Neuro Developmental Therapy a.k.a Bobath Concept From The Perspective Of Speech Language Pathologists..

1. DepartmentOfSpeech-LanguagePathology
Submitted By – Piyush Malviya
Topic – Neuro-Developmental Therapy
WHAT IS THE NEURO-DEVELOPMENTAL THERAPY?
 Dr Karel Bobath and his wifeBerta Bobath beganworking with children
with CP in the 1940sand continued developing their treatment concept
until they retired in1987.
 They said that their concept wasnot so much a treatment scheduleasa
way of thinking about how cerebralpalsycan affect children.
 The therapist must beableto observe and analyse what it is that
prevents a child from carrying out functionaleverydaytasks and then
devise a treatment programmethat willpreparethechild to do them.
 Each child is different and each one must be analysed and may be
treated inan entirely different way.

2.  The Bobath concept is an approach toneurologicalrehabilitationthat
is applied in patient assessment and treatment (such aswith adultsafter
stroke, or childrenwith cerebralpalsy).
 The goal of applying the Bobath concept is to promote motor learning
for efficient motor control in variousenvironments, therebyimproving
participation and function.
 Thisis done through specific patienthandling skills to guidepatients
through initiationand completionofintended tasks.
 Thisapproach toneurological rehabilitationismultidisciplinary,
primarilyinvolving physiotherapists, occupationaltherapistsand speech
and languagetherapists.
 In the United States, theBobath concept is also known as 'neuro-
developmentaltreatment (NDT).
HOW CAN IT HELP CHILDREN WITH CP & DYSARTHRIA?
 Normalposturaltone is the level of tensionin those groups of muscles
that keep us upright whengravitywould pull us down.
 Thisnormal level of tension also allows us to automaticallyadjust our
positionin a coordinated waytobalanceand move.
 It is the lack of thisfine-tuned COORDINATION that preventschildren
with cerebralpalsy from moving in functionalwaysand holding postures
against gravity.
 If a child’sposturaltone is too high she may be able to hold a position,
though she will not be able to keep her balanceor move much.
 If is too low, or if it fluctuatesbetweenlow and high, she will not be able
to hold a positionwhere gravitycaninfluence her, but she will be able to
move.
 However, her movementswill be uncoordinated and maybe involuntary.
 In normalmovement thereis reciprocalinteractionbetweenthegroups
of muscles.
 This reciprocalinteractiongivesusfixationPROXIMALLY (for example
in the trunk, SHOULDER GIRDLE and PELVIS) to allow for movement
DISTALLY (limbs).
 It gives us graded control of AGONIST and ANTAGONIST: inother
words, coordinated CO-CONTRACTION, for smooth timing, GRADING
and directionofmovement.
 It also givesus automatic adaptationofmuscles to changesin posture.
 So far, research hasnot been able to prove that NDT treatment can
directlyaffect the brain.

3.  However, we know that by giving a young child experienceof activenew
movementsand postures, he will achievefunctionalgainsthat canbe
measured.
 The more these new activitiesarepractised the easier theywill be to
perform.
 Thisis becausenew connections or SYNAPSES willbe madewithinthe
brain(neuroplasticity).
PRACTICE OF NEURO-DEVELOPMENTAL THERAPY –
 The practiceofthe Bobath approach or neurode- velopmental treatment
(NDT) is different in different countries, indifferent partsof a country
and in
different centres.
 Physiotherapistshavehad to make modificationsbased ontheir clinical
experiencesand on the criticalcommentsof others.
 As there is increasing scientificunderstanding ofthe brainand nervous
system, the theoriesand concept of the Bobath system have been
challenged by a number of therapistsand other workers(Gordon 1987;
Hora 1992; Shepherd 1995; Damiano 2004).
 Howle (2002) suggeststhat contemporarytheoriesdeveloped by other
approachesarenow used for NDT.
 She quotesMrs Bobath who maintainedthat theconcept (or philosophy)
had not changed through theyears but thetechniqueshave been
developed and refined.
 A series of several photographs inHowle's book show a skillful Bobath
treatment with handling not only with handsbut also with the
therapist'sbodyand legs to positionand treat a girl with cerebralpalsy
of a mild and moderatecondition.
 These are familiar Bobath methodsdespitethe 'new theories'. Mayston,
a former Director of the original Bobath Centreevidence is availableto
show that therapyoffered by the "named approaches" iseffectiveor that
one approach ismorebeneficialthananother' (Mayston 2004).
 Maystonhas provided new thinking and self- questioning by
physiotherapistswedded to thissystem.
 She also says that 'Bobath therapists' should and have becomemore
eclectic (Mayston2004, 2008).

