Physiotherapy Theory and Practice, 23(3):137
152, 2007

Copyright # Informa Healthcare

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.1080/09593980701209154

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The current theoretical assumptions of the Bobath

concept as determined by the members of BBTA
Sue Raine, Grad Dip Phys, BSc in Physiotherapy, MSc
Team Lead Physiotherapist, Walkergate Park for Neurorehabilitation and Neuropsychiatry,
Benfield Road, Newcastle upon Tyne, UK

The Bobath concept is a problem-solving approach to the assessment and treatment of individuals
following a lesion of the central nervous system that offers therapists a framework for their clinical
practice. The aim of this study was to facilitate a group of experts in determining the current theoretical
assumptions underpinning the Bobath concept.A four-round Delphi study was used. The expert sample
included all 15 members of the British Bobath Tutors Association. Initial statements were identified
from the literature with respondents generating additional statements. Level of agreement was determined by using a five-point Likert scale. Level of consensus was set at 80%. Eighty-five statements were
rated from the literature along with 115 generated by the group. Ninety-three statements were identified
as representing the theoretical underpinning of the Bobath concept. The Bobath experts agreed that
therapists need to be aware of the principles of motor learning such as active participation, opportunities for practice and meaningful goals. They emphasized that therapy is an interactive process between
individual, therapist, and the environment and aims to promote efficiency of movement to the individuals maximum potential rather than normal movement. Treatment was identified by the experts as
having change of functional outcome at its center.

Introduction
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 (Raine, 2006). Based on the systems
approach to motor control, the concept offers
therapists working in neurology a framework
for their clinical practice (Raine, 2006). The
Bobath concept is the most commonly used
approach in the United Kingdom for the management of people with neurological problems
(Davison and Walters, 2000; Lennon, 2001).
Berta Bobath (1970) initiated the concept, and
her therapeutic developments revolutionized the
assessment and treatment of patients worldwide.

The Bobath concept was developed as a living

concept, with the understanding that as therapists knowledge base grows, their view of treatment broadens (Raine, 2006). Although it is
recognized that the Bobath concept has undergone considerable developments since its inception (Partridge and de Weerdt, 1995), many
researchers continue to base their assumptions
and treatment principles, entirely on Bobaths
third edition textbook published in 1990
(Langhammer and Stanghelle, 2000; van Vliet,
Lincoln, and Robinson, 2001).
Pomeroy and Tallis (2002) state that developments in the approach are impossible to determine and criticize Bobath proponents for not
publishing these changes. Lennon (1996) suggests that updating the theory orally, through

Accepted for publicaiton 5 July 2006.

Address correspondence to Sue Raine, BSc, MSc, Team Lead Physiotherapist, Walkergate Park for Neurorehabilitation
and Neuropsychiatry, Benfield Road, Newcastle upon Tyne NE6 4QD, UK. E-mail: sue.raine@ntw.nhs.uk

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postgraduate courses and not through the publication of literature, contributes to problems in
evaluating the theoretical framework of the
Bobath concept and encourages the misconception that the approach has not developed since
1990. Pomeroy and Tallis (2002) believe that to
improve the evidence base, there is a need to
define the current theoretical framework and
therapeutic interventions in enough detail for
their effectiveness to be evaluated. Both surveys
and focus groups have used experienced physiotherapists to identify the theoretical assumptions of the Bobath concept (Lennon, Baxter,
and Ashburn, 2001; Lennon and Ashburn,
2000). The information collected in these studies
was based almost entirely on individual therapists interpretations of information delivered
in postgraduate courses over different time periods. The aim of this study was to facilitate a
group of experts in determining the current
theoretical assumptions underpinning the
Bobath concept. An opportunity was also provided for the experts to identify statements that
were not representative of the Bobath concept.

Methodology
A four-round Delphi study was used to establish the level of consensus for a number of statements taken from the literature relating to the
theoretical assumptions of the Bobath concept
and to provide an opportunity for respondents
to generate additional statements (Raine,
2006). The Delphi is a method for structuring
group communication (Linstone and Turoff,
1975) that entails the distribution of a series of
questionnaires interspersed with controlled opinion feedback (Ziglio, 1996). On the basis that
they are responsible for disseminating the current understanding and practice of the Bobath
concept in postgraduate courses, the total membership of the British Bobath Tutors Association
(BBTA) was chosen as the experts in this study.
The experts were all physiotherapists who had
undergone extensive training in the Bobath concept and were qualified as International Bobath
Instructors to lead the teaching at either basic or
advanced course levels (IBITA, 2003). They
each retained a high level of patient contact
(minimum of 300 hours annually), in addition
to their teaching commitments. Their experience

as qualified Bobath Instructors ranged between

2 and 25 years. The number of experts totaled
15, and the response rate for each round was
set at 80%.
Following a review of the literature between
1990 and November 2003, 347 statements were
identified that either defined the Bobath concept
or its theoretical underpinning. Eighty-five were
chosen by two independent therapists and the
researcher as representative of the statements
describing the theoretical assumptions and were
included in nine themed sections within the
postal questionnaire (another 10 statements
relating to the definition of the Bobath concept
were also included and reported in a second
paper [Raine, 2006]). Level of agreement was
rated on a five-point Likert scale.
Following collation of the data from each
questionnaire, feedback was provided in the subsequent questionnaire identifying the individuals rating in relation to the group opinions.
The respondent was then given the opportunity
to change his or her rating in view of the feedback, along with an opportunity to rate the
new statements generated by the group. See
Figure 1 for a summary of the procedure.
In between the third and fourth questionnaire
rounds, the results were presented to the experts
as a group. Their attention was drawn to similarities in wording and meaning of some of the
statements, and they were instructed to identify
their preferred statements in the fourth and
final round.
Related statements had been grouped into
nine categories in the first questionnaire and
retained throughout the four rounds, although
some statements could have been placed in more
than one category. Feedback from the group
indicated that there were some category headings that were preferred over others to represent
the current Bobath concept, and these preferred
category headings were used to summarize the
results.

