Evidence base for the clinical effectiveness of Bobath (Neurodevelopmental) therapy 

Therapy for children with cerebral palsy aims to optimise their potential and function, prevent and minimise secondary deformity and weakness, and advise on daily management. Bobath (Neurodevelopmental) Therapy emphasises observation and analysis of the client’s current functional skill performance and the identification of clear therapy goals. The aims of treatment are to work for better active participation and practice of relevant functional skills and to influence muscle tone and improve postural alignment by specific handling techniques (Mayston, 2001b; Mayston, 2001a).

General research into therapy for children with cerebral palsy

There have been several reviews of research into therapy for children with cerebral palsy:

NDT/Bobath: (Ottenbacher et al., 1986; Royeen & DeGangi, 1992; Butler & Darrah, 2001)

Other therapy interventions: Hourcade & Parette 1984; Parette & Hourcade 1984; Tirosh & Rabino 1989; Campbell 1990; Turnbull 1993

Research methodology: Vermeer & Bax 1990; (Hur, 1995)

When reviews of research regarding the effectiveness of physiotherapy for children with CP are analysed, it is difficult to determine whether different types of physiotherapy are effective because of

  • Poor quality of research
  • Small study groups
  • Poor quality measures
  • Difficulty with matching between groups
  • Difficulties with the creation of control groups
  • Lack of detailed description of intervention
  • Widely differing frequencies and intensities of therapy
  • Other technical and ethical problems (Siebes et al., 2002)

The widely held expert opinion is that therapy is of benefit and appropriate early treatment will lessen the effects of Cerebral Palsy. Some evidence exists within the literature demonstrating the effectiveness of Bobath therapy as follows:

Research reviews regarding Bobath (NDT) Therapy

(Ottenbacher et al., 1986) conducted a meta analysis on the use of NDT in paediatric populations including 37 reviews, and found that clients receiving NDT or combination of NDT and other intervention performed better than 62% of subjects receiving other services.

(Royeen & DeGangi, 1992) conducted reviews on 19 published studies investigating the effects of NDT. There was some evidence to suggest an immediate gain in range of movement in children treated with NDT.

(Butler & Darrah, 2001) reviewed 21 studies with level II evidence.  Comments from the authors of this study included that although there was no strong evidence to suggest that NDT was more effective than any other approach, neither was there any evidence to suggest that it was less effective. The evidence for the efficacy of NDT was as follows:

  • 86 out of 101 outcome results did not confer an advantage to NDT, but there were some questions about the validity & sensitivity of the outcome measures which were used
  • Small sample sizes may have reduced the power to detect an effect (total subjects in 21 studies =  416)
  • Heterogeneity of CP may have obscured treatment effects
  • A greater percentage of studies published after 1990 favoured NDT compared with those prior to 1990

Positive results:

  • 4 studies: evidence of an immediate gain in range of movement
  • 8 studies: evidence of some gains in quality of motor responses & aspects of gait

(Franki et al., 2012) investigated the evidence base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy with a systematic review using the international classification of functioning, disability and health as a framework. This included 37 studies on NDT, Conductive education, Vojta, Sensory integration, functional training and goal oriented therapy. Eleven studies of NDT were included (subjects =181).

  • Body structure & function: Level IV evidence for effectiveness of NDT on posture (n=1), spasticity (n=1), range of motion (n=1) and mechanical efficiency (n=1)
  • Activity level:
    • Level II & III evidence for effectiveness of NDT on gross motor function (n=3).
    • Two studies showed no significant effects on motor function
    • Two studies focussing on treatment context & intensity of treatment showed significant effects on motor function in intervention groups, but no between group differences
  • Participation level: Level III evidence on self care and care giver assistance (n=1)

Franki et al (2011) commented that previous reviews of studies of NDT used much older studies and that there was little overlap (Butler & Darrah 2001- one study; Brown and Burns, 2001 – two studies)

NDT Clinical trials and single subject design studies

Evidence for improvement

  • gross motor function, self care skills and reduced caregiver assistance (Knox & Lloyd-Evans, 2002; DeGangi, 1994)                                                                    
  • improved walking demonstrated by improving stride length, 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; Trahan & Malouin, 2002; Mayo, 1991)
  • stride, step length, heel contact and velocity of walking (Adams et al., 2000; Embray et al., 1990; Laskas et al., 1985)    
  • reaching, hand opening and hand use   (Jonnsdottir et al., 1997; Kluzik et al., 1990; Chakarian & Larson, 1993)
  • improved postural control in premature infants   (Girolami & Campbell, 1994)
  • Improved daily living skills (videoed GAS goals)   Bain & Chaparro 2012
  • Intensive NDT as effective as Constraint Induced Movement therapy (CIMT)   Acar et al 2012

