Bobath concept

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The Bobath concept is a problem-solving approach in the diagnosis and treatment of adults and children with neurological diseases.

The concept can be used in rehabilitation , especially after a stroke in people who are paralyzed on one side ( hemiplegics ) . In contrast to other therapies such as Forced Use Therapy (FUT), the Bobath concept has not yet been classified as significantly effective in scientific studies. Nevertheless, the Bobath concept is used worldwide with questionable success.

Foundations and founders of the concept

approach

The concept was developed from 1943 by the physiotherapist Berta Bobath and her husband, the neurologist and pediatrician Karel Bobath . The Bobath concept is based on neurophysiological and developmental neurological principles and is oriented towards the patient's resources. Even then, both Karel and Berta Bobath attached great importance to ensuring that the methods and techniques used always correspond to the latest neurological findings. This claim offers great opportunities in the further development of the concept itself and at the same time a reason for criticism of the concept.

Basic assumption and procedure

The concept is based on the assumption that the brain is able to reorganize (plasticity), which means that healthy regions of the brain can relearn and take over the tasks previously carried out by the diseased regions. Frequently, in the case of traumatic brain damage, it is not the actual control centers that are destroyed, but communication paths that are interrupted, which can be re-opened by all caregivers with consistent encouragement and stimulation of the patient.

The Bobaths recognized the possibilities offered by the plasticity of the brain . Functions that have been lost, for example after a stroke , can be regained by networking and intensifying other areas of the brain. For this purpose, movement sequences are "ground in" again through repetitive practice (constant repetition). This means that intact connections ( synapses ) are recruited between the nerve fibers so that neural functional groups are built up in order to establish the motor function. The treatment influences the participation level as well as the structural or functional level (ICF and ICFcy).

Hemiplegics often tend to neglect their paralyzed (more affected) side of the body - to the point of complete denial - and to compensate their limitations all the more with their mobile (less affected) side of the body. However, such one-sided movements only help the patient superficially, since the more affected side is not given the opportunity to receive and process new information. The brain is therefore not given the task of restructuring itself. Instead, there is a greater risk of developing painful spasticity due to asymmetrical movements . The main principle of the Bobath concept , on the other hand, repeatedly involves the more affected side of the body in everyday movements by stimulating it with sensors in order to keep its movements in harmony with the less affected half of the body.

The founders

Berta Bobath (1907–1991), born in Berlin, emigrated to England as a Jew with her son from her first marriage. As a physiotherapist, she recognized that spasticity could be influenced by various movements and positions. The development of the Bobath concept began around 1943. During the treatment of severely spastic patients, Mrs. Bobath discovered that the patient's spasticity decreased or even disappeared through certain positions, positions and movements. She recognized that spasticity is not a fixed, constant phenomenon, as previously generally assumed, but is influenced by the position and movement of the body. Systematic observation of many patients and testing of further treatment techniques resulted in the Bobath concept as an empirical (experience-based) treatment concept.

Her husband Kar (e) l (1906–1991) studied medicine in his native Berlin, where he passed his first state examination in 1932. After 1933, as a Jew, he was no longer allowed to take exams in Germany and therefore completed his studies in Prague and Brno . After the occupation of the Czech Republic by the German Wehrmacht in 1939, he fled to England, where he married “Bertie” in 1941. In 1951 they founded the Western Cerebral Palsy Center in London, a private center for the treatment of patients with cerebral movement disorders. The first Bobath courses for physiotherapists also took place at this center. In 1958 the Bobath couple came to Germany for the first time in a long time.

Karl Bobath initially contradicted his wife's considerations and discoveries, but had to determine from his own studies that she was right. As a neurologist he worked on the neurophysiological basics and worked with her for decades to spread the Bobath concept.

Concept, not method

The Bobath couple expressly described the working method they developed as a concept and not a method. The Bobath concept does not contain any prescribed techniques, methods or exercises that must always be completed in the same way with all patients, but rather it takes into account the individual possibilities and limits of a patient and incorporates them into care and therapy using certain principles.

