What is Bobath therapy?
Bobath therapy is a problem solving neurodevelopmental approach for the assessment and treatment of individuals with cerebral palsy and other allied neurological conditions. It addresses the problems that occur as a result of impairment of the developing central nervous system that affects the individual’s sensory-motor, cognitive, perceptual, social and emotional development.
It recognises that all clients with neurodisability have potential for enhanced function, emphasises a realistic approach, i.e. what is necessary for the person, and/or possible for the person to achieve, addresses the changing needs of the child with cerebral palsy as the lesion has occurred in an immature and still developing central nervous system, and in all treatment, emphasises the need for the person’s own activity.
It addresses the following impairments associated with the lesion within the central nervous system due to cerebral palsy:
- Abnormal muscle tone
- Muscle weakness
- Loss of selective movement
- Abnormal co-contraction of agonist and antagonist pairs
- Problems of postural control
- Musculo-skeletal problems
- Additional sensory, perceptual, visual and/or hearing impairments, learning difficulties, etc.
What does it entail?
Therapy at the Bobath Centre is delivered by highly experienced Bobath trained therapists, who only work with children with cerebral palsy and allied conditions. The child would normally receive ten x 90 minute sessions of therapy over two weeks. The child would receive the combination of therapy determined to best suit their needs (physiotherapy, occupational therapy, speech and language therapy). This would be decided by a senior therapist just prior to attendance depending on their current needs at that time. It is delivered as an outpatient.
Our treatment approach is based on one to one treatment following individual assessment and analysis of the child’s functional skills, including how the child is currently participating in daily life, how the quality of their movement may affect future skills and what factors are limiting the child developing new skills.
From this information an individual treatment programme is developed to enhance and develop new functional skills. Specialised handling techniques are used which influence abnormal postural tone to more normal levels, and assist and guide the child to move in more normal ways. Techniques are used to gain mobility at stiff joints, elongate muscle and improve postural alignment of body parts to ensure muscles are at optimal length for most efficient activation, and strength training is provided when appropriate to the child’s needs, within functional activities.
If sensory deficits or impaired processing of sensory information is present, this is addressed with techniques such as increasing tactile and proprioceptive input assisting the child with body exploration, and grading sensory input appropriate to the child’s ability to process it during treatment. The child is assisted to move so they are given experience of and practice more normal patterns of coordination in selected tasks to promote transfer of skills into daily life. The child is encouraged to problem solve, self initiate and self correct.
Treatment is goal directed with goals set in collaboration with families and children and is play centred. The aim is always to involve active participation by the child, with gradual reduction in handling or assistance. The approach is forward looking, anticipating possible future contracture and deformity and working to avoid or minimise this. A key feature is concentrated training and education of parents to carry out home activities and be empowered to know how best to carry out activities of daily living such as dressing, eating and drinking to maximise the therapeutic benefits to the child. Equipment such as orthotics, specialised seating etc. is utilised to enhance the effects of therapy.
How does it differ from community provision?
Typical non-Bobath therapy provision within the community often consists of a more eclectic approach utilising passive stretching techniques, a programme of postural management and provision of appropriate equipment. It may include some strengthening or active practise of functional skills. They may receive occupational therapy focussing on improving independence in activities of daily living and hand function and the provision of specialist equipment, e.g. seating, standing frame; and a programme of speech and language therapy aimed at improving her eating/drinking and/or communication. Typically these programmes are often carried out by a therapy or classroom assistant. It is typically not as intensive as Bobath therapy and would not involve as much focus on parent training, or as much time and emphasis on actively promoting and targeting new functional skills.
Bobath therapy is aimed at improving functional skills and is always ‘hands-on’ therapy by an experienced practitioner, with intensive training of parents in home therapy activities and management strategies for daily life.
