Running Head: FUNCTIONAL OUTCOMES OF NEURO-DEVELOPMENTAL TREATMENT 1

Functional Outcomes of Neuro-Developmental Treatment for Strokes

Meghan Berry, Derek Jones, Paige Handley

University of Utah
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 2

Introduction

Stroke is the leading source of long-term disability and something that many clinicians

have been dealing with for a long time (CDC, 2017). The costs associated with the lost

productivity, rehabilitation, and health care services of people surviving stroke in the U.S. is

around $33 billion each year (CDC, 2017). Dr. Karel and Mrs. Berta Bobath created neuro-

developmental Treatment (NDT), or the Bobath method, in the 1940’s. It was originally

developed for rehabilitation settings with children with Cerebral Palsy and adults who had

suffered a stroke (EBTA, 2017). This approach has been used in clinical settings for almost 70

years, but continued research has shown there is some question as to how effective it is when

dealing with the adult stroke population (EBTA, 2017). There is a significant amount of research

that has stated that this method is not the most effective in comparison to others when assessing

the improvement of functional mobility in stroke patients after rehabilitation. Despite these

findings, NDT continues to be taught as a viable method of treatment. It is important that we

examine its success in achieving maximum functional mobility outcomes and whether this should

continue to be a method recommended for patients recovering from stroke.

Currently, within the healthcare community, many different practitioners address stroke.

There is usually a treatment team of different experts working together to come up with the best

plan for each individual case. Because this condition affects so many different areas of

functionality, it is difficult to say that just one area of rehabilitative services increases overall

practical mobility the best. The role of an Occupational Therapist in this treatment is to address

and improve independence in activities of daily living. These areas include, but are not limited to:

self-care, grooming, bathing, eating, feeding, etc. The range of motion, and ability to safely

maneuver within the environment and context is a big factor when coming up with a treatment

plan for this. Occupational Therapy is a client-centered practice focused on a symbiotic

relationship between therapist and client to come up with the best plan of action to ensure the
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 3

needs of the client are met. The NDT/Bobath Method is a holistic approach; taking client specific

needs into account, when forming a treatment plan. The method involves modification as the

client performs and responds, or does not respond, to specific treatment. The exact hands-on

technique used can be adapted and evolved as the treatment goes on. This also includes

education to caregiver and specific adaptive equipment that may be required to improve

independence in daily occupations. This makes this approach extremely variable on a case-by-

case basis. This could be related to the reason that it has weaker research support and more

difficult to compare to more structured therapy methods. The purpose of this paper is to conduct

a systematic literature review to investigate the effectiveness of NDT on improving functional

outcomes after a Cerebrovascular Accident (CVA), also known more commonly as stroke.

Methods

Search Strategy

Studies were found through databases accessed through the University of Utah Eccles health

science online library. The databases searched were: Biomedical Reference Collection: Basic,

CINAHL, Health Source: Nursing/academic edition, Medline Complete, and psycINFO. The

phrase “NDT and Stroke,” “Functional Outcomes,””Bobath Method” yielded a total of 164 results.

Further exclusion criteria were implemented by limiting publication dates to 2005 to present. This

excluded 26 articles from the data pool leaving a total of 143 articles.

Study Selection

Articles were considered based on their relevance to our original question regarding the

effectiveness of NDT vs. alternative methods of treatment. Only studies that examined NDT

(Bobath method) specifically and involved individuals who had recently suffered a CVA within the

last year were considered for review. In an effort to allow our research to be inclusive to a wide

variety of treatments that might be used in place of NDT, we did not make a specific distinction

as to what type of alternative methods NDT might be compared to so long as they were
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 4

common, established methods used regularly to treat stroke survivors. Studies that exhibited

high levels of evidence consisting of RCT’s, systematic reviews, and cohort/case controls were

given preference for inclusion over studies that were lower levels of evidence.

