Running Head: NBT & Sensorimotor Post-Stroke 1

Evaluating if the Bobath treatment method is effective in improving sensorimotor performance in

adults post-stroke.
Melanie Canna & Bailey Moore
University of Utah
NDT & SENSORIMOTOR POST-STROKE 2

Evaluating if the Bobath treatment method is effective in improving sensorimotor performance in

adults post-stroke.

Introduction

According to the American Heart Association (2020), between 2013 and 2016, 121.5

million American adults had some sort of cardiovascular disease, a common underlying cause of

strokes. In the United States alone, on average, someone has a stroke every 40 seconds

(American Heart Association, 2020). This correlates to approximately 795,000 events per year.

Additionally, the number of strokes is expected to increase to over 1 million by 2025 (Goldsmith

& Kitago, 2015). Stroke is a leading cause of long term disability among Americans. About 3%

of males and 2% of females reported having a disability as a result of a stroke (American Heart

Association, 2020).

The effects of a stroke can vary widely depending on the cortical area of the brain

involved and the size of the lesion, or the amount of brain tissue damaged. Common long term

symptoms caused by a stroke are sensory and motor deficits, difficulty speaking and processing

language, and decreased cognitive functioning. It is estimated that between 30-66% of stroke

patients have clinically significant motor deficits of the upper extremity six months post-stroke

(Goldsmith & Kitago, 2015)

In the 1940s and last published in the 1990s, Karel and Berta Bobath developed a

sensorimotor rehabilitation treatment approach. Initially designed for the use in pediatric

movement disorders such as cerebral palsy, the method is now often used in the treatment of

similar motor and movement quality deficits resulting from strokes in adult populations. This

treatment approach is known generally around the world as the Bobath approach, and in North
NDT & SENSORIMOTOR POST-STROKE 3

America specifically, as neurodevelopmental treatment or NDT. The Bobath’s theorized that

people who never had the ability to move properly (without spasticity, or abnormal reflexes),

would not understand verbal cues given to them by therapists asking them to straighten a joint, or

move a limb in a certain way. They would not understand or be able to perform the movement

because they have no memory of what that feels like, or how their body should carry it out

(Stern, 1988). This idea became the basis for their treatment approach. Adults, however, have

had many years of normal movement before a stroke. The Bobath approach is used in adult

stroke rehabilitation because it explains movement dysfunction (hemiplegia) from a

neurophysiological perspective. Meaning, the individual receiving the therapy should be active

while the therapist assists them in moving through key points of control and reflex inhibiting

patterns (Kollen et al. 2009).

The Bobath approach in stroke rehabilitation focuses on improving movement quality

and normalization of muscle tone to allow for flexibility, full range of motion, coordination,

increasing amount of dissociated movement, target accuracy, stability, and other similar clinical

attributes of voluntary movement (Langhammer & Stanghelle, 2011).  In recent decades, the

underlying mechanisms that allow an individual to develop and refine movement patterns have

been studied more extensively, and knowledge of functional recovery after stroke has increased

(Kollen et al. 2009). Through this process, evidence has emerged that functional recovery from

stroke (improvements in gait and dexterity), initially thought only to include improvements in

motor function of the affected areas, also has a lot to do with compensatory movement strategies.

Allowing for compensatory movement strategies contradicts the original Bobath treatment

approach. The current Bobath Approach has selectively taken newer evidence in this area into

consideration (Kollen et al. 2009).

NDT & SENSORIMOTOR POST-STROKE 4

The Bobath Approach is one of the most commonly used methods for the treatment of

motor dysfunction as a result of strokes (Pollock et al. 2002). There is a general consensus that

therapy of some form can improve motor function, but there is not a significant amount of

research showing that one type of treatment or approach to treatment results in better patient

outcomes than other methods (Langhammer & Stanghelle, 2000). The goal of this systematic

review is to evaluate current research on whether the Bobath treatment approach is an effective

treatment strategy for improving functional sensorimotor performance in adults post-stroke.

These findings could give researchers valuable guidance for what information is still needed to

apply the approach to clinical practice.

Methods

The US National Library of Medicine National Institutes of Health search database

(PubMed), as well as the Cumulative Index to Nursing and Allied Health Literature (CINAHL),

were used to search the literature for articles relative to the topic. The search was conducted on

February 1st, 2020, to explore the following PICO question: “Is the Bobath treatment method

effective in improving sensorimotor performance in adults post-stroke?”