Analysis
Content analysis was used to identify major
themes and descriptive statistics (percentage
and average and dispersion) to identify the level
of consensus and rank the statements in order of
preference. To achieve consensus, a level of 80%
of the respondents votes within either the

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139

Figure 1. Delphi study procedure.

agreement or disagreement categories had to be

reached. Reliability was assessed by using a sensitivity analysis on the data provided by the percentage and average and dispersion methods.

Results

Statement generation
Eighty-five statements relating to the theoretical assumptions of the Bobath concept were
included in the first round. An additional 115
statements were generated in subsequent rounds;
102 of these were reworded versions of the original statements, and 13 were completely new.

Response rate
There was an 85.7% (12=14) response rate
achieved in the first round, with 93.3% (14=15)
in the second and third, and 92.9% (13=14) in
the fourth. There was one consistent nonresponder throughout the study.

Sensitivity analysis and level

of consensus
The data from both the percentage and average and dispersion methods of analysis were

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identical in the ranked order of statements.

There were, however, fewer statements in the
average and dispersion method that reached
the 80% level of consensus. The percentage
method more accurately represents 13 of 15
respondents (80%) rather than a mean of the
distributed scores. The statements presented
here are based on the results of the percentage
method.
A total of 200 statements were presented for
rating:
. 159 (80%) achieved the 80% level of consensus for agreement
. 52 (26%) achieved 100% consensus for
agreement
. 20 (10%) achieved the 80% level for disagreement
. 9 (5%) achieved 100% consensus for disagreement
. 3 (2%) achieved 80% level of consensus for
neutral opinion
. 21 (11%) did not achieve consensus for either
agreement or disagreement
Where there were several reworded versions
of one statement, the groups preferred statement was identified by its ranked order. In total,
93 statements were identified as representing the
Bobath concept; 43 of these were taken from the
published literature. Table 1a
i provides a list
of these statements within the nine categories.
Twelve statements from the literature were
identified as misrepresenting the Bobath concept
and can be found in Table 2.

Level of consensus between rounds

Group consensus for statement ratings
improved throughout each of the four questionnaire rounds. The main variation in ratings
between respondents was the extent of their level
of agreement or disagreement for a particular
statement.

Discussion
Previous studies have collected the views of
neurological physiotherapists in an attempt to
identify the theoretical assumptions of the

Bobath concept (Lennon and Ashburn, 2000;

Lennon, Baxter, and Ashburn, 2001). The aim
of this study was to determine the current theoretical underpinning using an expert sample. The
total membership of BBTA, clinicians responsible for the dissemination of the current understanding and practice of the Bobath concept
within the United Kingdom, were the experts
in this study. Response rates were high, with
85% in the first round and 93% in each of the
following rounds, which compares well to previous allied health Delphi studies (Deane et al,
2003; Ashburn et al, 2004). This study shows
concurrent validity (Raine, 2006), and the sensitivity analysis verified that both the percentage
and average and dispersion methods were comparable in the ranking of statements and identification of consensus.
For the 85 statements that were presented in
round 1, the respondents offered 113 reworded
versions that provided subtle but important
changes in meaning, which had an impact on
the level of consensus. Only 13 completely
new statements were generated during the
study, which suggested that the initial list of
statements was already comprehensive. The
experts agreed that 43 of the original statements
and 50 generated by the group were representative of the current theoretical assumptions
(Table 1a
i).

Statements representing the current

theoretical assumptions of the Bobath
concept
Normal movement (Tables 1a and 2)
Although the experts agreed with previous
authors who suggest that therapists need to be
skilled in the analysis of normal movement
(Lennon and Ashburn, 2000; Lennon, Baxter
and Ashburn, 2001), they stated that the aim
of therapy is to promote efficiency of movement to the individuals maximum potential
and not to achieve normal movement.
The experts highlighted that selective movement of the trunk and limbs, both concentric
and eccentric, are interdependent and interactive
with a postural control mechanism (BBTA,
2003). Therefore, the recovery of selective movement is a prerequisite for efficient postural control, alignment, and function. Balance in an

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Table 1. Statements representing the current theoretical assumptions of the Bobath concept.

Table 1a. Normal movement

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Abnormal coordination of movement patterns, poor balance, sensory deficits, and abnormal
tone are the main physical problems of people with hemiplegia.
Recovery of movement following brain injury occurs both proximally and distally.
Therapy aims to promote efficiency of movement to the individuals maximum potential rather
than normal movement.
Therapists need to be skilled in the analysis of normal movement.
In therapy there is a need to address the problem of an individuals specific ability to create tone
against gravity for the necessary postural stability on which selective movement is based.
Treatment aims to optimize postural and movement strategies to improve efficiency.
Therapists handling techniques give patients control over aspects of their stability and alignment
and guide them to achieve more efficient movement patterns.
Within therapy there is an emphasis on the patient learning to generate movements as efficiently
as possible.
If the CNS is damaged; it has to compensate; it is the therapists job to guide patients recovery
so that they can achieve their maximal functional potential within the constraints of the
damaged CNS.
A primary concern of the Bobath concept is the activation of the patient to overcome postural
hypotonia.
Therapists need to be skilled in movement analysis.
Selective movement of the trunk and limbs, both concentric and eccentric, are interdependent
and interactive with a postural control mechanism. Therefore, the recovery of selective
movement is a prerequisite for efficient postural control, alignment, and function.
Rehabilitation is a process of learning to regain motor control and should not be the promotion
of compensation that can occur naturally as a result of a lesion and also as a result of therapy.
Movements must be owned by the patient and be experienced both with and ultimately without
the handling of the therapist.
The Bobath concept directs treatment to overcome weakness of neural drive after an upper
motor neurons lesion, through selective activation of cutaneous and muscle receptors.
The therapist can only decrease compensation if patients are given control over their posture and
balance that is causing the compensation. Obviously, there may be many reasons interfering
with this such as sensory and perceptual problems.
Therapists both teach movements and make movement possible by using the environment and
the task appropriately.
Balance in individuals is achieved through improving their orientation and stability in relation to
postural control.
Movements may have to be cognitive (e.g., corticospinal system and the hand and during
initiation of goal-directed movements).
Patients should not be stopped from moving in a certain way unless they have been provided
with an alternate strategy, that achieves the same goal.
Table 1b. Normalizing tone

