Topics in Geriatric Rehabilitation • Volume 30, Number 3, 207-215 • Copyright © 2014 Wolters Kluwer Health | Lippincott Williams &
Wilkins
DOI: 10.1097/TGR.0000000000000029
Changes in Functional Outcomes in Elderly
Patients as a Result of Poststroke
Rehabilitation Using the NDT-Bobath Method
Preliminary Findings
Emilia Mikołajewska, PhD
Aim: To assess the use of the NDT-Bobath method in
poststroke geriatric rehabilitation. Subjects and Methods:
Thirty-five elderly poststroke patients admitted to the
neurologic rehabilitation ward took part in 10 sessions of the
NDT-Bobath therapy. Measurements of the parameters of
muscle tone, hand functions, selected activities of daily living,
and spatiotemporal gait parameters of velocity, cadence, and
stride length were conducted by the same therapist twice: on
admission, and after the last session of rehabilitation. Results
and Conclusions: Positive statistically significant results were
observed within all assessed areas. These findings confirm
that the NDT-Bobath method is an effective form of therapy
in the elderly after ischemic stroke. There is a need for
further research on larger samples of elderly patients,
including the control group.
Key words: elderly, gait reeducation, NDT-Bobath,
physiotherapy, rehabilitation, stroke, upper limb function
T he incidence of stroke increases with age. Stroke
prevalence is assessed below 3% in younger adults
(20-59 years), 8% in the age group of 60 to 79 years,
and 13% to 17% among persons 80 years and older (all
aforementioned amounts seem to increase with each
year).1,2 The consequences are very severe, from mortality,
morbidity, disability, and functional decline to social prob-
lems and health care costs. Moreover, poor functional out-
comes are considered more frequent in elderly patients
than in younger patients. Hypertension, diabetes, hyper-
cholesterolemia, and tobacco consumption are perceived
as the most common risk factors in this age group.3 In the
oldest group of patients (≥80 years old), risk factors
Author Affiliation: Rehabilitation Department, Military Clinical Hospital No.
10 and Polyclinic, Bydgoszcz, Poland.
The author has disclosed that she has no significant relationships with, or
financial interest in, any commercial companies pertaining to this article.
Correspondence: Emilia Mikołajewska, PhD, Rehabilitation Department,
Military Clinical Hospital No. 10 and Polyclinic, Powstańców Warszawy 5,
85-681 Bydgoszcz, Poland (e.mikolajewska@wp.pl).
Topics in Geriatric Rehabilitation
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TGR-D-13-00029_LR 207
depend on prestroke functional and health status.4 National
Institutes of Health Stroke Scale score, clinical parameters
of the stroke severity (need for oxygen, indwelling catheter,
or nasogastric tube), incident disability, and medical com-
plications are considered to be some of the most common
ischemic stroke predictors in elderly people (≥65 years
old).4 According to current knowledge, treatment (includ-
ing rehabilitation) in elderly people may significantly differ
from these processes in younger people, including high
risk of dementia.3,5 Thus the effectivity of primary and sec-
ondary prevention should be a priority in elderly patients.
From the other side, partly the increase of the ageing popu-
lation (including changes within age structure in the popu-
lation) may explain rise of the number of strokes in the
elderly. No doubt there is a need to improve the knowledge
of factors associated with poststroke rehabilitation out-
comes in the elderly to improve the quality of rehabilitation
and care. Contemporary rehabilitation plays a basic role
both in reducing functional deficits of stroke patients, and
reducing the impact of the stroke on the independence of
elderly patients.6 Thus the effectivity both of inpatient reha-
bilitation (acute/subacute phase), and ambulatory/home
rehabilitation (long-term ambulatory/home rehabilitation)
is critical. Increased community consciousness of the
biopsychosocial approach to intervention, the holistic
model of the therapy, and Quality of Life measurements
within geriatric rehabilitation need to be reflected in
patient-oriented goal setting aimed at self-service improve-
ment, mobility abilities, interpersonal communication pos-
sibilities, and social life participation. The newest tools such
as the “Vienna List” allow for differentiating between vari-
ous diseases, functional abilities, and their disturbances.7
This study aims at assessing the use of one of the lead-
ing methods on the basis of the NeuroDevelopmental
Treatment–-Bobath (NDT-Bobath) concept within post-
stroke geriatric rehabilitation. The NDT-Bobath method is
considered effective, but currently there is a lack of studies
like this, especially in the group of elderly patients. A limited
amount of reliable research is perceived as a key problem
in contemporary neurorehabilitation, and this study aims
to improve this situation. The NDT-Bobath intervention
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 method is considered one of the most common in con-
temporary poststroke rehabilitation, but no one method
is regarded as predominant concerning effectivity. Despite
the NDT-Bobath method having a long tradition (since the
1940s), there are only a few studies in the area of its effec-
tivity in poststroke patients. This method constitutes not a
set of exercises, but an entire concept of 24/7 neuroreha-
bilitation and care based on proper stimulation of patients’
nervous system neuroplasticity, movement patterns, and
avoidance of compensation, which results in the maximal-
ization of available independence of the patient in activities
of daily living (ADLs).8-13
SUBJECTS AND METHODS
Design of the research is a single group before-and-after
preliminary study. The expected result was to investigate
the feasibility of conducting a larger research (randomized
controlled trial) of the efficacy of the NDT-Bobath method
with the elderly adult stroke survivor population.