The search topics of “Bobath,” “post-stroke,” and “sensory-motor performance” were

used, and these concepts were expanded to include various search terms outlined in the table

below:

Concepts Search terms

Bobath (Neurodevelopmental[tiab] AND training[tiab]) OR

"bobath"[tiab]

Post-stroke "Stroke"[Mesh] OR
“stroke”[tiab] OR strokes[tiab] OR apoplexy[tiab]
OR “cerebrovascular accident”[tiab] OR
“cerebrovascular accidents”[tiab] OR "brain
vascular accident"[tiab] OR "brain vascular
accidents"[tiab] OR “brain infarction”[tiab] OR
NDT & SENSORIMOTOR POST-STROKE 5

“brain infarctions”[tiab]

Sensory motor performance

"Psychomotor Performance"[Mesh] OR "sensory
motor performance"[tiab] OR "psychomotor
performance"[tiab]

Articles included in the review were required to be within the date range of 2000 to the

present date of February 1st, 2020. PubMed yielded 18 results, and CINAHL yielded 66 articles

giving a combined total of 84 articles. The inclusion criteria were that articles must be written in

English, include sensory-motor performance as an outcome, have adult participants aged 18 and

over who had experienced a stroke, and the participants had sufficient cognition to complete the

treatment. Excluded articles included those that were using Bobath to treat different conditions or

individuals who had both strokes as well as other significant neurological problems. Articles

were systematically eliminated based on this set of inclusion/exclusion criteria. Disagreements

on article eligibility were discussed until an agreement was reached. This process resulted in

seven total articles used for this systematic review. The following PRISMA diagram is included

to show the elimination process. The remaining articles were reviewed, and bias and levels of

evidence were determined for each.