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Aim of treatment is to create the appropriate alignment of soft tissues and joints and to access
optimal muscle activation to achieve the functional task.
Hypertonicity is a combination of disinhibition, plastic reorganization, and mechanical changes.
Spasticity is difficult to quantify and is not universally understood to be the same by everyone.
(Continued)

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Table 1. Continued.

Table 1b. Normalizing tone

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Bobath therapists seek to find the causal effect of associated reactions rather than merely
changing the pattern produced by the associated reaction.
Therapists emphasize the reduction of increased tone and facilitation of movement by cutaneous,
proprioceptive, and other handling techniques.
Therapists work on tone to improve movement not to normalize tone for its own sake.
Therapy addresses abnormal=inefficient stereotypical movement patterns that interfere with
function.
There may be an element of conscious control over muscle tone, but the aim is for patients to
develop control of their balance and movement on an automatic basis to initiate and control
functional movements.
Weight bearing can help normalize tone but only if the patient is able to adapt and change
muscular alignment actively.
A major treatment goal is to prevent the establishment of spasticity and maximize residual
function.
Patients may use associated reactions as a pathologic form of postural fixation when stability
cannot be accessed.
Aim is to control rather than inhibit associated reactions.
The significance of hypertonia varies considerably from individual to individual and so its
impact also varies.
Therapists do not normalize tone, but they can influence hypertonia at a nonneural level by
influencing muscle length and range.
Associated reactions are abnormal, stereotyped movement patterns of the affected side that are
involuntary and triggered in many ways.
Associated reactions are phasic contractions lacking a background of postural control.
Associated reactions interfere with the recovery of function and the ability to perform efficient
and effective movement.
Table 1c Function

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The therapist must address both the specific movement components of the task and the
functional activity to achieve goals.
A role of the therapist is to facilitate balance and selective movement as a basis for functional
activity and successful goal acquisition. Successful goal acquisition in a given task must then
be practiced to improve efficiency and promote generalization.
Therapy is aimed at giving the patient movement choices.
Therapy is based on the assessment of the patients potential.
The therapist should not stop the patient from walking; however where walking may be
detrimental to recovery, the patient may be advised to walk only with the appropriate
facilitation or walking aid.
Preparation is of no value in itself; it must be incorporated into functional activity.
In therapy normal movement is facilitated and must be put into a functionally relevant task to be
meaningful to the patient and promote carryover.
The therapists handling is modified as the individual achieves independence.
Treatment has change of functional outcome at its center.
Goals need to be realistic according to the clients potential and appropriate to the environment
encountered during daily life.
(Continued)

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Table 1. Continued.

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Table 1d. Systems approach

Human motor behavior is based on continuous interaction between the individual, the
environment, and the task.
The CNS is a complex organization consisting of systems and subsystems. It uses a shifting focus
of control depending on many biomechanical, neuroanatomical, and environmental
influences.
Movement control is dependent on an integrated neurological and muscular system.
The person is evaluated in terms of total function within changing environments, and the
intervention process is individualized to his or her bio-psycho-social needs.
The concept involves the whole patient: sensory, perceptual, and adaptive behavior as well as
motor problems.
Treatment is tailored to the clients individual needs.
Table 1e. Motor learning

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If efficiency in the motor skill is inadequate, the individual may look at movement components
to improve skill (e.g., a tennis coach may encourage practice of a component to perfect the
tennis stroke).
Therapy is an interactive process between individual, therapist, and the environment.
As soon as patients are able to practice aspects of appropriate activity, this is encouraged as part
of their rehabilitation program.
The emphasis in treatment is on active participation of the patient on either an automatic or a
volitional basis or a combination of both.
Repetition is important in the consolidation of motor control, but it does not mean moving in
exactly the same way.
As part of the rehabilitation process, the therapist must consider the 24-hour management of the
patient and his=her way of life.
Patients should be given advice on how to move in between therapy sessions to achieve
carryover.
Preventative and promotive aspects of therapy need to be addressed.
The Bobath concept is goal oriented and task specific and seeks to alter and construct both the
internal (proprioceptive) and external (exteroceptive) environment in which the central
nervous system and therefore the person can function efficiently and effectively.
Therapists need to be aware of the principles of motor learning: active participation,
opportunities for practice, and meaningful goals.
For learning . . . relearning to occur, there needs to be the opportunity to practice.
Table 1f. Musculoskeletal system

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Altered muscle tone, changes in muscle length and alignment, muscle weakness and
incoordination may all limit functional recovery in patients following stroke.
Influencing muscle length and range enables improved alignment for more efficient muscle
activation and effective movement.
Body weight and gravity can be used to strengthen muscles as well as appropriate resisted
exercises.
Altered muscle tone, weakness, and altered viscoelastic properties may all impact the patients
ability to recover efficient movement.
Optimizing muscle length must incorporate the complex relationship of stabilizing and mobility
components.
(Continued)

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Table 1. Continued.