Thirty-five poststroke patients admitted to the neuro-
logic rehabilitation ward were assessed toward the criteria
described. The inclusion criteria were as follows: age 65
years or more, time after cerebrovascular accident from 1
month to 3 years, and clinical status each time confirmed
by medical records. The study population represents the
geriatric poststroke group compared with the age range in
conventional stroke rehabilitation literature. The patients’
profiles are presented in Table 1. The mean age of patients
observed was 73.086 (median: 73). The observed predomi-
nance of the ischemic stroke (100% cases) may be com-
mon in research based on small samples: ischemic stroke
constitutes 80% to 85% of all stroke cases (Table 1). Assess-
ment was made on the basis of changes of parameters:
TABLE 1 Patients’ Overall Profile
Feature Number and Percentage
Stroke type Ischemic (100%)
Side of paresis
Left 21 (60%)
Right 14 (40%)
Sex
Females 17 (48.6%)
Males 18 (50.4%)
Age, y
Min 65
Max 86
SD 4.86
Mean 73.086
Median 73
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TGR-D-13-00029_LR 208
1. muscle tone using the Ashworth Scale for Grading
Spasticity (validity and reliability14-16),
2. hand functions using selected items of the Bobath
Scale,
3. selected ADLs using selected items of the Barthel
Index (assessed as “valid”17-19),
4. spatiotemporal gait parameters: velocity, cadence,
and stride length using the author’s own method
of gait analysis described in20 is based on
– gait recording with a digital video camera,
– visual gait evaluation,
– measurement of the aforementioned parameters,
– calculating normalized values using the Clinical
Gait Analyzer—free software developed by Chris
Kirtley, MD, and
– their interpretation.
Measurements of all aforementioned parameters (where
available) were conducted by the same therapist twice: on
admission and after the last session of the rehabilitation. The
1 therapist who did all the intervention also did the outcome
measurements.
Ten sessions of the NDT-Bobath therapy for 2 weeks
were provided, constituting 10 days of the therapy—
the therapy was performed every day for 5 days a week
(from Monday to Friday). Each session lasted 30 minutes.
Techniques specific to the NDT-Bobath method were uti-
lized during the therapy. The consistency of the interven-
tion was maintained and fidelity to the NDT-Bobath method
was ensured because of the fact that all the patients were
treated and assessed by the same experienced therapist of
the NDT-Bobath method for adults (>10 years of experi-
ence) with international certificates in poststroke neuro-
rehabilitation:
– IBITA (International Bobath Instructors Training
Association) recognized Basic Course “Assessment
and Treatment of Adults with Hemiplegia—The
Bobath Concept,”
– IBITA recognized Advanced Course “Assessment
and Treatment of Adults with Neurological Condi-
tions—The Bobath Concept,”
– additionally EBTA (European Bobath Tutors As-
sociation) recognized NDT-Bobath 8-week Basic
Course and NDT-Bobath Baby Course.
The data were analyzed with Statistica 9 software.
The results of measurements, where available, were
given as mean, median, maximal value, minimal value,
and SD. Changes between first and second measure-
ment were calculated as a result of the subtraction and
called in the results section: “recovery” (if positive),
“relapse” (if negative), and “no changes” (if result of the
subtraction is zero). The level of statistical significance
was set at P < .05.
