐935. Janice Champion 2010

References • Raine,S. et al (2009) Bobath Concept‐Theory and Clinical Practice in Neurological Rehabilitation Wiley Blackwell • Schleichkorn, J.(1992) The Bobaths. An autobiography of Berta and Karel. USA Therapy Skill Builders • Shumway‐Cook,A.Woollacott, M. (2007) Motor Control – translating research into clinical practice. Lippencott, Williams and Wilkins • World Health Organisation (2002) Towards a Common Language for Functioning, Disability and Health: ICF. Geneva. • Wishart,L.R. et al (2000) Application of motor learning principles: the physiotherapy client as a problem solver.I. Concepts. Physiotherapy Canada, Summer ,229‐ 232 Janice Champion 2010

THE HISTORY OF THE BOBATH CONCEPT THE HISTORY OF THE

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