No difference between Casting alone V casting and NDTor Intensive NDT & Casting V General OT and casting (Law et al., 1991)  Law et al 1997

Less effective (Palmer et al., 1988) investigated 48 infants 12-19 months with mild to severe spastic diplegia. They were randomly assigned to NDT or learning games curriculum (control group). The control group improved more than NDT group. In this trial, NDT was aimed at improving righting and equilibrium balance reactions. The outcome measures used did not test righting & equilibrium reactions and were discriminative not evaluative. The reliability of tests was not demonstrated. There was some evidence that the NDT group may have been more neurologically involved.

Key features of the approach are as follows:

  1. Treatment programmes are goal focussed, and Bobath therapy follows a family centred approach with goals being set in collaboration with parents (Mayston, 2001b) Studies support a family-centred service and suggest it is valued by parents and professionals. Use of specific goals have been shown to enhance effectiveness of therapy, (Knox & Menzies, 2005; King et al., 2004; Bower et al., 1996).
  2. Treatment at a Bobath Centre is usually more intensive (daily sessions over 2 weeks) than typical local provision. Some comparisons of different intensities of therapy have been shown to correlate with increased improvement in motor skills: weekly more effective than monthly (Mayo, 1991); daily more effective than twice weekly or less (Tsorlakis et al., 2004; Bower & McLellan, 1992; Bower et al., 1996);  and intermittent intensive blocks may be an effective strategy for producing long term gains (Trahan & Malouin, 2002; Gagliardi et al., 2008). A few studies have shown no difference (Ustad et al, 2009; Christiansen & Lange 2008; Weindling et al, 2007). A meta- analysis of studies from Jan 1996-June 2007 of intensive V non-intensive PT for children with CP showed intensive therapy tended to have a greater effect than non-intensive therapy on motor function and the effect was stronger for children 2 years of age, (Arpino et al, 2010).
  3. Parent/carer education to enable the parent to handle and manage their child’s difficulties appropriately and facilitate the parent infant relationship is a central aim (Mayston, 1992). Parent/Carer education maximises the child’s functional abilities for participation in daily life, facilitates family relationships, improves quality of life and evidence suggests family centred care is associated with enhanced developmental progress, decreased parental stress and improved parent satisfaction with services, (Knox & Menzies, 2005; Law et al., 2003) Law et al, 1998. Research has shown the Bobath Centres to be family-centred in their approach (Knox & Menzies, 2005).

Bibliography

Adams M, Changler S & Schuhmann K. (2000) Gait changes in children with cerebral palsy following a neurodevelopmental treatment course Paediatric Physical Therapy 12: 114-20.

Bower E & McLellan DL. (1992) Effect of increased exposure to physiotherapy on skill acquisition of children with cerebral palsy  Developmental Medicine and Child Neurology 34: 25-39.

Bower E, McLellan DL, Arney J & Campbell MJ. (1996) A randomised controlled trial of different intensities of physiotherapy and different goal-setting procedures in 44 children with cerebral palsyDevelopmental Medicine and Child Neurology 38: 226-37.

Butler C & Darrah J. (2001) Effects of Neurodevelopmental Treatment (NDT). Developmental Medicine and Child Neurology 43: 778-90.

Chakarian D & Larson M. (1993) Effects of Upper-extremity weight bearing on hand-opening and prehension patterns in children with cerebral palsy Developmental Medicine and Child Neurology 35: 216-29.

DeGangi G. (1994) Examining the Efficacy of Short-Term NDT Intervention Using a Case Study Design: Part 1

Physical & Occupational Therapy in Pediatrics 14: 71-87.

Desloovere K, De Cat J, G M, Franki I, Himpens E, Van Waelvelde H, Fagard K & Van den Broeck C. (2012) The effect of different physiotherapy interventions in post-BTX-A treatment of children with cerebral palsy. European Journal of Paediatric Neurology 16(1): 20-8.

