Clinical Rehabilitation 2005; 19: 155 /164

Efcacy of Bobath versus orthopaedic approach on impairment and function at different motor recovery stages after stroke: a randomized controlled study
Ray-Yau Wang Institute and Faculty of Physical Therapy, National Yang-Ming University, Taipei, Hsiu-I Chen, Chen-Yin Chen Physical Therapy, Rehabilitation Department, Chung-Gung Memorial Hospital, Tao-Yuan and Yea-Ru Yang Institute and Faculty of Physical Therapy, National Yang-Ming University, Taipei, Taiwan Received 17th April 2004; returned for revisions 10th August 2004; revised manuscript accepted 25th September 2004.

Objective: To investigate the effectiveness of Bobath on stroke patients at different motor stages by comparing their treatment with orthopaedic treatment. Design: A single-blind study, with random assignment to Bobath or orthopaedic group. Setting: Physical therapy department of a medical centre. Subjects: Twenty-one patients with stroke with spasticity and 23 patients with stroke at relative recovery stages participated. Interventions: Twenty sessions of Bobath programme or orthopaedic treatment programme given in four weeks. Main outcome measures: Stroke Impairment Assessment Set (SIAS), Motor Assessment Scale (MAS), Berg Balance Scale (BBS) and Stroke Impact Scale (SIS) for impairment and functional limitation level. Results: Participants with spasticity showed greater improvement in tone control (change score: 1.209/1.03 versus 0.089/0.67, p 0/0.006), MAS (change score: 7.649/ 4.03 versus 4.009/1.95, p 0/0.011), and SIS (change score: 7.309/6.24 versus 1.259/ 5.33, p 0/0.023) after 20 sessions of Bobath treatment than with orthopaedic treatment. Participants with relative recovery receiving Bobath treatment showed greater improvement in MAS (change score: 6.149/5.55 versus 2.779/9.89, p 0/0.007), BBS (change score: 19.189/15.94 versus 6.859/5.23, p 0/0.015), and SIS scores (change score: 8.509/3.41 versus 3.629/4.07, p 0/0.006) than those with orthopaedic treatment. Conclusion: Bobath or orthopaedic treatment paired with spontaneous recovery resulted in improvements in impairment and functional levels for patient with stroke. Patients benefit more from the Bobath treatment in MAS and SIS scores than from the orthopaedic treatment programme regardless of their motor recovery stages.

Introduction
Experimental evidence demonstrates that rehabilitation leads to improved functional ability;
Address for correspondence: Yea-Ru Yang, Institute & Faculty of Physical Therapy, National Yang-Ming University, 155, Sec 2, Li Nong St., Taipei, Taiwan, ROC. e-mail: yryang@ym.edu.tw # 2005 Edward Arnold (Publishers) Ltd

however, it does not demonstrate that motor recovery has occurred on the affected side.1 The majority of studies have only measured treatment effects using activities of daily living (ADL) scores.2 This may hide the fact that patients could have become independent without regaining the use of the affected side through compensation by the unaffected side.
10.1191/0269215505cr850oa