Patients for the Bobath Concept

The Bobath concept is used by therapists in physiotherapy , occupational therapy and speech therapy as well as by doctors and nursing staff, ideally in cross-professional collaboration. The Bobath concept is used in the treatment of infants, children and adults with cerebral movement disorders , sensorimotor disorders and neuromuscular diseases such as stroke, multiple sclerosis , intracerebral hemorrhage , head and brain trauma , diseases of the spinal cord , encephalitis , brain tumors , Parkinson's disease and peripheral nerve damage.

Initially, only babies and children with congenital movement disorders (children with cerebral palsy) were treated “according to Bobath”. The concept is based on an understanding of developmental physiology and neurophysiology . In the 1960s the concept was extended to the care and therapy of adult patients. Today it is the most successful and globally recognized treatment concept for people with movement disorders as a result of a neurological disease.

A few years ago, patients with brain damage and central paralysis were considered to be care cases. With targeted nursing and therapeutic measures, they can be rehabilitated successfully today.

The disease in which the Bobath concept is most commonly used is apoplectic insult or stroke (cerebral infarction), which is associated with hemiplegia, or the various manifestations of cerebral palsy and diseases with various hypotonic manifestations such as spinal muscular atrophy .

The number of patients with ischemic (caused by reduced blood flow) insults (seizures) who survive the acute phase of the disease has increased significantly in recent years. Immediate onset of Bobath therapy and changes in the design of nursing based on the Bobath concept improve the future prospects of these patients with regard to independence and independence in daily living (ATL).

Teaching and disseminating the concept

The International Bobath Instructors Training Association (IBITA) has been in existence since 1984 with formal headquarters in St. Gallen, Switzerland, offices in Amstelveen, Netherlands, and country representatives in Germany, Austria and Switzerland. The association was founded with the consent of Berta and Karl Bobath in order to avoid excessive growth in the training of therapists in the Bobath concept. Among the approximately 250 members worldwide (as of March 2009) 51 instructors from physiotherapy and occupational therapy in Germany, 26 from Switzerland and 3 from Austria belong to it . Internationally recognized Bobath courses are held exclusively by IBITA instructors; reference is made to this in the course certificates. In August 2011 the worldwide IBITA annual conference was to take place in Vienna .

An organization of nursing staff has been working in Germany since 1994, the Bobath Initiative für Kranken- und Altenpflege e. V. (BIKA) based in Karlsbad-Langensteinbach . It promotes the dissemination and further development of the Bobath concept in nursing and care for the elderly and regulates the training of care instructors for Bobath.

The Association of Bobath Instructors (IBITA) Germany and Austria eV, based in Berlin, has been in existence since 1996 and has a comprehensive course program.

Bobath courses are offered by many institutions and professional associations for physiotherapists and nursing, in Germany by the Albertinen Academy in Hamburg (the largest provider of Bobath courses) and the VPT Academy Fellbach, in Austria by the Physiotherapists Association Physio Austria.

Detailed information

Goal, tasks

The goal of the Bobath concept results from the mutual agreement of goals between the patient and the caregivers (therapists, doctors, nurses). The general goal is the greatest possible independence, personal activity and ability of the patient to act in everyday life, taking into account and analyzing motor skills. The therapist, doctor and / or nurse analyzes the problems in the execution of actions and movements. Knowledge from developmental neurology, movement analysis and other related sciences such as pedagogy or psychology play an important role.

The goal-oriented and essential part of the work according to and with the Bobath concept is the individual design of the patient's environment, so that he can achieve the goals of action and movement. This also includes advice and testing of aids such as wheelchairs or orthoses in their use and handling.

Today the Bobath concept is used by all relevant medical professional groups. Infants, children and adults are treated. Whole teams, including doctors, therapists and nursing staff, have taken up the concept and are trying to operate it holistically in 24-hour management in appropriate facilities.

