Overview of Stroke and Disability
The World Health Organization (WHO) defines stroke as, “rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin” (WHO 1989). Stroke is characterized by an interruption of the blood supply to the brain (ischemia) or hemorrhage in the brain tissue, commonly involving a disruption in the motor and sensory pathways.
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Clinical manifestations include impaired motor control that can be characterized by muscle weakness, altered muscle tone, and abnormal movement patterns. These impairments limit the ability of the patient to perform functional activities, such as walking, climbing stairs, and self-care (Shelley & Brouwer, 1997).
In Britain, the incidence of stroke is 200 per 100,000 people per year, with three-quarters of first strokes occurring among people aged 65 years and above (Davidson & Waters, 2000). ). Approximately 500,000 Americans experience a stroke each year, and of this number 350,000 will survive. Even though the number of stroke patients is decreasing, their proportion in the population appears to be rising.
This is related to the increase in the number of stroke survival patients and the growth of the elderly population (Duncan 1994). The manifestations of the consequences of stroke in the surviving patients, whereby their functional abilities are severely impaired, bring into the picture the requirement of rehabilitation of these patients. It is in the rehabilitation of these surviving stroke patients that physiotherapy has a major role to play (Davidson & Waters, 2000). The objective of this paper is to present the Bobath concept as a part of the rehabilitation of stroke assessment and to critically evaluate its effectiveness.
The Bobath Concept
The Bobath concept was first established in the late 1940s. It is a concept based on the work of Berta and Karel Bobath, which offers therapists working in the field of neurological rehabilitation a framework for their clinical interventions. The Bobath concept views the functional disabilities of a stroke victim as a problem, that requires a solution, and hence the approach in the Bobath concept is a problem-solving approach (IBITA, 2006). In the words of Bobath, 1981, the concept is essential “…
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” (Mayston, 2000). The Bobath concept thus attempts to modify the traditional thinking on rehabilitation with the stress on teaching exercises, to a more individual-oriented and holistic approach, wherein the importance was on the individual nature of each person’s problems and the concomitant importance of setting goals and intervening on the basis of the specific individual needs of each patient (IBITA 2006).
According to Tatjana and Milvijov, 2006, the Bobath concept involves the whole person, not only his sensory-motor problems but also problems of development, perceptual-cognitive impairment, emotional, social, and functional problems of daily life. Thus the aims of the concept are re-education of normal movement, normalizing of tone, facilitation of postural adjustments and normal function, and preventing secondary complications. In other words, there are four aspects to the Bobath Concept namely facilitation, re-education of normal movement, tone reduction, and prevention of secondary complications (Lennon, Ashburn, & Baxter, 2001).
The theoretical framework behind the Bobath Concept in the rehabilitation program of a stroke patient includes muscle patterns, not isolated movements utilized for motion; inability to project nervous impulses in various combinations, as used by an individual with intact CNS; suppression of abnormal patterns prior to the introduction of normal patterns; avoidance of mass synergies, which may strengthen unresponsive muscles leading to strengthening of abnormally increased tone reflexes and spasticity; reflex-inhibiting patterns employed to reduce abnormal postural reactions and facilitate automatic voluntary movements; modification of abnormal patterns at proximal key points of control like the neck, spine, shoulder, and pelvis (Bruno-Petrina, 2007).
Facilitation as an Aspect of the Bobath Concept
Facilitation is part of an active learning process that requires manual contact and is designed to make the activity possible; it demands a response and allows the response to happen (IBITA 2006). This stems from the stress in the Bobath concept that “unless you stimulate or activate your patient in the way in which new activities are possible, you have done nothing at all” (Mayston 2003).
A critical evaluation of this aspect of the Bobath concept suggests that while clinical practice experience finds utility in the power of handling techniques, there is limited study evidence on the actual role that facilitation plays in the rehabilitation of a stroke patient. The Bobath concept came into place more than five decades ago, at a time when empirical knowledge was sufficient and accepted. However, since that time facilitation has hardly come under the scanner of scientific scrutiny and remained an accepted aspect in the rehabilitation of stroke victims (Brown, 2005).
Reduction of Normal Movement as an Aspect of the Bobath Concept
The Bobath concept founds the rationale of reducing normal movements on the knowledge that an individual with hemiplegia tends to compensate using the sound side of the body, for any loss of function on the affected side, when recovery is not to optimum levels. For example in an individual with spastic diplegia, there is the tendency to overuse the upper part of the body to compensate for the lack of optimum activity in the lower limbs.