NDT & SENSORIMOTOR POST-STROKE 6
NDT & SENSORIMOTOR POST-STROKE
Results
The articles all fell in the range of 1B-2B, meaning they consisted of randomized control
trials. The following table outlines the details of the research articles included in our review:
Author & Sample Design &
Date Variables
Araya et al. (2012) 103 people (62 men, randomized, controlled,
43 women, ages, mean double-blinded trial.
age is 50.93 ± 7.78 Received therapy 4-5 days a
years) 4-24 weeks week for 4 weeks.
post-stroke (mean 12.5
weeks). 95 completed 51 in EG and 52 in CG
8-week follow-up (Bobath & Brunnstrom)
DV: type of intervention, 2
levels (MTST v. MTST &
Brunnstrom & Bobath)
Level 1b
Dias Et al. (2007) 40 post-stroke Randomized control trial. 2
patients. Patients had groups. Control group (CG)
stabilized symptoms gets Bobath (generally 20
and were all more than min of joint mobility and
12 months post-stroke. muscle strengthening, plus
20 min of balance and gait
training), 40-minute
sessions, 5 times per week
for 5 weeks. Experimental
Group (EG) gets gait trainer
for same time frame and
frequency.
DV- time of testing.
Level 2B
Eich H. Et al. 50 patients with first Randomized Uncontrolled
(2004) time strokes. Ages 50- trial. Group is randomly
75. Stroke interval less split into A and B. Group A
than 6 weeks. Able to gets 30 minutes of treadmill
walk a minimum of 12 walking and 30 mins of
m with either physiotherapy every day for
intermittent help or six weeks. Group B gets 60
stand-by. Patients mins physiotherapy
selected from one pool
at an inpatient Level 2b
rehabilitation facility
Kılınç, M (2016) 22 participants (12 in RCT. Assessor blinded.
control, 10 in Study group (12people -
experimental mean age 55.9) and control
Measures &
Data Collection
Outcome measures
included; Fugl-Meyer
assessment (FMA), Action
Research Arm Test
(ARAT), Graded Wolf
Motor Function Test
(GWMFT), and Motor
Activity Log (MAL)
Pretest, posttest (4weeks
post) & follow up (8weeks
post).
Motricity Index (MI),
Toulouse Motor Scale
(TMS, modified Ashworth
Spasticity Scale (MAS)
Berg Balance Scale (BBS)
Rivermead Mobility Index
(RMI), Fugl-Meyer Stroke
Scale (FMSS), Barthel
Index (BI) Time up and go
(TUG).
Assessed before treatment,
after treatment, and 3
months follow up.
Outcomes measured include
walking velocity, capacity.
Secondary outcomes were
gross motor function
including walking ability
and walking quality. All
outcomes were blindly
assessed before
intervention, after
intervention, and at follow-
up three months later.
Gross Motor Function
assessed by RMA
(Rivermead Motor
Assessment). Examiners
blind. Rancheros Los
Amigos Gait Analysis used
for walking quality
Includes pre-test, post-test
and follow up.
Trunk function -consists of
17 items (3 regarding static
sitting balance, 10 regarding
7
Findings Section in
Paper
Treatment produced statistically Review
significant and clinically relevant
improvements in the upper extremity
motor recovery of the patients who
had a subacute stroke. However - it
utilized not only Bobath principles
but also Brunnstrom so it is difficult
to draw conclusions about Bobath
alone.
CG and EG both showed Review
improvements in almost all the
assessment scales post treatment.
EG showed statistically relevant
improvement on posttest and follow-
up in several assessment tools while
CG only showed improvement after
posttest and in some assessment
tools. Overall both improved. Only
subjects in EG maintained functional
gain at the 3 months follow up.
No significant difference b/w groups Review
during pre-testing. Significant
difference in groups during post-
testing.
Post intervention experimental group
had significantly greater gains in
walking speed than the control
group. No significant difference in
gait changes or walking quality.
Both groups improved in STREAM, Background
TIS and TUG. Only the study group & Review
improved in BBT, FR, 10 m
NDT & SENSORIMOTOR POST-STROKE
group (10people - mean age
54).
Individualized treatment
based on the Bobath concept
for all for 12 weeks, 3 days a
week, 1 hr. for experimental.
Control group received
standard physiotherapy for
equal amount of time.
DV: Trunk function (static
sitting balance, dynamic
sitting balance,
coordination), functional
capacity (UE, LE and basic
mobility) and gait.
Langhammer, B. 61 participants: 36 Randomized into 2 groups
& Stanghelle men and 25 women and stratified according to
(78= mean age. Range gender and hemisphere site.
2000, 2003, & 49–95 years, SD 9) Group 1 = motor relearning
2011 program (n=33) Group 2 =
first stroke Bobath (n=28)
hemiparesis
(convenience sampling)
No other severe
medical conditions w/ Therapy 5 days/week
stroke minimum of 40 minutes for
entire hospital stay
No subjects that scored
5+ points on each of Both groups received the
the scores in the Motor same treatment from
Assessment Scale doctors, nurses, OT’s,
were included SLP’s, etc.
Follow Up:1 and 4 Acute & Follow Up: DV =
years post stroke changes in motor function,
ADL, and QOL
Movement Quality: The
categories and group
assignments were IV’s and
physical mobility, energy,
emotion and social
interaction as DV’s
Strength: Double-blinded
includes follow up
Weakness: not recent
Level of evidence: 1B
dynamic sitting balance and
four about coordination.)
Measured with TIS
Functional Capacity & Gait
measured with
Stroke Rehabilitation
Assessment and Movement
(STREAM), 10 m Walking
Test.
Balance assessed with the
Berg Balance Test (BBT),
function reach (FR) and
timed up-and-go (TUG)
Acute Study (2000): 3 tests
- 3 days after admission, 2
weeks after, 3 months post-
stroke
Acute & Follow Up: The
tests used were: Motor
Assessment Scale (MAS)
-all tests Sødring Motor
Evaluation Scale (SMES) -
all tests
Barthel ADL Index - 1st
and 3rd test
Nottingham Health Profile
(NHP) - only 3rd test
Berg Balance Scale - follow
up
Follow up study (2003):
also collected data on
incidence of new strokes,
other diseases, use of
assistive devices, the
patient’s accommodation
and use of services from the
community
Movement Quality study
(2011): Triangulation of
test scores to create a
Movement Quality Model
with biomechanical,
physiological, psycho-,
socio-, cultural and
existential themes.
Structured interviewed and
informal conversation
contributed to movement
quality model
8
Walking Test. However, these gains
were not significantly different.
Acute Study: No significant Review
differences in SMES or Barthel ADL
Index between group 1 or 2 in before
intervention. Both groups improved
in MAS and SMES from 1st- 3rd test
and tendency towards difference was
found in test 2 - test 1. MRP group
improved more than the Bobath
group both in MAS and SMES part
2. SMES parts 1 & 3 showed the
same improvement in both groups.
Both groups had significant
improvement in Barthel ADL Index
from acute stage - 3 months. MRP
mean score improved from 56 to 83.
Bobath mean score improved from
46 to 72 (p-value = 0.0001 for both).
No significant difference between
the two groups in total score.
MRP group improved in bladder and
bowel function, and independence in
toileting at 3 months (significant)
Hospital stay significantly shorter in
the MRP group compared to Bobath.
(mean 21 days versus 34 days, p =
0.008).
36% of Bobath group used
wheelchairs compared to 24% of
MRP group (NS).
Follow Up Study: Motor function
and Barthel ADL Index scores
decreased at 1-year post-stroke
compared to 3 months. Decreases in
motor function and ADL
performance from 1 to 4 years post-
stroke. Incidence of new strokes was
low at one-year post initial stroke
(n=2 in MRP and n=0 in Bobath)
and increased at 4 years post initial
stroke (n=8 in both MRP and Bobath
groups). Use of assistive devices
increased over the years but there
was no significant difference
between the two groups. No
significant differences in measured
variables for NDT or MRP.
NDT & SENSORIMOTOR POST-STROKE
Pollock, A.S. 49 individuals with a pilot RCT
diagnosis of stroke
2002 that could Participants randomly
independently sit, but assigned to standard
could not take 10 physiotherapy group
independent steps (Bobath) or independent
practice group.
2 (control):1 Ratio
IPG was encouraged to
19 in SPG (Bobath) attend sessions (5x/week) in
addition to standard Bobath
9 in IPG treatment
no other previous Median % of sessions
disabilities or deficits missed = 20% (tiredness and
affecting mobility other appt.)
prior to stroke
DV = sitting balance
Strength: random
assignment to group, control
group
Weakness: pilot study with
small sample
Level of evidence: 2B
Measurement system was a
chair mounted on a platform
with force plates in the seat,
under the feet, in the
armrest, and in the backrest
outcome measures = (1)
mean symmetry of weight
distribution during sitting,
standing, sit to stand and
sitting down (2) max weight
transfer to affected and
unaffected sides during
lateral reaching (3) mean
symmetry of weight
distribution in quiet posture
after reaching tasks (4)
mean and peak symmetry
index for each participant
tested at 4 and 6 weeks
9
Individuals post-stroke will likely
lose independence and motor ability
progressively after initial
rehabilitation. Initial rehab by MRP
or Bobath did not have an impact on
this loss
Movement Quality Study: Arm (p
= 0.02–0.04) sitting (p = 0.04) and
hand function (p = 0.01–0.03) were
significantly better in the Motor
Relearning Program group than in
the Bobath group (both with MAS
and SMES). No significant
difference between the groups with
balance, transfer, walking and stair
climbing.
MQM and the movement qualities
showed higher scoring in the MRP
group, showing better quality of
movement in all items. Regression
models established the relationship
with significant models of motor
performance and self reported
physical mobility (adjusted R2
0.30–0.68, p < 0.0001), energy
(adjusted R2 0.13–0.14, p =0.03–
0.04, emotion (adjusted R2 0.30–
0.38, p < 0.0001) and social
interaction (arm function, adjusted
R2 0.25, p = 0.0001). This study
shows task-oriented exercises of the
MRP are preferable in the acute
rehab of stroke.
No significant differences between Review
the groups in any of the test weeks
for symmetry of weight distribution
during sitting, standing, rising to
stand, sitting down, or reaching (p>
0.05)
Significantly fewer participants in
the IPG (compared to Bobath) had
‘normal’ weight distribution during
sitting after reaching to the affected
side in week 4 (p>0.027). IPG
tended to distribute more weight on
the affected side than individuals in
the Bobath group
clinical implications of this finding
are not known
Proportion of participants who were
able to stand, rise to stand, and sit
down increased over the test weeks
but no patterns
No measured benefit for a practice
regime in addition to standard
physiotherapy (Bobath)
Therapy for 6 weeks (including
Bobath) did not improve the ability
of participants to maintain posture
and move with normal weight
distribution
NDT & SENSORIMOTOR POST-STROKE 10