4.  Thisis reassuring astheBobaths (Bobath & Bobath 1984), referring to
earlier editionsof this book, firmly stated that 'Eclectic treatment, using
a mixtureoftreatment techniques derived from variousschools of
thought which see the child'sproblems from different viewpoints,
cannot result in a cohesivetreatment programme'.
 Mayston(2004) also pointsout that conductiveeducation(which isa
learning approach) placesmoreemphasison the child'sinitiation,
participationand practise'which isdifferent to the Bobath approach'.
 Thisis also different to any motor learning approach.
 The dramaticchangesintheoriesunderlying NDT make it no longer
clear what this approach consistsofin theory and practiceand how
different it is from other therapistswhohave never been dedicated to
thisapproach.
FEATURES OF THE NEURO-DEVELOPMENTAL THERAPY –
 Preparation for movement patterns specificallyselected to treat
abnormaltone associated with abnormalmovement patternsand
abnormalposture.
 Key componentssuch as extension, rotationand symmetryoften form
the basisfor motor skills and receive treatment methods.
 Developmental sequencesweremorestrictlyfollowed in the past,
but are now modified (Mayston 1992, 2004).
 Sensorimotor experience - The reversal or 'break-down' of the
movement abnormalitiesissaid togive the child the sensationof more
normaltone and movements.
 Thissensory experience, now called 'feedback', is provided by the
therapist'shandling and isbelieved to gainmore normalmotion.
 Learning to move is entirely dependent on sensory experience' (Bobath
& Bobath 1984).
 Key pointsof controlare used by many therapists tochangethepatterns
of spasticity so that a child is prepared for movement and correct
posture.
 The key pointsare usually head and neck, shoulder and pelvic girdles, as
well as use of distalkey pointsto aim to 'normalise' abnormaltone.
 All-day management byparentssupplements treatmentsessions.
 Parentsand others areadvised on daily management and trained totreat
the children.

5.  NancieFinnie(1997) has writtena book for parentson thisall-day
handling of thechild in the home.
HOW CAN TREATMENT BE GIVEN?
 There area few therapycentresof great excellencein some of the richer
countries.
 These centresare a resourcefor teaching and research and give
examplesof good practice.
 It is not possible for every child with CP to receive treatment at such
centres.
 In specialist centres, therapistshavetimeto carryout long treatment
sessions with each child.
 During these sessions the therapist willbe able to use very skilled and
sensitive handling techniquestoenable the child to play and be activein
a satisfying way.
 She will also be ableto teach the child’s carersto carryout similar
treatment at home.
 All of this requires immensededicationand not every family will feel
ready or ableto commit togiving so much timeand effort, not only to
takethe child to the centrewhenever needed but also to carryout the
treatment at home.
 For most childrenand their families, theideal provisionof treatment
would be to have a centreof excellence close enough for them to visit
once in a while with their therapist or whoever is helping them in
treating their child.
 At this centrethe child will have a very thorough assessment so that the
factorsinterfering with her functionareclearly identified.
 Then a feasible programmefor her handling and managementwillbe
discussed with all those caring for her.
 If thisprogrammehasrealistic, achievablegoals, thefamily will be
motivated tocarryit out and to returnafter some monthsfor a
reassessment and a new programme.
 Also, in thisidealcentre, specialist doctorswillsee childrenfrom timeto
timeto assess their medicalneeds.
 Those childrenwho need medicationtoprevent seizures, for example,
need regular monitoring, and manychildrenneed to be X-rayed and
checked by orthopaedic specialiststomakesure they are not in danger of
hip dislocationand other DEFORMITIES.

6.  Alongsidethese services therewill also be ORTHOTISTS to provide
appropriatesplints, psychologists tohelp familieswith learning
disabilitiesand behaviour problems, perhapsa toy libraryto encourage
interesting play, and a workshop where specialequipment such as chairs
or standing framescanbe made.
 Thiskind of centrecanbe a resource for community-based rehabilitation
programmesto call upon.
 The role of the expertsbased in such a centreis to advisecommunity
workers when they need help in order to progress with a particular child.
 They can also monitor children’sprogress, particularlyinthe yearswhen
they are growing fast and are thereforein more danger of contractures
and deformities.
 When such centres arenot possible becausethereare no highly qualified
experts, thereis still a good deal that can be done for childrenwith CP by
communityworkersor volunteers who are readyto learn and who are
convinced that something worthwhilecanbedone.
 The most important thing for any child with CP is to be given
opportunitiesto socialize with other childrenin his family and in his
community.
 To do this he needs to be placed in positionsother thanlying down.
 Communityworkerswho have the possibilityof working with
carpenters, or who can makepieces of equipment for positioning
childrenout of cardboard (AppropriatePaper-based Technology, or
APT), canmake a hugedifference to the childrenthey work with.
LIMITATIONS & CRITICISM OF THE NEURO-DEVELOPMENTAL
THERAPY –
 The concept that Bobath can“evolve” and still be called Bobath has been
challenged by the president of theAmerican AcademyofCerebralPalsy
and DevelopmentalMedicineand the chair of the UK Associationof
Chartered PhysiotherapistsinNeurology(ACPIN).
 These eminent physiotherapistsbelievethat several of the key original
teachingsofthe founders have now been abandoned, whilst theideas /
conceptsof others (non Bobath therapists& scientists) have
unjustifiablybeengiven the name of Bobath.
 There is widespread useof the Bobath concept amongst therapistsin
stroke rehabilitation.