Overall goals

  • To recognize the skills and competencies of the patient and thus to achieve the greatest possible independence or development opportunities in order to promote participation and activity in his social environment.
  • The ability to learn or relearn movement skills in the sense of motor learning taking into account all levels of body functions and body structures (e.g. the perceptual functions)
  • Avoidance of secondary changes, such as B. Joint stiffeners

Benefits for the patient

In contrast to conventional methods, the Bobath concept is not intended to achieve a makeshift compensation of the paralysis, but rather the relearning of normal mobility skills. Provided that the patient cooperates intensively, he or she becomes more independent in the activities of daily life. In many cases, this can prevent the need for long-term care, dependence on outside help and accommodation in a nursing home. The early use of therapy and care according to the Bobath concept in the intensive care unit can help to reduce or avoid negative developments such as the development of spasticity and the learning of non-physiological movement sequences. The continued application of the principles of the Bobath concept leads to a better chance of success in further rehabilitation for all patients.

Team responsibility for care and therapy

The Bobath concept is a 24 hour concept. Since the brain is always learning, the learning opportunities must always be correctly designed in order to avoid faulty learning processes. The learning process according to the Bobath concept does not only take place during therapy units for a limited time, but is a constant part of the entire daily routine. For this it is necessary that everyone who is in contact with the patient orientates himself according to the two principles of the Bobath concept (regulation of the muscle tone and initiation of physiological movement). The patient himself, physiotherapists, nurses, occupational therapists, speech therapists, doctors, other therapists and relatives of the patient ideally orientate themselves towards a common approach that is individual for the patient in order to make the learning offer for the brain as similar and inconsistent as possible.

Caregivers spend most of their time with the patient. That is why the care of the elderly and the sick takes on a lot of responsibility in the Bobath concept; it becomes part of the therapy. It is therefore very important to train the nursing staff in the Bobath concept; a separate association (see below) is dedicated to this task.

Physiotherapists prepare for the fact that they have to work in a team to create an individual therapy concept for each patient that cannot be specified by the attending physician. (Most doctors are not trained in the Bobath concept; however, medical courses are offered to reduce this shortcoming.) Information about and training in the Bobath concept is most widespread among the professional group of physiotherapists.

The close cooperation in the therapeutic team includes the patient himself, occupational therapists, speech therapists, other therapists and relatives of the patient. (Many occupational therapists have completed Bobath courses.)

For everyone concerned with mobilization and handling of the patient, it is beneficial that the Bobath concept enables particularly back-friendly and body-economical procedures: You orient yourself to the normal movement of people and work exclusively with pulling and lever forces. The patient is never lifted.

The interlinking of the work, especially of physiotherapy and nursing, is a decisive factor for success. The Bobath concept places special demands on both professional groups, not only in terms of technical knowledge, but also in terms of the ability to work in a non-hierarchical manner and communicate.

Priorities in nursing

The Bobath concept aims at a learning process for the patient in order to regain control over the muscle tone and the lost movement functions. This learning process is based on the lifelong learning ability of the brain through constant reorganization of the cooperation between the nerve cells and the incomplete use of the nerve cells of the brain (plasticity). The "result" of this desired learning process is the facilitation of functions at the level of the nerve cells in the brain through the activation of existing synapses (connections between nerve cells) or the formation of new synaptic connections between the nerve cells.

The learning process according to the Bobath concept does not only take place during limited therapy sessions, but is a constant part of the entire daily routine. Everyone involved in rehabilitation works closely together. Patients, physiotherapists, occupational therapists, nurses, doctors and relatives of the patient orientate themselves around the clock on common, cross-professional working principles.

Storage course

Because of the regular repetition, especially in the acute phase, its positioning represents a particularly important learning opportunity for the patient. Through consistently carried out and professional positioning, an increase in muscle tone can be favorably influenced and limited in any case. An undesirable obstruction of the very desirable development of functional muscle tone is also prevented. Without therapeutic positioning, the rehabilitation prospects are much less favorable.

For patients with disorders of body perception, who often stand out due to great restlessness or severe spasticity, positioning is a good way of intensifying the awareness of their own body in a targeted manner. Contrary to popular beliefs about pressure ulcer prophylaxis, attempts will be made to position these patients rather hard. The patient should receive more information about his or her own body via the higher contact pressure and the additional embedding of solid storage material and thus more contact area, even on the non-supported body parts.