Thaut, M. H. 78 participants Randomized trial
2007 69.2 mean RAS Control group = NDT
69.7 mean for NDT experimental group =
Rhythmic auditory
RAS - n=43 (22 male stimulation
and 21 female)
study duration was 3 weeks
NDT - n= 35 (19 male, with gait training daily for
16 females) 30 min, 5x/week
DV = gait
entered the study Strength: randomized trial
within 4 weeks of the
with control group
stroke
Weakness: high attrition
level of evidence: 2B
all participants we were
tested 1 day before training
sessions started and 1 day
after they ended
all data was analyzed with
an intention to treat analysis
after drop out data was
removed
23% dropout at one testing
center and 10% at the other
testing = walking on a 10 m
flat walkway (no RAS) and
gait parameters were
recorded
4 major gait parameters
were measured
velocity, stride length,
cadence, & swing symmetry
no significant difference between the Review
control and experimental groups in
any of the 4 gait parameters at
pretest. Velocity (df = 76, t = 1.01, P
= .347), stride length (df = 76,t =
1.75, P = .111), cadence (df = 76, t =
1.49, P = .141), and swing symmetry
(df = 76, t = 1.13, P = .285).
significant differences were found in
favor of RAS after 3 weeks of gait
training for all 4 gait parameters:
velocity (df = 76, t = 2.83, P =.006),
cadence (df = 76, t = 5.13, P = .
0001), stride length (df = 76, t = 4.6,
P = .0001), and symmetry (df = 76, t
=2.13, P = .049)
Effect size analysis showed
improvements for RAS over NDT
of 13.1 m/min for velocity, 0.18 m in
stride length, 19 steps/min in
cadence, and 0.10 in gait symmetry.