156 R-Y Wang et al. The Bobath treatment, also known as the neurodevelopmental treatment (NDT) in the USA, is one of the major approaches used to rehabilitate patients following a stroke. Although extensive literature regarding the Bobath approach exists, there is still insufficient evidence to conclude that it is more effective than any other.3,4 Based on the Bobath concept, abnormal movement patterns combined with abnormal postural tone are considered to be main problems for the hemiplegic patient.5 Therapists using the Bobath concept believe that NDT contributes to effective recovery of movement of the affected side and functional activity.6 To evaluate therapy based on the Bobath concept, both recovery of movement and improvement in function need to be assessed by quantitative measurements. Moreover, in a recent review, Paci stated that it is not possible to abstract information from previous studies to understand which patient benefits from Bobath therapy and which does not.3 Pollock et al . also indicated that one of the limitations of the study methodology was the heterogeneous patient population.4 The present study, therefore, is designed to clarify the effectiveness of Bobath for patients with stroke at different motor stages. The aims of the present study are to examine: (1) if Bobath therapy decreases impairment and increases function more than orthopaedic therapy for adults with stroke at hypertonic stages; and (2) if Bobath therapy is more effective than orthopaedic therapy for adults with stroke in relative recovery stages. Hemiplegic patients with spasticity were defined in this study as being in Brunnstrom stage 2 or 3 of lower extremity motor recovery, whereas the relative recovery group was defined as in Brunnstrom stage 4 or 5.7 The diagnosis, age, sex, affected side, stroke type, and number of days since the onset of hemiparesis were obtained from patient interviews and medical charts. All information was evaluated by a single physical therapist. Twenty-one hemiplegic patients with spasticity participating in this study were randomly assigned to the Bobath group or the orthopaedic group (Figure 1). Twenty-three hemiplegic patients with relative recovery participated in this study and were also randomly assigned to the Bobath group or the orthopaedic group (Figure 1). The random assignment was achieved by an independent person who chose one of the sealed envelopes 30 min before the start of the intervention. Outcome measures The patients were assessed twice: once before and once after treatment. Impairment levels were tested by the Stroke Impairment Assessment Set (SIAS), while functional limitation levels were tested by the Motor Assessment Scale (MAS), Berg Balance Scale (BBS) and Stroke Impact Scale (SIS). Test results for each patient were assessed and evaluated by a separate physical therapist who was not involved in the treatment programme and did not know about the patients group. SIAS: Motor control of lower extremity Three subtests of the SIAS related to the lower limb: hip flexion, knee extension and ankle dorsiflexion were monitored as motor control of lower extremity.8 Each item was rated from 0 (severely impaired) to 5 (normal) for motor function. A total full score of SIAS / complete motor control of lower extremity / is 15. SIAS was tested here on an impairment level according to WHO criteria.9 SIAS: Tone Muscle tone evaluation was included because tone is an important treatment indicator for therapists using the Bobath approach. Muscle tone is evaluated by using both deep tendon reflexes and passive joint resistance of the lower

Methods
Participants Participants were recruited by convenience sampling from the rehabilitation inpatient department of a medical centre. The criteria for participant selection were: (1) diagnosis of hemiparesis secondary to recent cerebrovascular accident; (2) lower extremity Brunnstrom motor recovery stage 2, 3, 4 or 5; and (3) ability to communicate and willingness to co-operate. Fifty-eight subjects were identified as potential participants for this study. Twelve were excluded because they failed to meet the inclusion criteria (Figure 1). Forty-four subjects signed an informed consent before participating in the study.

Bobath versus orthopaedic approach after stroke

58 Patients with stroke were assessed for eligibility

157

Exclusion 1 unable to communicate 4 refused participation 3 lower extremity Brunnstrom motor stage at 1 4 lower extremity Brunnstrom motor stage at 6

46 patients on the basis of inclusion criteria 2 did not give informed consent

21 patients with spasticity (Brunnstrom stage 2 and 3)

23 patients with relative recovery (Brunnstrom stage 4 and 5)

Randomized

Randomized

Allocated to orthopaedic group (n = 11)

Allocated to Bobath group (n = 10)

Allocated to orthopaedic group (n = 12)

Allocated to Bobath group (n = 11)

11 completed trial N with data = 11

Figure 1 Flow diagram of the study.