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12/07/14 10:50 AM
 The study was accepted by the appropriate Bioethical
Committee. The subjects gave written informed consent
before entering the study, in accordance with the recom-
mendations of the Bioethical Committee, acting on the
rules of Good Clinical Practice and the Helsinki Declaration
of 1975, revised 2002.
RESULTS
The results are presented in Tables 2 and 3. Assessment
of the normalization of upper limb muscle tones in
patients was estimated on the Ashworth Scale for Grad-
ing Spasticity. Eleven (31.4%) patients achieved recovery.
The results of all these patients improved with mean
value 1 point. Twenty-one out of 23 “no change” results
achieved the best possible result in admission. Thus
recovery has been unavailable.
Assessment of the hand function used part of the Bobath
Scale for the assessment of upper limb mobility. Thirty-
two (91.43%) patients achieved recovery. The results of all
these patients improved with mean value 2.844 points.
Assessment of the selected ADLs used selected items of
Barthel Index. Nineteen (54.28%) patients achieved recov-
ery. The results of all these patients improved with mean
value 8.421 points (Table 2).
Despite the short-term of the rehabilitation (2 weeks),
high percentages of recovery were achieved, in particular:
– in gait velocity: 57.14%,
– in normalized gait velocity: 57.14%,
– in cadence: 57.14%,
– in normalized cadence: 57.14%,
– in stride length: from 80%,
– in normalized stride length: from 80%.
The aforementioned relapses are perceived as results
of the NDT-Bobath concept: within the first stage of the
therapy (eg, gait reeducation) NDT-Bobath therapist pays
particular attention to proper movement (eg, gait) pat-
terns. Proper gait patterns help achieve better and quicker
results within the next stages of the therapy. The rather
short-term of the therapy did not allow for showing this. It
seems the patients with relapses may achieve much better
results within the next stages of the long-term rehabilita-
tion (Table 3).
DISCUSSION
My study has focused on the determination of changes
observed in a group of elderly patients after ischemic
stroke as a result of the therapy conducted according to
the NDT-Bobath method. These changes, assessed as pos-
itive, were reflected in statistically significant changes in
the selected parameters values. It must be emphasized
that the aforementioned positive changes were observed
in gait parameters, upper limb function, and general inde-
pendence (ADLs). Unfortunately, there is a lack of similar
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TGR-D-13-00029_LR 209
studies for compartmental purposes. The main limitations
of the study are perceived as the lack of a control group,
and the small study sample. The next part of my research
will be both studies on larger samples, and compartmen-
tal studies between various group of elderly stroke survi-
vors with a control group. But despite the simplicity, this
study may indicate predictive values useful in further
research and clinical practice. Another limitation may be
the relatively short period of rehabilitation and lack of
follow-up—this short-term was chosen to provide occu-
pation to compare with other studies. Bigger positive, sta-
tistically significant changes in the health status of elderly
patients, and associated changes in selected parameters’
values are expected in the longer period of therapy. All
that is needed is subsequent research dedicated to the
long-term effects of poststroke rehabilitation in elderly
patients using the NDT-Bobath method. A potential limi-
tation may be the perceived heterogeneity in the sample,
specifically with regard to ethnicity, but it is common for
the Polish population.
Therapeutic techniques used in the research were
coherent with current knowledge and regulations of
IBITA. Compartmental studies including the NDT-Bobath
approach are rare. Moreover, some of them do not fulfill
the requirements of Paci21 in his 15 trials review: identi-
fied and compared experience and knowledge of the
therapist(s), confirmed with international certificates
(EBTA, IBITA, NeuroDevelopmental Treatment Associa-
tion, etc, recognized). Thus the effectiveness of the NDT-
Bobath concept, despite more than 65 years of clinical use,
is questionable. NDT-Bobath therapy is 24/7, so it may be
difficult to compare results of this approach when applied
for only 45 minutes a day. Methodological limitations do
not allow for conclusions of efficacy or nonefficacy.