Study appraisal

In our evaluation of the data, key features were assessed in order to determine the overall

quality and validity of the study in question. Quality of RCT’s was assessed by using the

Physiotherapy evidence database (PEDro) scoring system. RCT’s that scored a higher rating on

the PEDro scale were given preference over those with lower scores. For non-randomized

studies, we examined the level of equivalence between groups as well as control over

extraneous variables to ensure that the data collected was not a result of variables unrelated to

the treatment itself. We also paid particular attention to the sample sizes used in each study. We

determined that studies using less than 20 participants were not large enough to be considered

in our research. We gave higher appraisal to those studies that involved larger sample sizes

especially when the results found in the study were meant to be extrapolated to represent a

larger theoretical population.

Results

Out of the 143 articles found for this research question, eight articles have been included

in this literature review. The samples sizes for these studies ranged from 22-843 patients. All of

the participants included had a stroke diagnosis. The articles ranged from Level 1- Level 4. No

Level 5 articles were included in this study. Three of the Level 1 articles were randomized control

trials. These articles had PEDro scores of 7/10, 6/10 and 6/10.

Van Vilet, Lincoln, and Foxall (2005) conducted an RCT comparing Bobath treatment

with movement science-based treatment in 120 stroke patients (<2 weeks post stroke). The

patients underwent treatment, though few details about interventions were mentioned in the

article. Participants’ motor function, walking speed, spasticity, and functional abilities (ADLs)

were assessed at one, three and six months. While improvement was shown in all categories for
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 5

both groups, there were no significant differences between the two groups. Bobath was not any

better than MSB treatment. The main strengths of this study include consistency between the

groups (each psychotherapist had written instructions), having used multiple assessments,

having treatment last for six months, and using past studies to improve study design. One

limitation of the study was that only one environment was used. This makes it harder for

adaptations and increases contamination risk. Other limitations were that the intensity of the

treatment may have been too low and that there were few details about the intervention so it

would be hard to perform the study again.

Kollen et al. (2009) conducted a systematic review. Medline and Central databases were

used to determine the effectiveness of NDT compared to other methods. Of the 2,263 articles

found (any article until March, 2008), only 16 were included in the review. The articles included

tested the sensorimotor control, balance, dexterity, mobility, ADL’s, and QOL in subjects. There

was no significant evidence that Bobath treatment was any better than other stroke treatment

when testing for sensorimotor control, dexterity, mobility, and functional ability (ADL’s). One

strength about this study was that only RCT articles were included. It also included suggestions

for future research. Though only RCT articles were included, many did not describe what the

Bobath Concept entailed. There was also possibility of type 1 and type 2 errors in some studies.

Overall, it was difficult to find a significant effect because all the studies were done so differently.

Hafsteinsdottir et al. (2005) included 324 stroke patients in 12 different hospitals in a

prospective non-randomized parallel group design study comparing NDT treatment to a control

group receiving treatment as usual. All nurses were trained for this study to be performed in 12

wards across 12 different hospitals. Participants’ ADLs and quality of life were assessed at the

beginning of the study and again at 6 and 12 months. Both groups significantly improved;

however, there was no evidence to support that NDT was any better than the control group. This

article had a large sample and a low drop out rate. Limitations include having different staff at

each hospital performing the intervention, and the intervention was only 25-26 days long.
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 6

Mikolajewska (2014) conducted a single group pre- and post-therapy assessment study.

The assessments were given before and after 10 sessions of NDT. There were 35 stroke

patients from the neurological rehabilitation ward included in this study. The intervention tested

patients’ muscle tone, ADL’s, hand function, spatiotemporal gait, cadence and stride length. The

two-week intervention showed to have statistically significant improvements in all areas meaning

that the NDT treatment was effective for stroke patients in these areas. One strength of this

study was using many different areas for assessment. Some limitations include having no control

group, the shortness of length of the intervention, and having a smaller assessment group.

Tang et al. (2014) conducted an experimental study composed of 56 patients with a

severe motor deficit (SMD) after their stroke. All patients were greater than 60 years old. The

eight-week program compared contemporary Bobath approach (CBA) to CBA with “early sitting,

standing, and walking” (ECBA). Patients’ balance and upper and lower extremity mobility were

tested before, after and at four weeks of treatment. Both treatments were effective but the ECBA

proved to be more effective than CBA especially in lower extremities, mobility and balance. No

evidence showed that ECBA was better for upper extremities. The study was double blind, and

there were no significant differences between the two groups. The studies limitations were that

the sample does not represent all stroke patients and it only helped with upper extremity

recovery.