10 completed trial N with data = 10

12 completed trial N with data = 12

11 completed trial N with data = 11

158 R-Y Wang et al. extremity.8 Deep tendon reflexes are graded as follows: a score of 0 indicates that reflexes (the patellar and Achilles tendon reflexes) are all markedly increased and that even ankle clonus is present; a score of 1 represents that tendon reflexes are moderately increased; a score of 2 means that these reflexes are slightly exaggerated or absent; and a score of 3 signifies normal or symmetrical reflexes when compared to the unaffected side. Passive joint resistance is graded as follows: a score of 0 denotes that resistance is remarkably increased by passive motion (knee flexion and ankle dorsiflexion); a score of 1 shows that resistance is moderately increased; a score of 2 indicates that the resistance is only slightly increased; and a score of 3 means the resistance is normal. A combined score of 6 indicates normal muscle tone of the lower extremity. Berg Balance Scale (BBS) Balance was evaluated using the BBS, rating performance from 0 (cannot perform) to 4 (normal performance) on 14 different tasks. These tasks include ability to sit, stand, reach, lean over, turn and look over each shoulder, turn in a complete circle, and step.10 The total highest score of 56 on the BBS indicates good balance. The Berg Balance Scale has been shown to have excellent reliability (0.96) and relatively good concurrent validity.11 Berg Balance Scale correlate well with measurements obtained with other clinical balance scales and also with measurements of the gait speed of hemiparesis patients.11 The BBS tested here follow functional limitation level according to WHO criteria.9 Motor Assessment Scale (MAS) The MAS is a brief, easily administered and highly reliable clinical scale of eight categories of motor function.12 The scale consists of five categories of functional mobility (rolling to the side, sitting up from lying, balanced sitting, sitting to standing, and walking) and three categories of recovery of movement and functional abilities related to the upper limb. Each item is scaled from 0 to 6. In the present study, we chose the five categories of functional mobility, and hence, the scores range from 0 to 30. The MAS is also tested on a functional limitation level according to WHO criteria.9 Stroke Impact Scale (SIS) The SIS is one of the subjective measurements that assesses stroke-specific outcome using a questionnaire.13 Eight domains are evaluated by the participants self-assessment scale. Only the mobility domain among the eight, which contains 10 functional activities, was used in the present study. The assigned score to denote the degree of difficulty encountered in performing the 10 functional activities ranges from 1 (cannot do at all) to 5 (not difficult at all). The score for each functional activity / sitting balance, standing balance, walking balance, moving from a bed to a chair, getting out of a chair without hands support, walking one block, walking fast, climbing one flight of stairs, climbing several flights of stairs, and getting in and out of a car / were combined to obtain a total measure (highest score: 50 points).

Intervention Bobath approach Based on Bobath philosophy, the participant actively participates in a treatment that is individualized, constantly modified according to subject response, and geared toward functional activities. Emphasis was placed on retraining normal alignment and normal movement patterns based on Bobath treatment principles. These patterns were facilitated through appropriate sensory and proprioceptive input, direct manual facilitation, key point control, and verbal and visual feedback.5,14,15 Normalizing the muscle tone, re-educating the postural reaction and training for trunk control are integral parts of the Bobath treatment, and were practised extensively during the treatment session to optimize balance reaction and movement quality. The approach used in this study strictly adhered to the principles described in detail in the Bobath and Davis texts.5,15 In this study, two treating physical therapists had attended the Bobath course on adult hemiplegia. Both therapists had been qualified for more than 10 years with at least five years of Bobath practice. Each patient received 40-min Bobath programme

Bobath versus orthopaedic approach after stroke each session, five sessions a week, for a total of 20 sessions. Orthopaedic approach Orthopaedic treatment techniques included passive, assistive, active and progressive resistive exercise.4 The process attempted to elicit motion joint by joint, all under volitional control by the patients. The functional activities, such as rolling, sitting up, transfer and gait, focus on multiple repetitions of specific activities, were also practised as early as possible during the 40-min treatment session. Gait training was usually started near a horizontal bar that supported the patient on his or her non-affected side. The two treating physical therapists had been qualified for more than 10 years with at least five years of orthopaedic practice on patients with stroke. Patients in the orthopaedic group received 40-min treatment programme each session, five sessions a week, for a total of 20 sessions. Data analysis Data of patients age and duration of hemiparesis were analysed by the independent t -test. The chi-square test was used for between-group comparisons when the data were nominal, such as sex, side of hemiparesis and aetiology, etc. For the outcome variables, the paired t -test was used for within-group comparison, and the independent t-test was used for between-group comparison. For all the statistical testing performed in the present study, a level of probability of 0.05 was set for significance.