Table 1f. Musculoskeletal system

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Selective and specific strength training may be part of treatment within the Bobath concept.
Muscles need sufficient activity to generate force for action.
Although strength of individual muscle groups is less important than their coordination in
patterns of activity, strength may still be an issue for efficient movement in some patients.
If weakness is seen as a lack of or reduced specificity of neuromuscular innervation, this is as
much a problem as muscle tone.
Table 1g. Sensory systems

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Specific stimulation may be necessary to promote localization of movement (e.g., fingers), but
sensory stimulation on its own is not the whole picture; it has to be combined with active
movement.
Ultimately, the therapist is aiming to reeducate the patients own internal referencing system to
provide accurate afferent input to give the patient the best opportunity to be efficient, specific,
and have movement choices.
At some stages of skill acquisition, somatosensory referencing may be emphasized over verbal or
visual feedback.
Table 1h. Neuroplasticity

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The CNS and neuromuscular system can adapt and change their structural organization in
response to intrinsic and extrinsic information (i.e., they are plastic).
Changes within the structure of the CNS can be organized or disorganized producing adaptive or
maladaptive sensorimotor behavior.
Plasticity underlies all skill learning and is a part of CNS function.
The cellular mechanisms that take place during the development, refinement, and relearning of
motor control can result in long- or short-term learning (i.e., carryover or no carryover).
The manipulation of information can directly affect a change in the structural organization of
the CNS through spatial and temporal summation and the facilitation of pre- and post-synaptic
inhibition.
Motor skill is based on reciprocal innervation and sequential activation of motor units giving
selectivity of movement control.
Therapy addresses the neuromuscular system, spinal cord, and higher centers to change motor
performance.
Therapy takes into account neuroplasticity, an interactive CNS, and our individual expression of
movement.
Neuroplasticity is a primary rational for treatment intervention.
Each individual patient is assessed in terms of their lesion, individual movement expression, and
potential to maximize his or her movement efficiency.
Table 1i. Additional therapies

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The Bobath approach can be complemented with other modalities and adjuncts such as
structured practice, use of orthotics and muscle strengthening.
Splinting and orthoses may be indicated to gain alignment or a good weight-bearing base for
improved proximal and truncal activity.
The Bobath therapist may use motor mental imagery as part of a patients home programme.
The Bobath concept utilises selective constraint through posturing a limb and=or through an
environmental support.
(Continued)

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Table 1. Continued.

Table 1i. Additional therapies

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Therapists may use a treadmill and this could include facilitation to enable the most efficient
pattern.

Using other techniques in parallel, such as Maitland mobilisations, is compatible with the
Bobath Concept.
Restraint of the less affected body parts manually during a therapy session may be used to and
assist activation of the affected parts.

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Lightface statements indicate greater than 80% group consensus; those in bold indicate total consensus.

individual is said to be achieved through

improving their orientation and stability in
relation to postural control. The experts
expressed the opinion that in therapy there is a
need to address the problem of an individuals
specific ability to create tone against gravity,
for the necessary postural stability on which
selective movement is based. The aim of therapy
is to optimize postural and movement strategies
to improve efficiency.
Lennon (1996) suggested that in the Bobath
concept there is a great emphasis on decreasing
overcompensation of the unaffected side. However, the experts highlighted that the therapist
can only decrease compensation if the patient
is given control over their own posture and
balance, which is inadequate and causing the
compensation. They agreed that if the CNS is
damaged, it has to compensate and that it is
the therapists job to guide the persons recovery
so that they can achieve their maximal functional potential within the constraints of the
damaged CNS (Mayston, 2001). The experts
also agreed that rehabilitation is a process of
learning to regain motor control and should
not be the promotion of compensation that
can occur naturally as a result of a lesion or as
a result of therapy (BBTA, 2003).
The experts suggested that the focus in therapy is not the suppression of patient-generated
incorrect movements until normal movement
patterns are achieved (Sparkes, 2000). The focus
is on the patient learning to generate movements as efficiently as possible. Movements must
be owned by the patient and be experienced
both with, and ultimately without, the handling
of the therapist. They supported Maystons
(2001) statement that patients should not be

stopped from moving in a certain way unless

they have been provided with an alternate strategy, that achieves the same goal.
The experts agreed that the main physical
problems of people with hemiplegia were not
only abnormal coordination of movement patterns and abnormal tone (Lennon, Baxter, and
Ashburn, 2001) but also poor balance and sensory deficits. It was stated that recovery of
movement can occur both proximally and distally. However, facilitation of movement is not
always preferred on an automatic basis as
suggested by Lennon and Ashburn (2000). The
respondents provided examples such as in the
recovery of the hand or initiation of goaldirected movements where it is necessary for
movement to be cognitive.
Normalizing tone(Tables 1b and 2)
The experts stated that hypertonicity, rather
than spasticity (Lennon and Ashburn, 2000), is
a combination of disinhibition, plastic reorganization, and mechanical changes and that its
significance varies considerably between individuals. The experts believed that spasticity is difficult to quantify and is not universally
understood to be the same by everyone. Several
authors link the Bobath concept with therapy
that focuses on the normalization of tone before
active movement is facilitated (van Vliet,
Lincoln, and Robinson, 2001; Langhammer
and Stanghelle, 2000). The Bobath experts
strongly refuted this but agreed that therapists
work on tone to improve movement, not to normalize tone for its own sake (Lennon, Baxter,
and Ashburn, 2001) and that it can be influenced
at a nonneural level, by influencing muscle
length and range (Mayston, 2001).

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Table 2. Statements taken from the literature, which the experts agree are NOT representative of the theoretical assumptions
of the Bobath concept.

