What is the NDT-Bobath concept?
A world of difference for neurological rehabilitation
Until halfway through the last century, the approach to brain damage was mostly orthopaedic. But after the Second World War, Dr Karl Bobath (paediatrician) and his wife Berta Bobath (physiotherapist) caused a true revolution in the treatment of children and adults with brain damage. The combination of her fascination with movement and his medical knowledge resulted in the NDT-Bobath concept. To this day, it remains the most commonly used method globally for the treatment of patients with brain damage, says Tara Hanssen, physiotherapist.
“The Bobath method has been a game-changer in neurological rehabilitation”, Tara Hanssen confirms. Tara has a master’s degree in paediatric rehabilitation but now works at the department of neurological rehabilitation for adults at the specialist Sint-Ursula rehabilitation centre, which is part of the Jessa Hospital in Hasselt. “The method starts with observations. How does the patient move, how do they organise themselves? We then set out to find an inclusive, individual approach for each patient.”
Why an individual approach?
It may sound logical, but according to Tara the NDT-Bobath approach was far from it in traditional physiotherapy. “It requires a highly individualised approach that goes well beyond the affected limbs. The therapist is required to question everything all the time: your treatment, your own actions, the entire framework surrounding the patient. Contrary to what the textbooks claimed for a long time, there is no such thing as a standard haemiplegic motor profile. As a result, standard treatment is impossible. All the more interesting for the therapist!
Bobath therapy... doesn’t exist?
Though the NDT-Bobath concept is gaining in popularity, Tara emphasises that there is no such thing as the Bobath therapy. “There is no standard treatment. There are no treatments or tools where, if you use them, you can call yourself a true Bobath therapist. That is not how it works. The Bobath concept offers a framework for the analysis and recovery of functional movement. It requires a different perspective than the one taught in basic physiotherapy training. You learn to look more deeply.”
“The method starts with observations. How does the patient move,
how do they organise themselves? We then set out to find an inclusive, individual approach for each patient.”
Neurological rehabilitation requires specialisation
During her internship as a physiotherapist, Tara almost immediately encountered the Bobath concept. “I learned about all the different conditions during my physiotherapy training, but it wasn’t until my internships that I learned how to work with them. It struck me how often people would say: “This is a technique based on the Bobath concept.” Or: “I learned this during my Bobath training.” I realised that I was missing something. I knew what brain paralysis was and what hypertonia was. But how does a paralysed arm affect the entire torso, the entire motion pattern? When I ended up at my current place of work, the Sint-Ursula rehabilitation centre for adults, I got exposed to the Bobath concept for adults. I witnessed how my colleagues took further training and realised that the method goes much deeper than the basic knowledge of neurology taught at the university. It was the missing link to optimise my treatment. That is when I decided to start the course.”
Why two courses for the Bobath concept?
Tara explains that the Bobath method for children and the method for adults are very different and thus require very different training. “The paediatric course is an intense half-time post-graduate course of one academic year. It strongly emphasises the neurological cohesion of the motor development of babies and children. In layman’s terms: why does a baby need to learn to lie on its back and belly before it can learn other movements? This is then translated to pathology: if certain parts of the brain are damaged, how does that affect motor development and how do we approach it as therapists?
“The Bobath therapist for adults training course focuses on teaching us how to change our perspective of the patient. You learn to break down a functional movement until you reach a hypothesis as to why a patient moves the way they do. This is then linked to the current scientific knowledge from neuro(physio)logy. It is an intense full-time, three weeks course that emphasises clinical reasoning, observation and refining your treatment skills.”
There is another important difference between the two courses, Tara explains: “Upon successful completion of the Bobath therapy for children course, you may call yourself a Bobath therapist for children. With the course for adults, this is not the case. After your basic three-week training, you need to take two advanced courses within a certain period of time. For both courses, a refresher course is required within five years in order to keep your title.”
No crystal ball
What patients can expect from Bobath treatment depends very much on each individual situation, according to Tara. “Adult patients all have different expectations. Some want to be able to comfortably walk over from their sofa to the kitchen, others want to be able to use their bicycle again or take their children to Scouting. Of course, we hope to get as close as possible to that objective. But when you're dealing with neurological damage, you never have a crystal ball. One important factor is a person’s motivation. Our emotions regulate our movements and therefore also our recovery. This may sound a bit out there, but it has been scientifically proven that the part of the brain that regulates our emotions plays an important part in initiating movements. Of course, enthusiasm alone does not suffice and every case of neurological damage is different. It often takes a lot of hard work without any guaranteed success. It usually involves long rehabilitation times with many ups and downs. But no matter how hopeless a situation may seem, we are often surprised by our patients. We’ve had people at the rehabilitation centre who were completely unable to move against gravity but still managed to learn how to walk, with or without an aid. These cases are, of course, warming to the therapist’s heart! (smiles)”
Physically and mentally demanding for the neurological physiotherapist
Treating patients with non-congenital brain damage can be very difficult for Tara as well. “I find my patients and their environment at a very emotional intersection in their lives. You see them three to five times a week, sometimes even more. You talk to them and their environment, including about other elements of their lives. These are very intense, borderline intimate moments. After all, you share the same goal which is of immense importance to the rest of their lives. A very emotional process indeed.”
However, as Tara explains, their treatment can be physically demanding as well. “The patient is the one who works the hardest, of course, but the Bobath method requires quite a lot of physical labour of the therapist as well. You can’t just let go of the patient because this is likely to result in a falling incident. And especially in the early stages of rehabilitation, it takes some physically demanding techniques to ensure the safety of your patient. In the case of an old lady weighing 45 kilograms, it's not so bad. But this becomes a very different story when you’re dealing with a 120-kilogram adult.” (laughs)
Bobath treatment table
Luckily, a neurological therapist can rely on various aids such as stools, passive lifts, etc. According to Tara, the most important aid in therapy by far is the unique Bobath treatment table. “A Bobath table is almost the same size as a king-size bed, offering a lot of space to work. This allows the therapist to sit all around the patient to apply the right techniques with minimum strain on back. But it is also much safer for the patient. When some patients are on their back and an arm falls off the table, this may be enough to make them roll. With a regular treatment table, the patient will end up on the floor. A Bobath table is large enough to guarantee safety in these situations. It is also very useful for babies. It eliminates the need to do your exercises with the baby on a mat on the floor, which would require you to bend forward while sitting on your knees. Instead, you can place the baby on the Bobath treatment table while you sit on a stool in front of the baby. The Bobath table offers a comfortable, stable workstation with more than enough room to do your job.”
In addition to treating her patients lying down on the Bobath treatment table, she also has them sit on the edge or positions them standing next to the table. “Being stable as it is as well as height-adjustable, the table is perfectly suited to have patients stand besides it. My patients' first steps are usually taken next to a Bobath treatment table. This puts quite a lot of pressure on one side of the table, but the table is made to handle it.”
The Roy Orbison method
Despite the high mental and physical load of her job, Tara would not trade it for the world. “My job is extremely satisfying. To help someone go from being passive and suffering back to being an active, participating individual is a very special experience every single time. Some people you will carry with you for the rest of your life. This spontaneously reminds me of a man who was perhaps sixty years older than me, but with whom I connected very well. He loved Roy Orbison. So, every time we had a therapy session I proceeded to put on some Roy Orbison. He would light up and his posture would improve right away! (laughs). But I also recall people who were the same age as me, or those who remind me of my parents, relatives or friends. The only difference is that these people really drew the wrong straw and became severely dependent from one moment to the next. If I can apply the Bobath method to help them regain part of their life... These are moments and people you will carry in your heart for the rest of your life.”