159

four had a haemorrhagic stroke and six an ischaemic stroke in this group. There were no differences between these two groups in age, side of hemiparesis, duration of hemiparesis and other general characteristics. In both groups, all participants completed the treatment. After treatments, participants in both groups demonstrated significant improvements in SIAS motor control of lower extremity (p B/0.01), MAS (p B/0.001) and BBS (p 5/0.001). In addition, participants in the Bobath group further demonstrated significant improvements in SIAS tone (p 0/0.005) and in SIS (p 0/0.005), which were not noted in the participants receiving the orthopaedic treatment (Table 1). In comparison of change scores between the two groups, participants in the Bobath group showed significantly greater improvement in the tone control (p 0/0.006), MAS (p 0/0.011), and SIS (p 0/0.023) (Table 1). On the other hand, the changes in balance (BBS score) and the motor control of lower extremity measured by the SIAS showed no significant difference between the two groups (Table 1). Patients with relative recovery Participants in the orthopaedic group (n 0/12) had a mean age of 63.89/13.1 years and mean onset duration of 19.69/7.9 days. Eight of the participants were male and four female; four had a right hemiparesis and eight a left hemiparesis; two had a haemorrhagic stroke and 10 an ischaemic stroke in this group. Participants in the Bobath group (n 0/11) had a mean age of 62.49/11.6 years and mean onset duration of 21.69/9.3 days. Seven of the participants were male and four female; six had a right hemiparesis and five a left hemiparesis; three had a haemorrhagic stroke and eight an ischaemic stroke in this group. There were no differences between these two groups in age, side of hemiparesis, duration of hemiparesis and other general characteristics. All participants, 12 in the orthopaedic group and 11 in the Bobath group, completed the treatment. Participants in both groups demonstrated significant improvements in BBS score (p 5/0.001) and SIS (p B/0.01). Participants in the Bobath group also demonstrated significant improvements in MAS (p 0/0.001), which were not found in participants receiving the orthopaedic treatment (Table 2). However, participants in

Results
Patients with spasticity Participants in the orthopaedic group (n 0/11) had a mean age of 59.39/12.2 years and mean onset duration of 20.79/5.9 days. Six of the participants were male and five female; five had a right hemiparesis and six a left hemiparesis; five had a haemorrhagic stroke and six an ischaemic stroke in this group. Participants in the Bobath group (n 0/10) had a mean age of 53.99/11.8 years and mean onset duration of 21.99/7.4 days. Seven of the participants were male and three female; five had a right hemiparesis and five a left hemiparesis;

160 R-Y Wang et al.

Table 1 Outcome measures for participants with spasticity in the orthopaedic and Bobath groups Change scores Orthopaedic (n 0/11) Pretest Post-test Bobath (n 0/10) Orthopaedic Bobath (n 0/10) (n 0/11)

Outcome

Scores

p-valuea
Pretest Post-test

p-valuea

Post /pre

Post /pre

p-valueb

1.00 (1.86) 0.00 (2.25) 2.33 (0.79) 2.00 (0.00) 0.674 11.33 (4.62) 0.000 0.434 15.33 (4.59) 0.000 4.00 (4.50) 2.42 (0.99) 2.00 (1.50) 0.00 (1.00) 2.60 (0.97) 2.00 (2.00) 4.00 (5.50) 3.80 (0.63) 4.00 (0.00)

4.00 (2.63)

0.002

0.90 (1.91)

4.10 (2.81)

0.007 0.005

3.00 (2.66) 2.00 (4.25) 0.08 (0.67) 0.00 (0.00) 0.000 0.001 0.005 4.00 (1.95)

3.20 (2.89) 3.0 (5.50) 1.20 (1.03) 2.00 (2.00) 7.64 (4.03)

0.868 0.006

Impairment Stroke Impairment Assessment Set Motor control of Mean (SD) lower extremity (out of 15) Med (IQR) Tone Mean (SD) (out of 6) Med (IQR) 11.18 (4.02) 18.82 (5.84)

Mean (SD)

0.011 0.185 0.023 20.00 20.55 20.00 18.90 18.00 (7.00) (12.20) (25.00) (5.07) (6.50) 4.00 9.75 9.50 1.25 1.50 (3.25) 9.00 (6.00) (4.85) 14.55 (10.76) (8.00) 13.00 (12.00) (5.33) 7.30 (6.24) (3.50) 6.50 (6.75)

Function Motor Assessment Scale (out of 30) Berg Balance Scale (out of 56) Stroke Impact Scale (out of 50) 10.50 10.67 9.50 14.17 15.50 (7.75) (6.49) (13.00) (5.87) (10.75) 15.50 20.42 21.00 15.42 16.00 (5.75) (4.64) (7.75) (4.23) (8.75) 11.00 6.09 5.00 11.60 11.00 (7.00) (4.57) (3.00) (4.69) (4.50)

Med (IQR) Mean (SD) Med (IQR) Mean (SD) Med (IQR)

SD, standard deviation; Med (IQR), median (interquartile range). a Within-group comparison. b Between-group comparison.