All seven studies analyzed in this review showed that the Bobath approach is an effective

form of treatment to improve sensorimotor performance in adults post-stroke. However, the

Bobath approach did not prove to be the superior treatment choice when comparing it against

other clinical options.

Both Langhammer & Stanghelle (2000), and Arya et al. (2012) compared forms of

Bobath treatment to task-specific therapy. The studies found improvement in performance with

Bobath and task-specific training, however, the improvements were more significant with the

task-specific training group in both studies.

Langhammer & Stanghelle (2000, 2003 & 2011) compared the Bobath approach with the

Motor Relearning Program (MRP). During follow-up, the study determined that motor

functioning regressed after one year compared to the scores tested in the three-month post-

intervention group, which showed improvement regardless of the therapy approach used in the

acute treatment phase. The motor scores continued to decline from one to four years post-stroke,
NDT & SENSORIMOTOR POST-STROKE 11

progressively. In the movement quality portion of the research, both groups improved in

functions over time and in all outcome measures. Langhammer and Stanghelle (2000) concluded

that acute rehabilitation is essential, but the type of therapy has not shown any long term effects.

Overall, results showed that the MRP group regained better movement quality than the Bobath

group even though the Bobath concept and therapies are focused explicitly on movement quality.

The results of this study support the claim that task-oriented (MRP) exercises are more effective

in restoring function and movement quality after a stroke compared to Bobath.

Arya et al. (2012). combined the Bobath approach with Brunnstrom movement therapy

and compared it to Meaningful Task-Specific Training (MTST). Both groups showed an overall

improvement. However, MTST improved significantly more than the control group on all

outcome measures. It proved to be more effective in improving sensorimotor function, as well as

upper extremity recovery, than the clients receiving Bobath and Brunnstrom.

Dias et al. (2007), Eich et al. (2004), and Thaut (2007) all compared the use of Bobath

treatment to a form of gait training. However, each researcher devised the study differently. Dias

et al. (2007) examined the Bobath approach versus treadmill walking and found improvement in

both the post-treatment and follow up, but no statistical difference between the two. Eich et al.

(2004) compared the Bobath approach alone against the combined use of Bobath and gait

training and found minimal strength in the combination of the two over Bobath alone. The

examiners of the study assessed overall gross motor function, walking speed, and walking

quality. Before the treatment started, there was no significant difference between the two groups.

Although both groups improved, the experimental group saw significant improvement in only

walking while changes in walking quality and gross motor were not significantly different
NDT & SENSORIMOTOR POST-STROKE 12

between the groups. These findings stayed consistent in the 12 week follow up assessment with

walking speed continuing to improve for the experimental group over the control group.

Lastly, Thaut (2007) found that a three-week Rhythmic Auditory Stimulation (RAS) gait

training program was significantly more effective than the Bobath approach. Improvements

were found in both groups. However, significant differences were discovered after the 3-week

training program in favor of the RAS group in all gait parameters. Thaut et al. (2007) concluded

that RAS facilitated significantly greater improvements in gait function in hemiparetic stroke

participants compared to the Bobath treatment approach.