Normal movement
. Therapy is aimed at the reeducation of normal movement.
Normal tone
. Patients needs to learn to consciously exert control over their muscle tone during activities of
daily living mainly by using reflex-inhibiting patterns or positions.
. Therapy focuses on the normalization of tone before active movement is facilitated.
. Reflex inhibitory and facilitatory strategies are used in the treatment of hemiplegic patients.
Function
. Patients are not encouraged to walk independently until they can walk with normal patterns
without increased spasticity.
Motor learning
. Unsupervised patient practice is strongly discouraged because the adoption of an incorrect
pattern of movement is deemed detrimental to rehabilitation.
Musculoskeletal system
. Body weight and gravity are used to facilitate normal movement but not to increase muscle
strength.
. Muscle tone is seen as a greater problem than weakness in patients following stroke.
. Therapists discourage resistive exercises in patients with hemiplegia.
. It is muscle coordination that is disturbed in stroke patients, not muscle strength.
Neuroplasticity
. Therapy does not take into account neuroplasticity, an interactive CNS, or our individual
expression of movement.
Additional therapies
. Therapists are unlikely to prescribe walking aids or orthotics to enable a patient to walk
independently more quickly because this may reinforce abnormal tone and movement,
thereby proving detrimental to recovery.
Lightface statements indicate greater than 80% group consensus; those in bold indicate total consensus.

The group concurred that associated reactions are abnormal, stereotypical movement
patterns of the affected side that are involuntary and triggered in many ways (Lennon,
1996). They are phasic contractions lacking a
background of postural control that interfere
with the recovery of function and the ability
to perform efficient and effective movement
(Lynch-Ellerington, 2000). The experts also
agreed that patients may use associated reactions as a pathologic form of postural fixation
when stability cannot be accessed. The aim in
therapy is to control rather than inhibit associated reactions.
A major treatment goal is not to reduce spasticity but to prevent its establishment and to
maximize residual function (Cornall, 1991).
Therapists address abnormal or inefficient
stereotypical movement patterns that interfere

with function (Lettinga, Helders, Mol, and

Rispens, 1997) by creating the appropriate alignment of soft tissues and joints to access optimal
muscle activation to achieve the functional task
(Mayston, 2001). The experts opposed the
suggestion that current Bobath therapists use
reflex inhibiting patterns or positions (Wagenaar
et al, 1990; Hesse et al, 1998; Langhammer and
Stanghelle, 2000). They strongly agreed that
there may be an element of conscious control
over muscle tone, but the aim is for patients to
develop control of their balance and movement
on an automatic basis to initiate and control
functional movements. Sackley and Lincoln
(1996) reported that weight bearing through the
affected limb would normalize tone. However,
the experts agreed that this would only happen
if patients were able to adapt and change muscular alignment actively.

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Function (Tables 1c and 2)

Lennon and Ashburn (2000) suggest the role
of the therapist is to give patients enough balance and movement to be able to achieve their
functional goals. However, the experts stated
that the role of the therapist is to facilitate balance and movement as a basis for functional
activity and successful goal acquisition, which
in a given task must then be practiced to
improve efficiency and promote generalisation.
It was agreed that the therapist must address
both the specific movement components of the
task and the functional activity to achieve the
goals and that the therapists handling is modified as the individual achieves independence
(IBITA, 1999). Although the experts agreed with
Lennon (1996) that normal movement needs to
be facilitated within functional tasks, they stated
that these tasks must be relevant and meaningful
to the patient to promote carryover. They
agreed with Mayston (2001) that preparation is
of no value in itself; it must be incorporated into
functional activity and that therapy is based on
the assessment of the patients potential and
aimed at giving the patient movement choices.
Goals need to be realistic according to the
patients potential and appropriate to the
environment encountered during daily life.
Treatment was said to have change of functional outcome at its center.
One contentious issue within the literature is
related to Bobath therapists delaying patients
walking (Partridge and de Weerdt, 1995; Lennon,
1996; Rice-Oxley and Turner-Stokes, 1999; Punt,
2000). The experts refuted the statement that
patients are not encouraged to walk independently until they can walk with normal patterns,
without increased spasticity (Lennon, 1996).
They stated that the therapist should not stop
patients from walking. However, where walking
may be detrimental to their recovery, patients
may be advised to walk only with the appropriate
facilitation or walking aid.
Systems approach (Tables 1d and 2)
Statements on the systems approach were
identified from literature published, coincidentally, by proponents of the Bobath concept
(Lennon, 1996; IBITA, 1999; Panturin, 2001;
BBTA, 2003) and produced the strongest
consensus, with all respondents rating strong
agreement and providing few rewordings. The

147

statements emphasized that the CNS is a complex organization of systems and subsystems
and the importance of the continuous interaction between the individual, environment and
the task (Shumway-Cook and Woollacott,
2001). The concept involves the whole patient,
their sensory, perceptual, and adaptive behavior
as well as their motor problems. The intervention process is individualized to the patients
bio-psycho-social needs. Unlike results of previous studies (Lennon, Baxter, and Ashburn
2001), the experts reported the importance of
an integrated neurological and muscular system
in movement control.
Motor learning (Tables 1e and 2)
Bobath proponents have been criticized in the
past for not integrating principles of motor
learning theories into their theoretical framework (Goodgold-Edwards, 1993; Lennon, 1996).
The experts strongly agreed that therapists need
to be aware of the principles of motor learning,
which include active participation, meaningful
goals, and opportunities for practice (BBTA,
2003). They believed that therapy is an interactive process not only between the individual
and the task (IBITA, 1999) but also the environment (Shumway-Cook and Woollacott, 2001).
Lennon (1996) stated that active participation
of the patient is on either an automatic or volitional basis in the Bobath concept. However,
the experts stated that it could also be a combination of both. Although the experts agreed
with IBITA (1999) that the individual focuses
on the goal rather than the specific movement
components of the task in the acquisition of
functional motor skill, they considered that,
more importantly, the therapist might identify
the movement components to improve ability
when the motor skill is inefficient.
The experts concurred with Lennon and
Ashburn (2000), who state that patients should
be given advice on how to move in between therapy sessions to achieve carryover and that
repetition is important in consolidation of motor
control, but this does not mean moving in
exactly the same way. They also agreed that
for learning or relearning to occur, there needs
to be the opportunity to practice (Mayston,
2001) and that preventative and promotive
aspects of therapy need to be addressed (IBITA,
1999). The experts disagreed with the suggestion