Embray D, Yates L & Mott D. (1990) Effects of neuro-developmental treatment and orthoses on knee flexion during gait: a single-subject design. Physical Therapy 70(10): 626-37.

Franki I, Desloovere K, De Cat J, Feys H, Molenaers G, Calders P, Vanderstraeten G, Himpens E & Van den Broeck C. (2012) The evidence base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy: a systematic review using the international classification of functioning, disability and health as a framework. Journal of Rehabilitation Medicine44: 396-405.

Gagliardi C, Maghini  C, Germiniasi C, Stefanoni G, Molteni F, Burt D & Turconi A. (2008) The effect of frequency of cerebral palsy treatment: a matched-pair pilot study. Pediatric Neurology 39(5): 335-40.

Girolami G & Campbell S. (1994) Efficacy of a Neuro-Developmental Treatment Program to Improve Motor Control of Preterm Infants. Pediatric Physical Therapy 6(4): 175-84.

Hur J. (1995) Review of Research on Therapeutic Interventions for Children with Cerebral Palsy Acta Neurologica Scandinavica 91: 423-32.

Jonnsdottir J, Fetters L & Kluzik J. (1997) Effects of Physical Therapy on Postural Control in children with Cerebral Palsy Pediatric Physical Therapy 9: 68-75.

King S, Teplicky R, King G & Rosenbaum P. (2004) Family-centred service for children with cerebral palsy and their families: a review of the literature Seminars in Pediatric Neurology 11: 78-86.

Kluzik J, Fetters L & Coryell J. (1990) Quantification of control: A preliminary study of effects of neuro-deveopmental treatment on reaching in children with spastic cerebral palsy  Physical Therapy  70: 65-78.

Knox V & Lloyd-Evans A. (2002) Evaluation of the functional effects of a block of Bobath therapy in children with cerebral palsy: a preliminary study Developmental Medicine and Child Neurology 44: 447-60.

Knox V & Menzies M. (2005) Using the Measure of Processes of Care to assess a Paediatric Therapy Service British Journal of Occupational Therapy 68(3): 110-6.

Laskas C, Mullen S, Nelson K & Wilson-Broyles M. (1985) Enhancement of two motor functions of the lower extremity in a child with spastic quadriplegia

Physical Therapy 65 11-6.

Law M, Cadman D, Rosenbaum P, Walter S, Russell D & DeMatteo C. (1991) Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Dev Med Child Neurol33: 379-87.

Law M, Hanna S, King G, Hurley P, King S, Kertoy M & Rosenbaum P. (2003) Factors affecting family-centred service delivery for children with disabilities. Child: Care, Health & Development 29: 357-66.

Mayo N. (1991) Effect of Physical Therapy for Children with Motor Delay and Cerebral Palsy: A Randomised Clinical Trial American Journal of Physical Medicine and Rehabilitation 70: 258-67.

Mayston M. (1992) The Bobath Concept – Evolution and Application. Basel.

Mayston M. (2001a) The Bobath concept today Synapse Spring: 32-4.

Mayston M. (2001b) People with cerebral palsy: Effects of and perspectives for therapy  Neural Plasticity  8(1-2): 51-69.

Ottenbacher K, Biocca Z, DeCremer G, Gevelinger M, Jedlovec K & Johnson M. (1986) Quantitative Analysis of the Effectiveness of Pediatric Therapy

Physical Therapy 66: 1095-101.

Palmer F, Shapiro B, Allen M, Mosher B, Bilker S & Harryman S. (1988) The effects of physical therapy on cerebral palsy: A controlled trial in infants with spastic diplegia. New England Journal of Medicine318: 803-8.

Royeen C & DeGangi G. (1992) Use of Neurodevelopmental treatment as intervention: annotated listing of studies 1980-1990

Perceptual and Motor skills 75: 175-94.

Siebes R, Wijnroks L & Vemeer A. (2002) Qualitative analysis of therapeutic motor intervention programmes for children with cerebral palsy: an update. Dev Med Child Neurol 44: 593-603.

Trahan J & Malouin F. (2002) Intermittent Intensive physiotherapy in children with cerebral palsy: a pilot study.

Developmental Medicine and Child Neurology 44: 233-9.

Tsorlakis N, Evaggelinou C, Grouios G & Tsorbatzoudis C. (2004) Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsyDevelopmental Medicine and Child Neurology 46  740-5.