Kılınç et al. (2016) conducted an RCT comparing conventional exercise to Bobath-style

exercise for 22 volunteer stroke patients, with an average age of 55. Patients’ trunk function,

gait, balance, functional reach, and functional capacity were assessed before and after

treatment. The 12-week program included one-hour sessions three times a week. Both groups

improved in STREAM, TIS, and TUG scores. The Bobath treatment was significantly better in the

BBT, FR, and 10m walking test scores. Overall, the Bobath treatment had more improvement in

trunk performance, walking and balance. The studies strengths were that it was assessor-blind
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 7

and the program was three months long. The small sample size, and having each patient on an

individual training program were some limitations to the study.

Likhi et al. (2013) conducted a cross-sectional correlation study with 23 first-time stroke

patients. Patients’ trunk, upper and lower limb function and overall function were tested eight

days after stroke. This study tested for correlation of trunk, arm and leg function to overall

function. There was a high correlation with trunk and overall function but both upper and lower

limb didn’t have a significant correlation. The homogeneous population and the immediate

treatment after stroke were two strengths of the study. Limitations included a small sample size,

only performing three tests, only using patients with ischemic strokes, and dominant hemisphere

was not considered in the outcomes.

Overall, the NDT treatment has shown to be effective but not the most effective

treatment. It is sometimes better than a control group but has not been shown to be better than

alternative treatments.

Discussion

Through our research and articles analyzed, this approach cannot be proven superior

over alternative methods. Some of the methods it was compared to within the articles were

conventional exercise or control group of no treatment. Since this is considered an approach and

not a method of treatment, the guidelines of what is actually performed with a client vary case-

by-case. It seems that the client and therapist preference play a big role in whether this

treatment should be chosen or not. Furthermore, the functional deficits that result from a CVA

fluctuate on a wide range of possibilities. This makes this approach only effective for certain

patients that require motor rehabilitation, or other services that lend themselves to incorporating

this method of treatment.

The majority of the articles we used in our research had strong study designs that

exhibited high levels of evidence. The methods used to test treatments in each study were sound

and collectively produced results that questioned the effectiveness of NDT in stroke patients.
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 8

There were however, limitations found in the consistency of the type of NDT treatment given in

each case. Many of the studies included in our research did not specifically define the type of

NDT treatment methods used. Because NDT is a broad, evolving method, there is room for

variability in the techniques used from therapist to therapist. By not providing a thorough report of

the type of NDT methods and techniques used, it is difficult to discern whether the findings can

be attributed to NDT as a general treatment approach, or if it was instead a result of the specific

methods and techniques used in that particular case. This creates an external validity concern

when collecting and comparing data from multiple studies that very likely possess a wide range

of variability in the type of NDT used.

We have classified NDT as a Level A class IIb on the American Heart Association. This

type of treatment may be considered because the benefit is still greater than risks involved but it

was not shown to be more beneficial than other interventions. Multiple populations were

evaluated and we had three RCT’s and one systematic review. The treatment is effective, but

just may not be the best treatment. Future research to be done could include a better research

design and actually describing how the intervention was done would be most beneficial.

As Occupational Therapist consider this approach of treatment, it is important to take into

account a few concepts of the Bobath approach. It is a very hands-on method, that evolves as

the patient responds, or does not respond for that matter, to the treatment. This aligns very well

with the client-centered practice of OT. If well versed in this method, with up to date training and

support, it may be the best method for treating patients with CVA. However, if a therapist is not

properly trained in this method and feels more comfortable with other approaches, it is in the

patient and client’s best interest to pursue those treatments. The evidence of the reliability of

NDT has fluctuated back and forth, and seems to be extremely variable case by case. It is

suggested that the therapist choose the method they are most comfortable with when dealing

with patients with CVA, since NDT has not reliably been proven superior to other approaches.
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 9

References

European Bobath Tutors Association - The Bobath Concept. (n.d.). Retrieved April 08, 2017,

from http://www.bobath-ndt.com/concept.php#conceptToday

Hafsteinsdottir, T. B., Algra, A., Kappelle, L. J., & Grypdonck, M. H. F. (2005).