Pollock (2002) and Kılınç et al. (2016) studied the Bobath method in relation to trunk

control, balance, gait, and distribution of weight during sitting and sit and reach tasks. Kılınç et

al. (2016) found improvement in both Bobath and a traditional physiotherapy regime but no

statistical difference in trunk function (static and dynamic sitting balance as well as

coordination), functional capacity, and gait. Pollock (2002) also found no significant differences

between the two groups. Pollock et al. (2002) compared the effectiveness of an independent

practice regime (IPG) focused on balance tasks to physiotherapy using the Bobath Approach in

improving balance and posture in sitting, standing, rising to stand, sitting down, lateral reaching,

and posture after reaching. The results post-intervention showed improvement in both groups

and no significant differences between them. The only difference was that those in the IPG

tended to distribute more weight on the affected side while sitting than individuals in the Bobath

group post-intervention.

These results are based on a moderate level of evidence. One higher evidence level study

consisted of a study group that received Bobath in combination with another treatment

method (Araya et al. 2012). Other higher evidence level studies we reviewed compared
 NDT & SENSORIMOTOR POST-STROKE 13

the Bobath treatment approach to task-oriented methods of rehabilitation. Therefore, there is

quality evidence suggesting that the Bobath treatment approach facilitates functional

improvement, but is not significantly more effective than alternative rehabilitation approaches.

Based on the selected articles in this review, the best choice for sensorimotor recovery in stroke

patients would be task-specific training. Factors such as relative cost, therapist expertise, and

client experience should be examined more closely in comparing Bobath to task-specific

training.

Risk of Bias Table: RCT and 2 or 2+ Non-RCT

Selection Bias (risk of bias arising from Performance Bias (effect of Detection Bias Attrition Bias Reporting Bias
randomization process) assignment to intervention)

Baseline Blinding of
differences Outcome
between Assessment:
intervention Objective
groups Outcomes Selective Overall Risk
Allocation (suggest Blinding of (assessors Reporting of Bias
Concealment problem with Study Blinding of aware of Incomplete (results being Assessment
(until randomizatio Blinding of Personnel Outcome intervention Outcome Data reported (low,
Random participants n?) Participants During the Assessment: received?) (data for all selected on the moderate,
Sequence enrolled and During the Trial Self-reported or nearly all basis of the high risk)
Citation Generation assigned) Trial outcomes participants) results?)

Araya et al. + + + - + + + + + Low

(2012)

Dias et al. + + + - + + + + + Low

(2007)

Eich et al. + + + - + + + + + Low

(2004)

Kılınç, M + + + - + + + + + Low
(2016)

Langhammer + - + + + + + + + Low
(2000)

Pollock (2002) + - - - - + + + + Moderate

Thaut (2007) + + + + + + + + + Low

Discussion 

This systematic review aims to evaluate the effectiveness of a widely used stroke

rehabilitation program, the Bobath approach, in improving functional sensorimotor performance

NDT & SENSORIMOTOR POST-STROKE 14

in adults with hemiparesis, hemisensory loss, or both. A total of seven articles met the inclusion

criteria for this systematic review and were evaluated.  

Across the research articles, the Bobath treatment approach was shown to be effective

in facilitating improved sensorimotor performance in adults post-stroke with hemiparesis. The

Bobath approach is one of the most common stroke rehabilitation approaches and has been

practiced widely for decades. It is based on a theoretical framework in reflex-hierarchical theory

and focused on normalization of tone and movement of paretic muscles and limbs, a condition

commonly seen after strokes (Langhammer & Stanghelle, 2000 & 2011). Using the Bobath

treatment approach in stroke rehabilitation requires expensive clinician certification, and is also

quite labor-intensive. To practice, clinicians are required to be certified by the Neuro-

Development Treatment Association (NDTA). This certification process has several steps,

including an initial application cost of $150. In addition to applying, each training through the

NDTA requires an additional fee and a specified amount of completed hours. One must go

through training, practice, and then begin the certification process. Once certified, one must

report continuing education to NDTA and re-certify every three years with an additional fee. To

maintain certification, one must also re-new NDTA membership each year. Certification in the

Bobath treatment approach is a timely and expensive process (NDTA, n.d.). Because the

functional improvement using this approach is equal to or less than that of other treatments, it

does not make the Bobath approach a compelling choice of treatments. Labor and cost should be

considered when making decisions regarding the implementation of stroke rehabilitation

programs. 