Of course, in each individual case, an individual balance must be made between the risk of bedsores on the one hand and the therapeutic benefit of harder positioning on the other. In many cases, you will achieve adequate decubitus prophylaxis simply by repositioning yourself regularly at shorter intervals!

Learning offer mobilization and handling

The therapeutically correct handling (the "handling") of the patient during movement must z. B. be observed with every mobilization, including when bed, when repositioning, when getting up and transferring to the wheelchair. Handling techniques are used whenever a patient is being moved or transported or is supposed to move with the aid. By shaping the situation and guiding the affected body parts, the caring person (therapist, nurse, relatives) offers the patient a learning opportunity to regain the lost movement functions. The patient uses the abilities of the less affected side of the body. By guiding into physiological movement sequences and thus correct input as a learning offer, the initiation or regaining of normal, bilateral movement is made possible.

Self-help training (ADL training)

Self-help training is also called ADL training (activity of the daily living), as it is here that you practice independence in activities of daily living (ADL). By including regularly recurring everyday activities in the Bobath therapy, the patient's learning process is particularly intensified. By designing the initial situation (positioning or initial position of the patient, aids, surroundings), the aim is to control the muscle tone.

From this tone-controlled situation, the patient learns through guidance to repeatedly involve his affected body parts or his entire body in activities. In addition to independence or self-employment, this also involves the initiation or retrieval of physiological exercise programs learned before the illness. Suitable areas for therapeutically designed ADL training are e.g. B. Personal hygiene, dressing and undressing and eating. These are actions familiar to the patient from the time before his illness, for which he had precise concepts and exercise programs before his illness. Care and therapy can thus fall back on concrete movement experience and do not have to develop new, initially abstract movements from scratch. The patient's motivation and orientation are usually better due to the familiar, concrete and practical life situation than in abstract exercise situations that are far removed from real life practice.

In body care in particular, there are possibilities of therapeutic stimulation of the body's self-perception (proprioception). Interesting parallels can be found here between the Bobath concept and basal stimulation , which suggest that both concepts can be used in complementary ways in some patients.

Limits of work according to Bobath

The success of rehabilitation in brain-damaged patients cannot be guaranteed even when working according to the Bobath concept and depends on numerous factors. The brain damage underlying the disease cannot be undone with the work of Bobath. In terms of type and extent, it naturally affects the ability to learn, ie the ability of the brain to reorganize the cooperation of intact nerve cells. Especially multiple brain damage or diffuse brain damage z. B. due to a general lack of oxygen after resuscitation (hypoxemic brain damage) are less favorable for the learning process, since they impair the ability of the brain to reorganize not only in a focal manner, but globally. In addition, brain performance disorders (neuropsychological disorders) caused by brain damage can limit the ability to learn.

The patient's motivation to actively cooperate is a crucial factor. It is determined by the personality of the patient before his illness, his individual way of coping with the illness and also the type of brain damage. The motivation must be maintained through repeated and open information to the patient. The best motivation is achieved through success and progress that the patient himself can see.

Relatives play an important role. You can influence the patient's motivation positively and negatively, activate him or encourage him to be passive, have a decisive influence on coping with the illness and thus have a considerable influence on the rehabilitation process. That is why their early involvement and information is provided for and crucial in the Bobath concept.

For the effective design of the learning process according to Bobath, it is important that all those involved in the rehabilitation of the patient work together and as similarly as possible. The less such interdependent cooperation takes place and the more differently the patient works, the less successful the patient will be in learning.

Under favorable conditions, almost complete recovery of the patient is quite possible; In any case, the rehabilitation success will be significantly better with a coordinated approach by all those involved.

criticism

Criticism of the Bobath concept comes from the Icelander Þóra B. Hafsteinsdóttir ( Thora B. Hafsteinsdottir ), whose aim is to base the treatment of stroke patients on reflective, scientific studies.