Neurodevelopmental treatment after stroke: a comparative study. Journal of Neurology,

Neurosurgery & Psychiatry,76(6), 788-792. doi:10.1136/jnnp.2004.042267

Kilinç, M., Avcu, F., Onursal, O., Ayvat, E., Demirci, C. S., & Yildirim, S. A. (2016). The effects of

Bobath-based trunk exercises on trunk control, functional capacity, balance, and gait: a

pilot randomized controlled trial. Topics in Stroke Rehabilitation, 23(1), 50-58.

doi:10.1179/1945511915y.0000000011

Kollen, B. J., Lennon, S., Lyons, B., Wheatley-Smith, L., Scheper, M., Buurke, J. H., . . .

Kwakkel, G. (2009). The effectiveness of the Bobath Concept in stroke rehabilitation:

What is the evidence? Stroke, 40(4), e89-e97. doi:10.1161/strokeaha.108.533828

Likhi, M. (2013). Does trunk, arm, or leg control correlate best with overall function in

stroke subjects? Topics in Stroke Rehabilitation, 62-67. doi:10.1310/tscir2001-62

Mikołajewska, E. (2014). Changes in Functional Outcomes in Elderly Patients as a Result of

Poststroke Rehabilitation Using the NDT-Bobath Method. Topics in Geriatric

Rehabilitation, 30(3), 207-215. doi:10.1097/tgr.0000000000000029

Natarajan, P., Oelschlager, A., Agah, A., Pohl, P., Ahmad, O., Liu, W. (2008). Current clinical

practices in stroke rehabilitation: Regional pilot survey. The Journal of Rehabilitation

Research and Development,45(6), 841-850. doi:10.1682/jrrd.2007.04.005

Stroke Facts. (2016, December 30). Retrieved April 08, 2017, from

https://www.cdc.gov/stroke/facts.htm

Tang, Q., Tan, L., Li, B., Huang, X., Ouyang, C., Zhan, H., . . . Wu, L. (2014). Early Sitting,
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 10

Standing, and Walking in Conjunction With Contemporary Bobath Approach for Stroke

Patients With Severe Motor Deficit. Topics in Stroke Rehabilitation,21(2), 120-127.

doi:10.1310/tsr2102-120

Vilet, P. M., Lincoln, N. B., Foxall, A. (2005). Comparison of Bobath based and movement

science based treatment for stroke: a randomised controlled trial. Journal

of Neurology, Neurosurgery & Psychiatry,76(4), 503-508. doi:10.1136/jnnp.2004.040436

Table 1.

Author/Date Population Design Outcome Findings

Measures

van Vilet, P. 120 stroke Design: RCT Rivermead Bobath (NDT)

M., Lincoln, N. patients in (2 groups of Motor was not shown
B., Foxall, A. rehabilitation 60. One with Assessment, to be
(2005). over 21 Bobath Motor significantly
months. treatment, Assessment more effective
one with Scale, Ten-hole than MSB
Stroke movement peg test, 6m treatment in
diagnosis science- walk test, stroke patients.
and based Modified
physiotherap treatment) Ashworth Scale,
y referral Level of Nottingham
Evidence: 1 Sensory
Pedro Assessment,
Score: 7/10 Barthel Index
and ADL’s test
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 11

Natarajan, P., 51 Design: Clinicians Most therapists

Oelschlager, Occupational Survey preferences in: were trained in
A., Agah, A., Therapists, (questionnair Aim of and used
Pohl, P., 55 Physical e) treatment, Bobath/NDT
Ahmad, O., therapists, Muscle tone, and
Liu, W. (2008) and 1 PT and Level of Facilitation of Brunnstrom/PN
OT from Evidence: movement, F
Kansas and Level 4 Function and
Missouri Motor Only 12
Rehabilitation clinicians were
trained in CIMT
Clinicians even though 25
training and clinicians said
treatments used they used CIMT.
in practice
There should be
more continuing
education and
clinicians should
make sure they
are using the
most up to date
practices