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by Sparkes (2000) that unsupervised patient

practice is strongly discouraged because of the
possibility of the adoption of incorrect patterns
of movement; they suggested that as soon as
patients are able to practice aspects of appropriate activity, this should be encouraged as part
of their rehabilitation program. Similar to
Lettinga, Helders, Mol, and Rispens (1997),
the respondents agreed that therapists must consider the 24-hour management of the patient and
his or her way of life as part of the rehabilitation
process. The experts considered the Bobath concept to be goal orientated and task specific; it
seeks to alter and construct both the internal
(proprioceptive) and external (exteroceptive)
environment in which the central nervous
system, and therefore the person, can function
efficiently and effectively.
Musculoskeletal system (Tables 1f and 2)
It is suggested that the Bobath concept considers muscle tone a greater problem than weakness in patients following stroke (Mayston,
2001). However, the experts agreed that if weakness is seen as a lack of, or reduced specificity of,
neuromuscular innervation, then weakness is as
much a problem as muscle tone. The experts
agreed that strength of individual muscle groups
is less important than their coordination in patterns of movement (Partridge and de Weerdt,
1995; Lettinga, Helders, Mol, and Rispens,
1997). However, they stated that strength may
still be an issue for efficient movement in some
patients. Altered muscle tone, changes in muscle
length and alignment, muscle weakness, and incoordination may all limit functional recovery in
patients following stroke. They concurred with
Mayston (2001) that muscles need sufficient
activity to generate force for action, length and
range to enable improved alignment for efficient
activation and effective movement, and a complex relationship between muscle groups to provide components of stability and mobility.
Unlike Mayston (2001), the experts stated that
altered muscle tone, along with weakness and
altered viscoelastic properties, may all impact the
patients ability to recover efficient movement.
Jones, Tallis, and Pomeroy (2003) stated that
Bobath therapists discourage resistive exercises
in patients with hemiplegia and that body weight
and gravity are used to facilitate normal
movement and not to increase muscle strength.

The Bobath experts disputed this and stated that

selective and specific strength training using
body weight, gravity, and appropriate resisted
exercises may be part of treatment within the
Bobath concept.
Sensory systems (Tables 1g and 2)
The experts suggested that providing specific
sensory stimulation may be necessary to promote localization of movement rather than to
facilitate movement in certain patterns (BBTA,
2003). Ultimately, the therapist is aiming to
reeducate the patients own internal referencing
system to provide accurate afferent input giving
the patient the best opportunity to be efficient,
specific, and have movement choices. The
experts disagreed with the blanket statement by
Lennon and Ashburn (2000) that therapists
strive to develop the patients internal reference
system by limiting the use of visual and verbal
feedback and emphasizing manual feedback at
all stages of skill acquisition. They identified
that at some stages of skill acquisition somatosensory referencing may be emphasized over verbal or visual feedback. However, there is a
selective process to both the choice and timing
of the sensory system used in treatment.
Neuroplasticity (Tables 1h and 2)
There was total consensus for the following
statements:
. The CNS and neuromuscular system can
adapt and change their structural organization
in response to intrinsic and extrinsic information (i.e., they are plastic) (BBTA, 2003).
. Changes within the structure of the CNS can
be organized or disorganized producing
adaptive or maladaptive sensorimotor behavior (BBTA, 2003).
. The cellular mechanisms that take place during
the development, refinement, and relearning of
motor control can result in long- or short-term
learning (i.e., carryover or no carryover)
(BBTA, 2003).
. The manipulation of information can directly
affect a change in the structural organization
of the CNS through spatial and temporal
summation and the facilitation of pre- and
postsynaptic inhibition (BBTA, 2003).
. Plasticity underlies all skill learning and is a
part of CNS function (Mayston, 2001).

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Table 3. Summary of the theoretical assumptions of the Bobath concept.

Systems approach

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The CNS is a complex organization consisting

of systems and subsystems. It uses a shifting
focus of control depending on many
biomechanical, neuroanatomical, and
environmental influences.
Human motor behavior is based on continuous
interaction between the individual, the
environment, and the task.
Ultimately, the therapist is aiming to reeducate
the patients own internal referencing system
to provide accurate afferent input giving the
patient the best opportunity to be efficient,
specific, and have movement choices.

Motor learning
The Bobath concept is goal oriented and task
specific and seeks to alter and construct both
the internal (proprioceptive) and external
(exteroceptive) environment in which the
central nervous system and therefore the
person can function efficiently and effectively.
Therapists need to be aware of the principles
of motor learning: active participation,
opportunities for practice, and meaningful
goals.
Therapy is an interactive process between
individual, therapist, and the environment.
Plasticity underlies all skill learning and is a
part of CNS function.
As part of the rehabilitation process, the
therapist must consider the 24-hour
management of the patient and his=her
way of life.