The implications of the current study for clinical practice
in poststroke rehabilitation of elderly people seem to be
important. Observed positive changes confirm the effec-
tivity of the NDT-Bobath method in this group of patients,
but do not make this method predominant. There is a
need for more compartmental research, including sepa-
rately various methods of rehabilitation (proprioceptive
neuromuscular facilitation; constraint induced therapy;
therapy supported by rehabilitation robots and/or virtual
reality systems). Scientists and clinicians still look for more
effective therapies for poststroke survivors because a lot
of patients are not able to function independently after
finishing the therapy. From the other side with poststroke
patients, therapists cannot guarantee recovery to full
health—sometimes (in the most severe cases) it may be
only recovery to the best achievable functioning. Neuro-
biology states that function after focal lesion of the central
nervous system can be recovered, that is, using intensive
physiotherapy,22 but patients with disorders of conscious-
ness (DoCs) are a different reality, and we try to help them
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 TABLE 2 Results for Upper Limb Muscle Tonus, Hand Function, and Selected Activities of
Daily Living
Parameter Number and Percentage (n = 35)
Upper limb muscle tonus
Recovery 11 (31.4%)
No change 23 (65.7%)
Relapse 1 (2.86%)
N/A 0
Min change for recovery [pts] 1
Max change for recovery [pts] 1
Mean change for recovery [pts] 1
Median change for recovery [pts] 1
t-test results for changes between before/ Before therapy:
after therapy mean = 0.69, standard deviation = 1.08, standard error = 0.18
After therapy:
mean = 0.4, standard deviation = 0.81, standard error = 0.14
P = .003
Hand function
Recovery 32 (91.43%)
No change 3 (8.57%)
Relapse 0
N/A 0
Min change for recovery [pts] 1
Max change for recovery [pts] 12
Mean change for recovery [pts] 2.844
Median change for recovery [pts] 2
SD for recovery [pts] 2.489
t-test results for changes between before/ Before therapy:
after therapy mean = 10.03, standard deviation = 6.21, standard error = 1.07
After therapy:
mean = 12.71, standard deviation = 5.49, standard error = 0.94
P = .000
Selected ADLs
Recovery 19 (54.28%)
No change 16 (45.72%)
Relapse 0
N/A 0
Min change for recovery [pts] 5
Max change for recovery [pts] 25
Mean change for recovery [pts] 8.421
Median change for recovery [pts] 5
SD for recovery [pts] 4.881
t-test results for changes between before/ Before therapy:
after therapy mean = 29.43, standard deviation = 11.43, standard error = 1.93
After therapy:
mean = 34, standard deviation = 8.81, standard error = 1.49
P = .000

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 TABLE 3. Results of the Gait Assessment
Parameter Number and Percentage (n = 35)
Velocity
Recovery 20 (57.14%)
No change 5 (14.28%)
Relapse 6 (17.14%)
N/A 4 (11.43%)
Min change for recovery, m/s 0.1
Max change for recovery, m/s 0.8
Mean change for recovery, m/s 0.315
Median change for recovery, m/s 0.3
SD for recovery 0.179
Min change for relapse (abs), m/s 0.1
Max change for relapse (abs), m/s 0.2
Mean change for relapse (abs), m/s 0.14
Median change for relapse (abs), m/s 0.1
SD for relapse (abs) 0.045
t-test results for changes between before/after Before therapy:
therapy mean = 0.44, standard deviation = 0.19, standard error = 0.04
After therapy:
mean = 0.62, standard deviation = 0.36, standard error = 0.06
P = .000
Normalized velocity
Recovery 23 (65.71%)
No change 2 (5.71%)
Relapse 6 (17.14%)
N/A 4 (11.43%)
Min change for recovery [−] 0.01
Max change for recovery [−] 0.24
Mean change for recovery [−] 0.091
Median change for recovery [−] 0.09
SD for recovery 0.063
Min change for relapse (abs) [−] 0.01
Max change for relapse (abs) [−] 0.05
Mean change for relapse (abs) [−] 0.03
Median change for relapse (abs) [−] 0.025
t-test results for changes between before/after Before therapy:
therapy mean = 0.15, standard deviation = 0.07, standard error = 0.01
After therapy:
mean = 0.21, standard deviation = 0.12, standard error = 0.02
P = .000

(continues)

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 TABLE 3. Results of the Gait Assessment (Continued )
Parameter Number and Percentage (n = 35)
Cadence
Recovery 20 (57.14%)
No change 1 (2.86%)
Relapse 10 (28.57%)
N/A 4 (11.43%)
Min change for recovery [steps/min] 7
Max change for recovery [steps/min] 69
Mean change for recovery [steps/min] 20.6
Median change for recovery [steps/min] 19
SD for recovery [steps/min] 13.629
Min change for relapse (abs) [steps/min] 1