Some of the Icelander's criticisms are:

  • lack of scientific and above all current studies on the concept
  • partly wrong or outdated assumptions, but also missing basics of the concept with regard to the neuroscientific foundations
  • Inconsistency in the whole concept and its understanding
  • no noticeable differences in outcome in comparison between conventional approaches and the Bobath concept
  • Costly and time-consuming training and implementation without any discernible benefit

The academization of the nursing professions in Germany, which is currently being established, makes it difficult to find concrete scientific studies and studies.

See also

Notes and individual references

  1. ↑ Born in Berlin March 14, 1906, shared suicide with Berta Bobath on January 20, 1991 in London
  2. ↑ TB Hafsteinsdottir, J. Kappelle, MHF Grypdonck, A. Algra: Effects of bobath-based therapy on depression, shoulder pain and health-related quality of life in patients after stroke. In: Journal of Rehabilitation Medicine. 39 (8), 2007, pp. 627-632. PMID 17896054
  3. ^ TB Hafsteinsdóttir, A. Algra, LJ Kappelle, MH Grypdonck; Dutch NDT Study Group: Neurodevelopmental treatment after stroke: a comparative study. In: Journal of Neurology, Neurosurgery & Psychiatry. Jun; 76 (6), 2005, pp. 788-792. PMID 15897499

literature

  • Frauke Biewald (ed.): The Bobath concept . Urban & Fischer . 2004 , ISBN 3-437-45636-9 .
  • Ute Steding-Albrecht (Ed.): The Bobath concept in everyday life for children. Thieme Verlag, 2003, ISBN 3-13-130861-3 .
  • Hille Viebrock, Barbara Forst (ed.): Bobath . Thieme Verlag, 2008, ISBN 978-3-13-143381-7 .
  • Katharina Scheel: Models and practical concepts of physiotherapy . LIT, 2013, ISBN 978-3-643-12040-3 .
  • Gisela Ritter, Alfons Welling: The 10 principles of the Bobath concept in child therapy . Thieme Verlag, 2008, ISBN 978-3-13-145691-5 .
  • Berta Bobath, Karel Bobath: The motor development in cerebral palsy . Thieme Verlag, 1998, ISBN 3-13-539006-3 .
  • Alfons Welling: Niklas and the Bobath therapy documentation of a single case study . Thieme Verlag, ISBN 978-3-13-143651-1 .
  • Pat M. Davies: Hemiplegia . Springer Verlag, 2002, ISBN 3-540-41794-X .
  • Karin Cornelius, Gisela Ritter: Living and working with the Bobath concept . 2011.
  • Karl-Michael Haus: Neurophysiological treatment in adults . Springer Verlag, Berlin 2010, ISBN 978-3-540-95969-4 .
  • Bettina Paeth Rohlfs: Experiences with the Bobath concept. Basics, treatment, case studies. 2nd Edition. Thieme 2005.
  • Birgit Dammshäuser: Bobath concept in care. Basics, problem identification and practice (with DVD on the handlings). Elsevier, Stuttgart 2005, ISBN 3-437-26740-X .
  • Herma Purwin, S. Korte, M. Längler: Handling according to Bobath using the example of hemiplegia. Companion book for lessons and everyday care. 3. Edition. Verlag Vincentz Network, Hanover 1999, ISBN 3-87870-602-2 .
  • Carina Schmelzle among others: Yesterday was correct - today a care mistake? In: Care magazine. 4/2004, pp. 233-236.
  • Lothar Urbas: Care of a person with hemiplegia according to the Bobath concept 2nd edition. Georg Thieme Verlag, Stuttgart 1996, ISBN 3-13-113802-5 . (outdated, also in the unchanged edition from 2005)
  • Reinhard Lay: What's new in the Bobath concept? In: The sister / the nurse . 6/2007, pp. 488-494.
  • Barbara Ohrt: The roots of the Bobath concept. In: Movement and Development . 1/1998, pp. 3-10.
  • Bente E. Bassoe Gjelsvik: The Bobath Therapy in Adult Neurology . Georg Thieme, 2007, ISBN 978-3-13-144781-4 .