Function
Treatment has change of functional
outcome at its center.
The therapist must address both the specific
movement components of the task and the
functional activity to achieve goals.
Goals need to be realistic according to the
clients potential and appropriate to the
environment encountered during daily life.
A role of the therapist is to facilitate balance
and selective movement as a basis for
functional activity and successful goal
acquisition. Successful goal acquisition in
a given task must then be practiced to
improve efficiency and promote
generalisation.
Movement analysis
Therapists need to be skilled in the analysis
of normal movement.
Altered muscle tone, changes in muscle
length and alignment, muscle weakness,
and incoordination may all limit
functional recovery in patients
following stroke
Selective movement of the trunk and limbs,
both concentric and eccentric, are
interdependent and interactive with a
postural control mechanism. Therefore,
the recovery of selective movement is a
prerequisite for efficient postural control,
alignment, and function.
In therapy there is a need to address the
problem of an individuals specific ability
to create tone against gravity for the
necessary postural stability on which
selective movement is based.
Therapy aims to promote efficiency of
movement to the individuals maximum
potential rather than normal movement.
(Continued)

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Table 3. Continued.

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Adjuncts to treatment
The Bobath approach can be complemented with other modalities and adjuncts such as structured
practice, use of orthotics, and muscle strengthening.
Selective and specific strength training may be part of treatment within the Bobath concept.
Using other techniques in parallel, such as Maitland mobilizations, is compatible with the Bobath
concept.
Therapists may use a treadmill, and this could include facilitation to enable the most efficient
pattern.
Splinting and orthoses may be indicated to gain alignment or a good weight-bearing base for
improved proximal and truncal activity.
Restraint of the less affected body parts manually during a therapy session may be used to try to
assist activation of the affected parts.

The experts stated that each individual

patient is assessed in terms of his or her lesion,
individual movement expression, and potential
to maximize movement efficiency. The group
believed that therapy addresses not only the
neuromuscular system and spinal cord but also
higher centers to change motor performance
(BBTA, 2003). The experts suggested that motor
skill is based on reciprocal innervation and
sequential activation of motor units giving selectivity of movement control, simplifying the original BBTA statement (2003). Neuroplasticity is a
primary rationale for treatment in the Bobath
concept.
Additional therapy (Tables 1i and 2)
The additional therapy statements consider
where other therapy techniques or approaches
fit in relation to the Bobath concept. It was
agreed that the Bobath approach can be complemented with other modalities and adjuncts such
as structured practice, use of orthotics, treadmill, and muscle strengthening and can include
other techniques such as Maitland mobilisations
(Lennon and Ashburn, 2000; Mayston, 2001,
2003). The experts agreed that restraint of the
less affected body parts manually during a
therapy session may be used to try to assist
activation of the affected part, a variation on
the initial statement by Mayston (2001).
The experts agreed that, by using the treadmill, the therapist will include facilitation to
enable practice of the most efficient pattern,
which aims to provide the optimal performance

(Mayston, 2003). The experts concurred with

Mayston (2001) that the basis for splinting and
orthotics is to gain alignment or a good weightbearing base for improved proximal and truncal
activity. Lennon, Baxter, and Ashburn (2001)
suggested that Bobath therapists are unlikely to
prescribe walking aids or orthotics to enable a
patient to walk independently, more quickly,
because this may reinforce abnormal tone and
movement and therefore be detrimental to recovery. There was total disagreement with this statement, and although the experts did not offer an
alternative in this case, previous statements indicated that the experts would not stop the patient
walking and they would consider where appropriate the use of orthoses.
Summary
Five category headings were identified in the
group feedback session. Statements achieving
consensus consistently throughout the study
have been presented as a summary of the key
theoretical assumptions of the Bobath concept
within these categories in Table 3.
The experts in this study were members of
only one group within an international organization that is responsible for disseminating the current understanding and practice of the Bobath
concept worldwide and based on their individual
interpretation of the teachings of the Bobaths
(Raine, 2006). It is important to acknowledge
that the statements presented here are representative only of the expert group in the United
Kingdom. It would be valuable to collect the

Raine/Physiotherapy Theory and Practice 23 (2007) 137
152

opinions of members from the International

Bobath Instructors Training Association to
identify the theoretical assumptions of the
Bobath concept as they are understood and
practiced worldwide.

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Conclusion
By using a four-round Delphi method and
expert panel, a number of theoretical assumptions
underpinning the Bobath concept were determined. Statements that the experts disagreed with
were also highlighted. Two specific features that
were consistently in contrast with statements in
the literature included the use of efficient movement compared to normal movement, and
the emphasis placed on the patient being in control
of their own movement, rather than dependent on
the therapist. It was evident from this study that
Bobath therapists need to be aware of principles
of motor learning, such as active participation,
opportunities for practice, and meaningful goals.
Therapy is an interactive process between the individual, therapist, and the environment. In therapy,
there is a need to address the problem of an individuals specific ability to create tone against gravity
for the necessary postural stability on which selective movement is based. The aim of therapy is to
promote efficiency of movement to the individuals maximum potential and has change of functional outcome at its center. The Bobath concept
can be complemented with other modalities and
adjuncts such as structured practice, use of orthotics, treadmill, restraint, and muscle strengthening.
This study provides a long-awaited snapshot
of the current theoretical assumptions, as identified by the members of BBTA. It is expected that
with advances in knowledge and research, the
Bobath concept and its underpinning theory will
continue to change. It is important that this basis
for therapeutic intervention is described and
updated to enable both clinicians and researchers
to evaluate advances in their clinical practice.

Acknowledgments
The author thanks British Bobath Tutors
Association and Ms. S. V. Smith, Principal
Lecturer, School of Allied Health Professions,
Leeds Metropolitan University.