7.  Yet, a large review of randomized controlled trials(RCTs) of Bobath for
stroke rehabilitationfound only three instancesof significantdifferences
in favour of Bobath, yet 11 in favour of alternatives.
 The authorsconcluded that therapistsshould basetheir treatment
methodson “evidence-based guidelines, accepted rulesof motor
learning, and biologicalmechanismsoffunctionalrecovery, rather than
therapist preferencefor any named therapyapproach”.
 Thisreview pointed out that the approach isnow regarded as“obsolete”
in some Europeancountriesand it is thereforeno longer taught.
 In 2018a major review of upper limb interventionsfollowing stroke
found significant positiveeffects for constraint and taskspecific
therapiesand the supplementaryuseof biofeedbackand electrical
stimulation.
 However, they concluded that theuse of Bobath therapywas not
supported.
 In the UK, an NHS review of stroke rehabilitationbyProfessor Tyson
concluded that "thestrength of evidencethat taskspecific functional
training and strength training areeffective, whilst Bobath is not,
indicatesthat a paradigm shift isneeded in UK stroke physiotherapy.....
it is increasinglydifficult to justifythe continued use of the Bobath
concept or itsassociated techniques".
 More recentlyProfessor Tyson and Dr Mepsted have both written
comprehensiveand criticalreviewsof Bobath/NDT methods, theoryand
effectiveness.
 Nationalevidencebased guidelinesfor stroke rehabilitationhavebeen
published for England, Netherlands, Canada, Australiaand New
Zealand; yet in none of these is the Bobath approach recommended.
 Conversely, in 2016 the AmericanStrokeAssociationconcluded that
although the effectivenessof NDT/Bobath (compared with other
treatment approaches) had not been established that it still “maybe
considered” asa treatment optionfor mobility.
 Thishowever wastheir lowest classificationofan acceptabletreatment.
Their two highest recommendationgroups(“should be performed” and
“reasonableto perform”) contained a varietyof treatmentsfor which
there wasmuch better evidence.
 NDT/Bobath wasnot listed as an optionfor arm/hand rehabilitation.
 Also in 2016, therevised RCP guidelinesfor stroke madeno mentionof
Bobath/NDT, whilst many alternativeswererecommended.

8.  Importantlythey stated that ifa treatment wasnot mentioned then it
was not recommended and need not be funded.
 They also stated that therapistsusing such methodsmust objectively
review their optionsin the light of the evidencesupporting the
recommended alternatives.
 Furthermore, patientsreceivingsuch interventionsshould be informed
that it was outsidemainstreampractice.
 The Bobath (NDT) approach isalso widely used on childrenwith
cerebralpalsy (CP).
 However, when the effectivenessof interventionsfor the treatment ofCP
was reviewed by Novak et al. they concluded “Consequently, there areno
circumstanceswhereanyof the aimsof NDT could not be achieved by a
more effectivetreatment.
 Thus, on the grounds of wanting todo the best for children with CP, it is
hard to rationalizea continued placefor traditionalNDT withinclinical
care”.
 They consequently recommended “ceasingprovisionof the ever-popular
NDT”.
 The dichotomybetweenthepopularityand institutionalfunding of this
approach versusthe negative findingsof most RCTs has been excused on
the groundsthat RCTs may not be suitablefor neurorehabilitation.
 Yet, theBritish Bobath TutorsAssociationwebsitedoesquotethe
minorityof RCTs that support their approach.
REFERENCES -
1. Early Diagnosis& InterventionalTherapyIn CerebralPalsy: An
InterdisciplinaryAge-Focused Approach; 3rd EditionByAlfred L.
Scherzer
2. Treatment OfCerebralPalsy & Motor Delay: 5th EditionBy Sophie Levitt
3. Children With CerebralPalsy – A ManualFor Therapists, Parents&
CommunityWorkers; 2nd EditionBy ArchieHinchcliffe
4. Article – A ComparisonOf Intensive Neuro-DevelopmentalTherapy
Plus Casting And A Regular OccupationalTherapyProgram For
Children With CerebralPalsy; By – MaryLaw & Dianne Russell et. al