Kollen, B. J., Searched Design: Medline and Bobath Concept

Lennon, S., through 2263 Systematic Central doesn’t show to
Lyons, B., articles Review databases used be any better
Wheatley- than other
Smith, L., Only 16 Level of Articles search approaches
Scheper, M., articles fit the Evidence: up until March when testing for
Buurke, J. H., inclusion Level 1 2008 upper and lower
Halffens, J., criterion limb control,
Geurts, A. C. Searched for dexterity,
H., Kwakkel, 813 stroke effectiveness od mobility, ADL
G. (2009) patients total NDT vs. other function,
methods HRQOL, and
cost-
effectiveness
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 12

Hafsteinsdottir 324 patients Design: Barthel Index 59 patients of

, T. B., Algra, diagnosed Prospective, Scale, Quality of NDT group and
A., Kappelle, with strokes non- Life (measured 24 patients in
L. J., randomized, with Sickness the control
Grypdonck, M. Must have a parallel group Impact Profile group did not
H. F., (2005) Glasgow and Visual have a good
come scale One group Analogue Scale) outcome after a
score of 14 used NDT year
Measured at 6
Patients with The other and 12 months The difference
severe group was between NDT
dementia the control and the control
were not group group were not
included significant,
Level of showing that
Patients Evidence: NDT was no
came from Level 2 better than the
12 different conventional
Dutch non-NDT
Hospitals approach.

Mikołajewska, 35 post Design: Ashworth Scale Results showed

E. (2014) stroke Single group for Grading to be statistically
patients. with pre- and Spasticity, significant in all
post-therapy Bobath Scale, tested areas:
17 females, assessments Barthel Index, the NDT-Bobath
18 males, after 10 Clinical Gait approach was
sessions of Analyzer, shown to be an
Ages 65-73 NDT effective method
(IV: Bobath
Admitted to method, DV:
neurologic 3 ambulation
rehabilitation scores, hand
ward functions,
and ADL
abilities)
Level of
Evidence:
Level 3
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 13

Tang, Q., Tan, 56 patients Design: Stroke ECBA showed

L., Huang, H., with SMD Experimental Rehabilitation significantly
Ouyang, C., after stroke design, used Assessment of higher results in
Zhan, H., Pu, purposive Movement the STREAM
Q., Wu, L. (33 men, 15 sampling and (STREAM), the test compared
(2014) women) also Berg Balance to CBA.
randomized Scale (BBT) (Especially in
60-74 years participants lower
old into groups extremities and
mobility)
IV: ECBA
and CBA ECBA was also
DV: significantly
STREAM, higher in
and Berg balance function
Balance than the CBA
Scale scores group
Level of
Evidence: ECBA was
Level 3 showed to be a
Pedro better
Score: 6/10 intervention for
stroke patients
in this study
FUNCTIONAL OUTCOMES OF NDT FOR STROKES 14

Kılınç, M., 22 volunteer Design: RCT Trunk Both groups

Avcu, F., patients. IV: Impairment improved in the
Onursal, O., Conventional Scale (TIS), STREAM, TIS,
Ayvat, E., Mean age: exercise STREAM, the and TUG scores
Demirci, C. S., 55.9 (study (control) and 10m walking
Yildirim, S. A. group) Bobath-style test, BBT, The study group
(2016) exercise functional reach (Bobath)
54 for control DV: TIS, (FR) and timed showed
group BBT, up-and-go significant
STREAM, (TUG) tests improvement in
TUG, and FT the BBT, FR
scores and 10 meter
walking test
Level of scores.
Evidence: Also
Level 1 significantly
Pedro better in trunk
Score: 6/10 performance,
walking, and
balance than
the control
group.

Likhi, M, 23 first-time Design: TIS, Simplified There was a

Jidesh, V. V., stroke Cross- Stroke high significant
Kanagaraj, R., patients (all sectional Rehabilitation correlation
George, J. K. ischemic) correlation Assessment of between trunk
(2013) study Movement function overall
50-75 years (Purposive (SSRAM) and function
old sampling) overall function
Correlation in
All patients Level of upper and lower
admitted to Evidence: limb to overall
hospital Level 4 function wasn’t
within 5 wks as significant as
of stroke trunk function