Table 2 Outcome measures for participants with relative recovery in the orthopaedic and Bobath groups Change scores Orthopaedic (n 0/11) Pretest Post-test Bobath (n 0/10) Orthopaedic Bobath (n 0/10) (n 0/11)

Outcome

Scores

p-valuea
Pretest Post-test

p-valuea

Post /pre

Post /pre

p-valueb

0.127 0.104 9.00 (5.00) 3.73 (0.65) 4.00 (0.00) 17.86 (5.93) 24.00 (4.87) 10.00 (5.00) 4.00 (0.00) 4.00 (0.00)

10.27 (3.13)

11.00 (2.83)

0.070 0.192

0.91 (1.81) 0.00 (1.00) 0.36 (0.67) 0.00 (1.00) 0.001 0.001 0.000 2.77 (9.89)

0.73 (1.19) 0.00 (1.00) 0.27 (0.65) 0.00 (0.00) 6.14 (5.55)

0.784 0.750

Impairment Stroke Impairment Assessment Set Motor control of Mean (SD) 10.36 (2.84) 11.27 (2.97) lower extremity (out of 15) Med (IQR) 9.00 (5.00) 10.00 (5.00) Tone Mean (SD) 3.64 (0.67) 4.00 (0.00) (out of 6) Med (IQR) 4.00 (1.00) 4.00 (0.00) 23.31 (6.19) 25.54 (7.05) 0.000 0.008 0.333

Mean (SD)

0.007 0.015 0.006 25.00 35.18 43.00 23.60 25.00 (3.50) (16.15) (30.00) (6.96) (12.00) 2.00 6.85 5.00 3.62 3.00 (14.00) (5.23) (9.50) (4.07) (4.00) 4.00 19.18 13.00 8.50 9.00 (7.25) (15.94) (33.00) (3.41) (3.25)

Function Motor Assessment Scale (out of 30) Berg Balance Scale (out of 56) Stroke Impact Scale (out of 50) 25.00 33.46 42.00 13.31 11.00 (9.25) 28.00 (16.83) 40.31 (27.50) 46.00 (5.74) 16.92 (10.50) 17.00 (11.50) (12.89) (23.00) (6.03) (9.00) 18.50 16.00 11.00 15.10 14.00 (8.25) (15.28) (13.00) (4.72) (7.75)

Med (IQR) Mean (SD) Med (IQR) Mean (SD) Med (IQR)

Bobath versus orthopaedic approach after stroke

SD, standard deviation; Med (IQR), median (interquartile range). a Within-group comparison. b Between-group comparison.

161

162 R-Y Wang et al. neither group demonstrated significant improvements in SIAS motor control of lower extremity or tone control. In comparison of change scores between the two groups, participants in the Bobath group showed significantly greater improvement in the MAS (p 0/0.007), BBS score (p 0/0.015), and SIS scores (p 0/0.006) (Table 2). On the other hand, the changes in the tone and motor control of lower extremity measured by SIAS were not significantly different between the two groups (Table 2). city and those with relative recovery, were considered separately to examine the effectiveness of treatment. In addition, the equivalent amount of therapy, an independent assessor, and experienced therapists might also be contributing factors to different results from the previous studies. In the present study, we found significant improvements in motor function (as measured by MAS) and subjective ratings of functional level (as measured by SIS) in patient with stroke who received the specialized Bobath intervention compared with orthopaedic treatment. Moreover, patients with spasticity in the Bobath group demonstrated better tone control of lower extremity compared with patients in the orthopaedic group. Bobath approach to motor loss not only treats the body as a whole, but also integrates development of the patients sensory, perceptual and cognitive skills into the process. The goals are not limited to motor performance, but also stress the reduction of spasticity and pain, and the return of balance, sensation and confidence. These explain why, in our study, patients in the Bobath group demonstrated more improvements in motor function and tone control especially in patients with spasticity, and subjective ratings of their functional abilities. This finding supports a belief of therapists that the Bobath approach of reeducation of movement after a stroke is not only possible, but also effective.21 However, from the present results, the effectiveness of Bobath for the impairment of muscle tone is minimal in patients with relative recovery. It seems very difficult for relative recovery patients to achieve the level of normal tone by the studys 20-session Bobath