The reduction in normal movement that the Bobath concept recommends is to avoid the overuse of the normal parts of the body by training the affected parts to function more effectively. Thus during rehabilitation, the Bobath concept restrains the use of the less affected parts of the body manually to try and encourage activation of the affected parts of the body. This in essence is the basis of the Bobath concept proposal that working towards normal movement patterns leads to function.
Unfortunately, there is a tendency to misunderstand the reduction of normal movement as an aspect of the Bobath Concept to imply that patients with neurological impairment due to stroke can become normal only if the right form of rehabilitation is provided and spasticity is avoided due to overactivity or activity too early of the unaffected side and in that avoiding movement altogether.
The emphasis in the Bobath Concept, with its patient-centered approach, is that the role of the physiotherapist is to assist the affected individual towards functioning in the best possible manner, helping them to counteract any unwanted increase in tone in tone, not stopping movement altogether. (Mayston, 2000). According to Mayston, 2000, “although learning movement patterns might be a part of the re-learning process, clients need the opportunity to practice functional, meaningful tasks if therapy is to be effective”.
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Tone Reduction as an Aspect of the Bobath Concept
The Bobath Concept perceives tone as the major issue in the rehabilitation of hemiplegic patients (Lennon & Ashburn, 2000). Such a perception arises from the proposal of Bobath that the main reason for reduced functional ability is the result of abnormalities in tone, for example, spasticity, and is thought to occur as a result of an abnormal increase in tonic reflex activity. Such being the case abnormalities in tone could be inhibited and should be one of the targets of the rehabilitation process (Mayston, 2000).
In the Bobath Concept, physiotherapy techniques are targeted at improving motor performance partially through the manipulation of the muscle tone of the stroke victim. This approach advocates the reduction of spasticity and primitive postural reflexes in advance of facilitating voluntary activity in paretic muscles by paying attention to trunk posture and controlled muscle stretch of limbs. This objective is obtained by segmental reflex hyper-excitability by the inhibition of distal segmented reflexes through inhibitory interneurons (Bhakta, 2000).
Prevention of Secondary Complications
There are several exacerbating factors that need to be considered in the management of a stroke patient. These factors include soft tissue rheumatism, pressure sores, and deep venous thrombosis, and post-stroke pain syndrome. Preventing the occurrence of these factors that could affect the rehabilitation program of the stroke patient in a negative manner is essential to the success of the rehabilitation of the stroke patient (Bhakta, 2000).
There is evidence to suggest that cardio-respiratory deficits in the form of atherosclerosis, hypertension, and coronary heart diseases are seen quite often in patients with stroke and could pose clinical problems during the rehabilitation program. The co-morbid or resultant cardio-respiratory deficits need to be addressed as a part of the rehabilitation program to prevent the deficits from developing into serious secondary complications (Brownlee & Durward, 2005).
The Bobath Concept is a holistic approach to the rehabilitation of the stroke patient, which takes into accounts any existing co-morbidities and the possibility of the secondary complications that could develop as a result of the existing co-morbidities or from the disabilities brought about by the stroke event. The Bobath concept emerged as an improvement to the traditional approach to the rehabilitation of stroke patients.
Lettinga & Reynders, 2002, point out that the major concern here was in the prevention of undesirable side effects that were commonly seen in the use of the traditional orthopedic approach to rehabilitation of a stroke patient. Perceived from this context the Bobath concept attempts not just to prevent secondary complications as a result of the stroke and any possible existent co-morbidities, but also any possible secondary complications that could develop as a result of the rehabilitation program of the stroke patient.
Effectiveness of the Bobath Concept
Were effectiveness to be a measure of the popular use of the rehabilitation concept in the stroke patients, then it would be easy to claim that the Bobath concept is effective, for it is one of the most widely used approaches in stroke patients’ rehabilitation in Europe (Lennon, Baxter & Ashburn,2001). A study by Davidson and Waters (2000) showed that 88% of neurological physiotherapists in the UK use the Bobath approach in the rehabilitation of stroke patients.
Yet effectiveness cannot be measured on the basis of popular use and evidence is necessary for the measure of effectiveness. It also needs to be understood that it is more than five decades since the Bobath concept was developed for the rehabilitation of stroke patients and over these five decades there have been several changes to the underlying basis of the concept. However, there is a clear lack of relevant literature to make known the changes and the extent of the changes, which has led to many misconceptions of the Bobath Concept on one side and the continuation of outdated ideas on the other.