151

References
Ashburn A, Jones D, Plant R, Lovegreen B, Kinnear E,
Handford F, Loader S 2004 Physiotherapy for people
with Parkinsons disease in the UK: An exploration of
practice. International Journal of Therapy and Rehabilitation 11(4): 160
167
British Bobath Tutors Association. 2003 BBTA neurophysiology handbook. Basic Adult Hemiplegia Course
Bobath B 1970 Adult hemiplegia: Evaluation and treatment.
Oxford, Butterworth-Heinemann
Bobath B 1990 Adult hemiplegia: Evaluation and treatment,
3rd ed. Oxford, Butterworth-Heinemann
Cornall C 1991 Self-propelling wheelchairs: The effects on
spasticity in hemiplegic patients. Physiotherapy Theory
and Practice 7: 13
21
Davidson I, Waters K 2000 Physiotherapists working with
stroke patients. Physiotherapy 86: 69
80
Deane KHO, Ellis-Hill C, Dekker K, Davies P, Clarke CE
2003 A Delphi survey of best practice occupational
therapy for Parkinsons disease in the United Kingdom.
British Journal of Occupational Therapy 66(6): 247
254
Goodgold-Edwards SA 1993 Principles for guiding action
during motor learning. A critical evaluation of Neurodevelopmental treatment. Physical Therapy Practice 2(4):
30
39
Hesse S, Jahnke MT, Schaffrin A, Lucke D, Reiter F,
Konrad M 1998 Immediate effects of therapeutic facilitation on the gait of hemiparetic patients as compared
with walking with and without a cane. Electroencephalography and Clinical Neurophysiology 109: 515
522
International Bobath Instructors Training Association 1999
Theoretical assumptions (Internet). Available from:
hhttp:==www.ibita.orgi (Accessed 11 November 2003)
International Bobath Instructors Training Association 2003
Categories of instructors. (Internet). Available from:
hhttp:==www.ibita.org=instructor training.htmi
(Accessed 11 November 2003)
Jones M, Tallis RC, Pomeroy VM 2003 Use of resistive exercise for muscle strengthening in early stroke rehabilitation.
A survey of UK neurophysiotherapists. Synapse Spring:
3
7
Langhammer B, Stanghelle JK 2000 Bobath or motor
relearning programme? A comparison of two different
approaches of physiotherapy in stroke rehabilitation: A
randomised controlled trial. Clinical Rehabilitation 14:
361
369
Lennon S 1996 The Bobath concept: A critical review of the
theoretical assumptions that guide physiotherapy practice
in stroke rehabilitation. Physical Therapy Reviews 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
Lennon S, Ashburn A 2000 The Bobath concept in stroke
rehabilitation: A focus group study of the experienced

Physiother Theory Pract Downloaded from informahealthcare.com by Athlone Institute of Technology on 08/31/13
For personal use only.

152

Raine/Physiotherapy Theory and Practice 23 (2007) 137
152

physiotherapists perspective. Disability and Rehabilitation 22(15): 665
674

Lennon S, Baxter D, Ashburn A 2001 Physiotherapy based
on the Bobath concept in stroke rehabilitation: A survey
within the UK. Disability and Rehabilitation 23(6):
254
262
Lettinga AT, Helders PJM, Mol A, Rispens P 1997 Differentiation as a qualitative research strategy. A comparative analysis of Bobath and Brunnstrom approaches to
treatment of stroke patients. Physiotherapy 83(10):
538
546
Linstone HA, Turoff M 1975 The Delphi method: Techniques and applications, pp 15
35. London, AddisonWesley Publishing Company
Lynch-Ellerington M 2000 What are associated reactions?
Synapse Spring: 28
30
Mayston MJ 2001 The Bobath concept today. Synapse
Spring: 32
35.
Mayston MJ 2003 What has changed and what stays
the same in the concept? (Internet) Available from:
hhttp:www.fysio.dk=sw15980.aspi
(Accessed
11
November 2003)
Panturin E 2001 The Bobath concept. Letter to the editor.
Clinical Rehabilitation 15: 111
Partridge CJ, de Weerdt W 1995 Different approaches to
physiotherapy in stoke. Reviews in Clinical Gerontology
5: 199
209
Pomeroy VM, Tallis RC 2002 Restoring movement and
functional ability after stroke. Now and the future.
Physiotherapy 88(1): 3
17

Punt TD 2000 No success like failure: Walking late after

stroke. Physiotherapy 86(11): 563
566
Raine S 2006 Defining the Bobath conceptusing the Delphi
technique. Physiotherapy Research International 11(1):
4
13
Rice-Oxley M, Turner-Stokes L 1999 Effectiveness of brain
injury rehabilitation. Clinical Rehabilitation 13 (suppl 1):
7
24
Sackley CM, Lincoln NB 1996 Physiotherapy treatment for
stroke patients: A survey of current practice. Physiotherapy Theory and Practice 12: 87
96
Shumway-Cook A, Woollacott MH 2001 Motor control:
Theory and practical application, 2nd ed. Baltimore,
MD, Williams & Wilkins
Sparkes V 2000 Physiotherapy for stroke rehabilitation: A
need for evidence-based handling techniques. Physiotherapy 86(7): 348
356
van Vliet PM, Lincoln NB, Robinson E 2001 Comparison of
two physiotherapy approaches for stroke. Clinical
Rehabilitation 15: 398
414
Wagennar RC, Meijer OG, van Wieringen PCW, Kuik DJ,
Hazenberg GJ 1990 The functional recovery of stroke:
A comparison between neurodevelopmental treatment
and the Brunnstrom method. Scandinavian Journal of
Rehabilitation 22: 1
8
Ziglio E 1996 The Delphi method and its contribution to
decision-making. In: Adler M, Ziglio E (eds), Gazing into
the oracle. The Delphi method and its application to
social policy and public health, pp 3
33. London, Jessica
Kingsley Publishers