Discussion
Patients with spasticity in both the Bobath and orthopaedic groups showed significant improvements in motor control of lower extremity, MAS and BBS scores, as expected, during rehabilitation after stroke. However, Bobath therapy can result in better tone control and SIS. Patients with relative recovery in both groups demonstrated significant improvement in BBS and SIS scores. For patients with relative recovery, only the Bobath group showed significant improvement in motor control of lower extremity and MAS. Although Bobath provides a framework for the treatment of neurological patients, quantitative evidence for its value has yet to be provided. Several investigators have examined the effects of Bobath therapy as well as other forms of therapeutic intervention typically for patients with hemiparesis.16 20 Although careful measurements of progress in motor and neurological functions were made in these studies, none of the investigators found statistically significant findings to substantiate the use of Bobath therapy.16 20 Furthermore, the recent reviews also showed that no evidence proving the effectiveness of Bobath treatment is more effective than other treatments.3,4 The researchers suggested that the lack of significant differences between the Bobath therapy and other types of exercise therapies may be attributable to the use of a measurement that was nonspecific to assessing the highly interrelated aspects of motor dysfunction with enough reliability and validity.4 Heterogeneous patient populations could be another contributing factor. In this study, two patient populations, those with spasti-

Clinical messages
. Patients at different motor recovery stages benefit more from the Bobath treatment than from the orthopaedic treatment programme. . Bobath and orthopaedic treatment paired with spontaneous recovery resulted in improvements in impairment and functional levels for patient with stroke.

Bobath versus orthopaedic approach after stroke approach. This may reflect a problem with the Bobath concept of normalizing tone. The present results shown in Tables 1 and 2 show appreciable improvements in functional balance activities measured by BBS in patients at different motor recovery stages receiving either Bobath or orthopaedic treatment with or without improvements in tone or motor control. Comparing the improvements between the impairment levels (tone and motor control) and the functional limitation level (BBS score), it is seen that the functional level can be improved without a significant change in the impairment level. In assessing the effectiveness of interventions that progress over time, clinical researchers frequently are asked to define clinically meaningful change. In developing such a definition, investigators must consider the precision of the outcome measure and the magnitude of change that is physiologically relevant or has value to the patient. From these two perspectives, changes in SIS domain scores of 10 points or greater appear to represent a reasonable definition of clinically meaningful change.13 In the Bobath group, three out of 10 participants with spasticity and six out of 11 patients with relative recovery demonstrated clinically meaningful change. While in the orthopaedic group, two out 12 participants with spasticity and two out of 12 patients with relative recovery demonstrated clinically meaningful change. The changes of SIS scores between the two studied groups are not different statistically, but are different clinically. The shortcomings of our study derive from several sources. First, because the pace of improvement is individual, our decision to limit the treatment period arbitrarily to four weeks may not be optimal. Secondly, the criterion variables were almost always measured using ordinal scales. Such measurement scales, although prevalent in clinical settings, lack fine discriminative power and introduce subjectivity into assessments. Thirdly, because changes in patients with hemiparesis are influenced by numerous variables, it is practically impossible to discuss the effects of more than only a few of these variables in one study. Future studies should be based on large groups of patients and use a variety of objective measurement tools and time frames. We hope that through many such projects, physical therapists will learn the relative

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therapeutic effects of the procedures that apply to the patients. However, due to relatively short interval after stroke in our patients, the results and conclusions are not supposed to be generalized to chronic stroke patients. In summary, specific and orthopaedic treatment paired with spontaneous recovery resulted in improvements in impairment and functional levels for patient with stroke. Patients with different motor recovery stages, either with spasticity or relative recovery, benefit more from the Bobath treatment than from the orthopaedic treatment programme, as reflected in MAS and SIS scores.

Acknowledgements This study was supported partly by the National Science Council of the Republic of China, grant no. 91-2314-B-010-069, and partly by the National Health Research Institutes of the Republic of China, grant no. NHRI-EX91-9129EI.

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