The examination of the efficacy of the Bobath Concept thus has to tread through these difficulties to arrive at a clear picture (Edwards, 2001). Such a perception finds support from Raine, 2006, who points out that according to the experts the Bobath concept as developed by the Bobaths is a living concept, which accepts that as the knowledge base of the physiotherapists grows, so too would the view of the treatment broaden. Unfortunately along with this broadening has come about the misunderstanding that has led to the Bobath Concept being considered in a narrow manner to target inhibition of spasticity and facilitation of normal movement (Raine, 2006).
Evidence on the Effectiveness of the Bobath Concept
There is evidence to show the effectiveness in the use of the Bobath Concept in early rehabilitation of stroke patients on activities of daily living and prevention of the development of a complication when the rehabilitation program was initiated within a month of the stroke event. Patients receiving the rehabilitation program based on the Bobath Concept showed significant positive effects in terms of bed chair transfer, eating capabilities, and preliminary ambulation in comparison to patients who did not receive any rehabilitation at this early stage. This evidence suggests that starting rehabilitation of a stroke patient at the early stage could prove useful in initiating functional recovery. (Xu, et al, 2004).
From Pomeroy and Tallis, 2001, comes evidence to suggest that rehabilitation of stroke patients, using the Bobath Concept, does have immediate beneficial effects on the co-duction in the corticospinal pathway and the ability to control joint movement.
It is possible for a large proportion of stroke patients to regain the ability to walk, but this ability is seldom near the normal walking ability. This makes gait re-education an important part of the physical therapy intervention in patients subsequent to a stroke. Abnormal tone either higher or lower is one of the key factors that have an adverse effect on the movement patterns of the patient. Normalization of tone is, therefore, a critical element in the preparation of the patient to return to the functional activity of walking.
Re-education of the basic movement patterns involving the trunk, pelvis, and limbs are the critical features in the Bobath concept to the facilitation of selective control of movement. Based on the findings of a study involving the use of the Bobath concept for rehabilitation of the impairment and walking disability on patients after stroke, there is evidence to suggest that there is credibility in the Bobath Concept belief in the possibility of re-education of movement follow a stroke (Lennon, 2001).
From Ansari and Naghdi, 2007, comes evidence of the efficiency of the Bobath approach on the excitability of the spinal alpha neurons in patients with spasticity subsequent to stroke. This study shows that using a rehabilitation program based on the Bobath Concept there was a significant reduction in spasticity, which was detectable through measurement using the Ashworth scale. The authors conclude that the use of the Bobath Concept enables excitability of the alpha neurons on the affected side in comparison to the unaffected side in stroke patients, who have developed spasticity (Ansari & Naghdi, 2007).
However, this evidence does not provide any definite conclusion on the efficacy of the Bobath Concept. There is evidence that is either neutral to it being the optimal mode of physiotherapy intervention or shows it in a weak light in comparison to other approaches. Based on a literature review of fifteen trials Pace, 2003, concluded that there is hardly any evidence to support the Bobath Concept being the optimal mode of rehabilitation of patients subsequent to stroke. The author goes on to acknowledge that methodological limitations of the studies involved do not permit concluding that the Bobath Concept is ineffective either (Pace, 2003).
Luke, Dodd & Brock, 2004, arrived at similar findings of the efficiency of the Bobath Concept with regard to reducing upper limb impairments, activity limitations, and participation restrictions after stroke, through a review of suitable literature. However, the authors were unable to draw any conclusion due to the limitations relating to methodological quality, the outcome measures used and contextual factors investigated. According to Vliet, Lincoln & Foxall, 2005, there were no significant differences in movement abilities or functional independence between patients receiving a Bobath- based or a movement science-based intervention.
In other studies comparing the outcome of different physiotherapy regimes to the Bobath Concept in the rehabilitation of patients after stroke, the findings do not favor the Bobath Concept. Langhammer & Stanghelle, 2000, found the Motor Relearning Program more effective than the Bobath Concept in the acute rehabilitation of stroke patients. Again Carr & Shepherd, 1998, have found that the Motor Re-learning Programme was more beneficial in terms of improved motor function and reduced a patient’s stay in hospital as compared with the Bobath program after the first three months of stroke.