Max change for relapse (abs) [steps/min] 36
Mean change for relapse (abs) [steps/min] 15.1
Median change for relapse (abs) [steps/min] 11.5
SD for relapse (abs) 12.494
t-test results for changes between before/after Before therapy:
therapy mean = 74.29, standard deviation = 21.59, standard error = 3.87
After therapy:
mean = 82.61, standard deviation = 32.43, standard error = 5.83
P = .037
Normalized cadence
Recovery 20 (57.14%)
No change 2 (5.71%)
Relapse 9 (25.71%)
N/A 4 (11.43%)
Min change for recovery [−] 0.04
Max change for recovery [−] 0.34
Mean change for recovery [−] 0.101
Median change for recovery [−] 0.09
SD for recovery [−] 0.063
Min change for relapse (abs) [−] 0.01
Max change for relapse (abs) [−] 0.18
Mean change for relapse (abs) [−] 0.08
Median change for relapse (abs) [−] 0.05
SD for relapse (abs) [−] 0.063
t-test results for changes between before/after Before therapy:
therapy mean = 0.37, standard deviation = 0.11, standard error = 0.02
After therapy:
mean = 0.41, standard deviation = 0.16, standard error = 0.03
P = .037
(continues)
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 TABLE 3. Results of the Gait Assessment (Continued )
Parameter Number and Percentage (n = 35)
Stride length
Recovery 28 (80%)
No change 1 (2.86%)
Relapse 2 (5.71%)
N/A 4 (11.43%)
Min change for recovery, m 0.1
Max change for recovery, m 1.32
Mean change for recovery, m 0.385
Median change for recovery, m 0.295
SD for recovery, m 0.31
Min change for relapse (abs), m 0.13
Max change for relapse (abs), m 0.55
Mean change for relapse (abs), m 0.34
Median change for relapse (abs), m 0.34
SD for relapse (abs), m 0.21
t-test results for changes between before/after Before therapy:
therapy mean = 1.4, standard deviation = 0.39, standard error = 0.07
After therapy:
mean = 1.72, standard deviation = 0.53, standard error = 0.09
P = .000
Normalized stride length
Recovery 28 (80%)
No change 1 (2.86%)
Relapse 2 (5.71%)
N/A 4 (11.43%)
Min change for recovery [−] 0.11
Max change for recovery [−] 1.36
Mean change for recovery [−] 0.44
Median change for recovery [−] 0.32
SD for recovery [−] 0.338
Min change for relapse (abs) [−] 0.15
Max change for relapse (abs) [−] 0.6
Mean change for relapse (abs) [−] 0.375
Median change for relapse (abs) [−] 0.375
SD for relapse (abs) [−] 0.226
t-test results for changes between before/after Before therapy:
therapy mean = 1.57, standard deviation = 0.53, standard error = 0.09
After therapy:
mean = 1.97, standard deviation = 0.63, standard error = 0.11
P = .000

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 another way (eg, using brain-computer interfaces,23,24 as an
element of the eclectic approach to intervention).25
Despite alternatives there is lack of research in the area
of their effectivity in elderly people. The group showed
meaningful task-specific training more effective than a
dose-matched standard training program based on the
Brunnstrom stage and Bobath neurodevelopmental tech-
nique, 4 to 5 days a week for 4 weeks with Fugl-Meyer
assessment, Action Research Arm Test, Graded Wolf Motor
Function Test, and Motor Activity Log. Recent assessment
showed the effectiveness of the meaningful task-specific
training on the upper extremity motor recovery during
the subacute phase after a stroke.26 From the other side,
a compartmental study of interventions based on the
Bobath concept, in conjunction with task practice, and
structured task practice alone showed significantly greater
walking velocity, but no significant difference in improve-
ment between the 2 groups for the adapted 6-minute walk
test and for the Berg Balance Scale.27
Outcomes of an earlier study by Lennon et al28 did not
support the hypothesis that the Bobath approach restored
more normal movement patterns to the gait cycle. Further
research is required to investigate the treatment tech-
niques that are effective at improving walking ability in
people after stroke.
A follow-up studies provided by Langhammer and
Stanghelle29 1 year and 4 years poststroke showed no
major influence of 2 different initial physiotherapy regi-
mens (NDT-Bobath and motor relearning programme) on
long-term function.
CONCLUSIONS
My findings confirm that the NDT-Bobath method for
adults may be considered an effective form of therapy in
the elderly after ischemic stroke. There is a need for further
research on larger samples of elderly patients, including
control group. No doubt elderly should be more often
included in therapeutic trials in the area of poststroke reha-
bilitation.
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