The review indicated the Bobath treatment approach and multiple other approaches to

stroke rehabilitation had similar effects on desired outcome measures. There were no significant
NDT & SENSORIMOTOR POST-STROKE 15

differences in functional sensorimotor performance between Bobath treatment groups, and

treadmill walking, gait training, standard physiotherapy, and independent practice of balance

exercises (Pollock, 2002; Kılınç et al., 2016; Eich et al. 2004; Dias et al. 2007). Participants in

the treadmill walking research with Eich et al. (2004) reported enjoying the added challenge of

aerobic exercise that the intervention provided and chose to continue treadmill walking after the

end of the study, potentially contributing to additional functional improvements.

Although the research showed effectiveness in facilitating improvement, the Bobath

approach was less effective in improving scores on motor assessments. The Motor Assessment

Scale (MAS) and Sodring Motor Evaluation Scale (SMES) measure performance in activities of

daily living and functional mobility, as well as the quality of movement (Langhammer &

Stanghelle, 2011). Task-specific treatment approaches such as the Motor Relearning Program

(MRP) and MTST demonstrated greater effectiveness in improving scores on the MAS and

SMES (Langhammer & Stanghelle 2000; Araya et al. 2012). 

Bobath training, standard gait training, and treadmill walking were all similar in their

effectiveness in facilitating functional motor performance in regards to walking (Dias et al. 2007;

Eich et al. 2004). The Bobath treatment approach also showed improvement in trunk control and

balance outcome measures compared to pre-intervention scores. However, the scores in the

Bobath groups were not significantly better than those recorded by participants in the

comparison groups (Pollock, 2002; Kılınç et al., 2016). 

These findings indicate that the Bobath treatment approach can be an effective tool in

stroke rehabilitation for improvements in gait, trunk control, and balance, and overall motor

function. However, task-specific rehabilitation programs such as MRP and MTST showed
NDT & SENSORIMOTOR POST-STROKE 16

statistically significant better outcomes in quality of movement scores as well as motor function

relating to performance in activities of daily living.

Participants in the task-specific rehabilitation groups spent more time performing

specific motor tasks (Arya et al., 2012). The MTST program used by Arya et al. (2012)

specifically targeted activities of daily living, making the task highly specific, an important part

of a rehabilitation concept known as neuroplasticity, or the brain's ability to form new neural

connections. The MRP used by Langhammer and Stanghelle (2000), was also very task-oriented.

The focus on functional, every day tasks as part of task-specific programs makes this approach

more relevant to client goals and preferences, a significant component of clinical occupational

therapy practice. Expensive clinician certifications are not a factor in implementing task-specific

training programs. 

Based on these findings, the Bobath approach can be an effective tool used to improve

performance in adults with functional sensorimotor deficits as a result of a stroke, more than the

absence of intervention, or intervention that doesn’t address these outcome measures. However,

factors such as client preferences, desired outcome measures, therapist experience, and the time

commitment required to implement this approach should be considered. 

The Bobath approach is one of the most common and widely used methods for stroke

rehabilitation and has been used since the 1940s. It was based on the knowledge of neuroscience

available at that time (Pollock, 2002; Vaughn Graham, 2009). The Bobath approach was one of

the first to focus on facilitating recovery instead of simply teaching compensatory strategies

(Vaughn Graham, 2009). Proponents of the Bobath approach claim the theory behind the original

program has changed over the years as knowledge in the fields of neuroscience and stroke

rehabilitation has grown exponentially (Vaughn Graham, 2009). However, there are only small
NDT & SENSORIMOTOR POST-STROKE 17

amounts of literature published on the evolving theoretical framework of the Bobath treatment

approach and how it affects more contemporary clinical practices, specifically stroke

rehabilitation. This lack of clarity on the treatment approach may have influenced clinical

studies, where the Bobath treatment approach implemented by the researchers may not have been

current practice (Vaughn Graham, 2009). There is substantial research evidence demonstrating

Bobath as a potential stroke rehabilitation tool for improvement in functional sensorimotor

performance when other clinical factors are taken into consideration. As knowledge of

neuroscience and stroke rehabilitation techniques advance, and as the Bobath’s original theory is

built upon to include new information, further research on the effectiveness of the Bobath

treatment approach may be needed.

NDT & SENSORIMOTOR POST-STROKE 18

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