The lack of any convincing evidence in favor of the Bobath Concept or against it finds reflection in the words of Cheng & Shaw, 2006, that “traditional rehabilitation strategies (Bobath, Brunnstrom, proprioception neuromuscular facilitation, and motor relearning) have been used for many years. However, few of these interventions have been tested in clinical trials and are thus practiced on an empirical basis”.
An examination of the efficiency of the Bobath Concept throws light on the state of the role of physiotherapy in the rehabilitation of stroke patients. Going back to the IBTA 2006 implications of the Bobath Concept we find that importance is on the individual nature of each person’s problems and the concomitant importance of setting goals and intervening on the basis of the specific individual needs of each patient.
Yet even today the goal-setting process sees a difference in the expectations between the patient and the physiotherapist. Though the importance of goal setting is understood, it is the understanding of the term that is not shared by the patients and the physiotherapists. For the Bobath Concept to become efficient it thus becomes necessary that the basis of its foundation needs to be understood, for the Bobath is a shared experience between the care seeker and the care provider (Forster & Young, 2002).
The Bobath Concept is not rigid but is expected to grow with the increasing knowledge acquired in the rehabilitation of stroke patients leading to improvements in the treatment. It has and over the more than five decades since its inception, there have been changes to the Bobath Concept is accepted today. The problem with the developments in the Bobath concept has been the lack of proper dissemination of the Bobath Concept as it is accepted today.
This leads to a misunderstanding of the Bobath concept, where it is considered as the inhibition of spasticity and the facilitation of normal movement, as described in some literature (Raine, 2006). In this aspect Tyson & Selley, 2007, point out that though many physiotherapists look upon themselves as eclectic in practice, in actuality they follow a traditional Bobath model in practice without incorporating the recent developments in the Bobath concept.
Yet again on the issue of resistive exercise, it is misunderstood that the Bobath Concept rules out any resistive exercise. (Brownley & Durward, 2005). If the use of the body weight and gravity is considered as resistive exercise then the Bobath Concept is not against it, as body weight and gravity are a natural part of the Bobath Concept to facilitate normal movement. It is when resistive exercise is used to develop strength in the muscles that it runs against the grain of the Bobath Concept (ACPIN, 2003).
Thus the definition of terminology and a proper understanding of the Bobath Concept are required to remove misconceptions and arrive at a true picture of the efficiency of the Bobath Concept. According to Raine, 2007, “the Bobath experts agreed 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 the individual, therapist, and the environment and aims to promote the efficiency of movement to the individual’s maximum potential rather than normal movement. Treatment was identified by the experts as having “change of functional outcome” at its core”.
Moving on to the issue of lack of evidence either in support of the efficiency of the Bobath Concept or against it, we need to take a cue from Luke, Dodd & Brock, 2004, when they refuse to conclude draw any conclusion due to the limitations relating to methodological quality, the outcome measures used and contextual factors investigated. Lettinga, Reynders & Milder, 2002 in a remarkable manner highlight the reasons why the analysis of treatment goals and the outcome measurements in the different stroke rehabilitation interventions fail to provide an answer on the efficiency of the Bobath Concept.
They point out that though scientifically credible tools may be neutral as far as the user is concerned, they are not neutral to the therapies being compared in the researches carried out. For example, when the Bobath Concept is compared to the traditional exercise therapy, the Bobath concept fails when the selected outcome is based on the development of muscle strength the intended goal of exercise therapy and not in terms of the evaluation of the possible harmful side of the exercise therapy (fixation in a few abnormal patterns of posture and movement) and the desired effects of the Bobath Concept like the ability of the patients to make selective movements on their hemiplegic side.
Again in the comparison between the Brainstorm model and the Bobath Concept the ARA test is a blunt instrument that fails to distinguish between pathological movements and normal movement patterns in a stroke patient and in that blurs the efficiency of the Bobath Concept in comparison to the Brainstorm model. (Lettinga, Reynders & Milder, 2002).
The Bobath Concept still remains an extremely relevant model in the rehabilitation of patients after stroke. However for this to have greater acceptance, the developments that have occurred in the Bobath Concept as a result of increased knowledge need to be spelled out with clarity with terms clearly defined to make way for a proper understanding of the Bobath Concept. The onus then shifts to the neuron-physiotherapists to understand the basis of the Bobath Concept and its developments in the application of the model in the rehabilitation of the patients after stroke. There is a need for further studies to confirm the efficiency of the Bobath Concept. The measures of efficiency in comparative studies need to be so selected so that they are not in favor of any of the models of rehabilitation being evaluated.
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