Bobath therapy delivered by a community based Bobath trained therapist is different to that provided at the Bobath centre: The Basic 8 week Bobath training course undertaken by local therapists provides a good foundation for applying the concept to children with cerebral palsy, but a higher level of expertise is available from the therapists at the Bobath Centre which may be needed to problem solve more difficult issues. Children with more complex presentations of cerebral palsy, e.g. athetosis (dyskinetic cerebral palsy), GMFCS levels IV & V (children with more significant limitations in their activity) form 40% of the caseload at the Bobath Centre in comparison with about 6.5% in the local community, so the level of expertise in this area is far higher than that of community therapists. Joint trans-disciplinary therapy sessions are available on a daily basis which is often not possible within typical community settings. The daily treatment over a short period can result in a greater cumulative gain in skills, which is not always possible to achieve within usual therapy provision.
What is the current evidence that Bobath therapy is effective?
Reviews of research about Bobath (NDT) Therapy have shown that receiving NDT or a combination of NDT and other intervention led to better performance than children receiving other services (Ottenbacher et al., 1986) and to an immediate increase in range of movement (Butler and Darrah, 2001, DeGangi, 1994). Studies of children who have received Bobath (NDT) therapy, have demonstrated improvement in:
- gross motor function, self care skills and reduced caregiver assistance (Knox and Lloyd-Evans, 2002, DeGangi, 1994)
- improved walking demonstrated by achieving goals in improving stride length, gaining range of movement, strength, reducing spasticity and other gait parameters (Desloovere et al., 2012)
- motor progress with more intense NDT and following intermittent blocks of therapy (Tsorlakis et al., 2004, Mayo, 1991, Trahan and Malouin, 2002)
- stride, step length, heel contact and velocity of walking (Adams et al., 2000, Embray et al., 1990)
- reaching, hand opening and hand use (Jonnsdottir et al., 1997, Kluzik et al., 1990, Chakarian and Larson, 1993)
What features of the Bobath approach are supported by other research evidence?
- The Bobath Centres offers a family centred approach with goals set in collaboration with parents (Knox and Menzies, 2005). Studies support a family-centred service and suggest that it is valued by parents and professionals alike (King et al., 2004). The use of specific goals has been shown to enhance effectiveness of therapy (Bower et al., 1996)
- Therapy intervention at a Bobath Centre is more intensive than typical local provision. More intensive therapy has shown correlations with increased improvement in motor skills (Tsorlakis et al., 2004, Trahan and Malouin, 2002, Bower et al., 1996, Bower and McLellan, 1992)
- Parent/carer education is considered to be essential to enable each child to maximise their functional abilities for participation in daily life, to facilitate family relationships and to improve quality of life (Law et al., 2003)
What are the anticipated benefits of the intervention when compared against standard intervention?
It is difficult to compare against a ‘standard’, but if local therapy consists of a programme of stretching and positioning, and is delivered on a less frequent basis than that offered at the Bobath Centre, depending upon the focus of therapy at the Bobath Centre, the anticipated benefits could include:
- Improved gross motor function, self care skills and reduced caregiver assistance (Knox and Lloyd-Evans, 2002, DeGangi, 1994)
- increase in range of movement (Butler and Darrah, 2001, DeGangi, 1994)
- improved supported walking demonstrated by achieving goals in improving stride length, gaining range of movement, strength, reducing spasticity, step length, heel contact and velocity of walking (Desloovere et al., 2012) (Adams et al., 2000, Embray et al., 1990)
- more motor progress as this has been shown to occur after more intense NDT delivered in a block (Tsorlakis et al., 2004, Mayo, 1991, Trahan and Malouin, 2002)
- improvements reaching, hand opening and hand use (Jonnsdottir et al., 1997, Kluzik et al., 1990, Chakarian and Larson, 1993)
- More effective therapy as strongly family centred (King et al., 2004) using specific goals set in collaboration with parents (Knox and Menzies, 2005) (Bower et al., 1996) and with a strong emphasis on parent/carer education to empower them to maximise their child’s functional abilities and facilitate family relationships so improving quality of life (Law et al., 2003)
How will the results of therapy be measured? / What outcome measures will be used?
- Goal attainment scaling (with goals set in collaboration with the parents)
- Standardised outcome measures (specific measure dependent on aims of therapy in a future therapy block) – typical ones used are the Gross Motor Function Measure, Melbourne assessment of unilateral upper limb function, Assisting Hand Assessment or the Paediatric Evaluation of Disability Inventory.