The Bobath Concept

Dr and Mrs Bobath

The Bobath Concept was conceived and developed in the early 1940s by Dr Karel and Mrs Berta Bobath who came to Great Britain as Jewish refugees from Germany in the 1930s. They taught the Bobath Concept as a clinical treatment approach for adults with stroke, and for children with cerebral palsy, from their London treatment centres for almost 5 decades. They took their post graduate courses to the United States, where it subsequently became known as Neuro-Developmental Therapy (NDT), and were invited to lecture extensively in Europe. They wrote many papers and books and were showered with National and International honours.


What is the Bobath concept or approach?

The EBTA response to a review article by Novak et al 2013

Gill Stern President European Bobath Tutors’ Association on behalf of the EBTA Executive Committee

We are writing in response to the review paper by Iona Novak et al (DMCN 2013), a conclusion of which is to give the ‘red light, don’t do it’ to NDT-Bobath. Before accommodating this drastic step of outlawing a particular approach, we believe it is important to attempt to clarify exactly what the Bobath approach or concept is, and to correct some misunderstandings about it, using previously published material.

Dr Karel Bobath, a medical doctor, and his wife Berta, a physiotherapist, developed the Bobath approach 70 years ago in the United Kingdom at a time when it was thought that little could be done to alter the pathology or the participation of people with stroke or children with cerebral palsy. Neuro-Developmental Treatment (NDT) is a name coined by Mrs Bobath, and used by ‘Bobath’ practitioners in the USA and elsewhere (Mayston 2004).

Dr and Mrs Bobath were among the very first to recognise and write about plasticity within the nervous system as well as the relevance of sensory disturbances, sensorimotor learning, individualised goal setting, outcome measures, activity limitation, functional participation, home programmes and parental education long before these terms were officially coined. (Bobath B and Bobath K in Foreword to Finnie 1968, Bobath B 1970, Bobath & Bobath 1984)..

The Bobaths also wrote in 1958 about the importance of motor learning based on a child’s own activity “…therefore one of the greatest art of the treatment is to know where and for how long to take our hands away, or to release our hold, so that the child has a chance of his own control whenever possible, even if only for a moment at first. This has been reaffirmed in current models by authors in the field of Motor Learning such as Schmidt and Lee 2005 “…learning cannot be measured directly – instead it is inferred based on behavior.” *

In her editorial in Physiotherapy Research International 2008, Margaret Mayston a Senior Teaching Fellow at University College London, as well as a Senior Bobath Tutor who has worked with Dr and Mrs Bobath, states that ‘there is an urgent need for an integrated approach to neurorehabilitation that is not based on approaches, but rather is client based with a sound theoretical, and where possible, evidence base. This does not negate the practice and teaching of Bobath-based therapy, but requires a shift in focus to recognize Bobath as a contributor to client-based neurorehabilitation, not the leading actor who wishes to be centre stage at all times.’

Mayston,(2008) gives the current view of the Bobath Concept and a reasoned argument for continuing use of a Bobath-based approach; an approach which has given thousands of therapists worldwide a framework and a sound basis for analysis of the complexities of cerebral palsy, a heterogeneous group of conditions, as well as empirically observable results, often transferable to improved levels of activity and participation (Bain 2012, Knox 2002).

Bobath analysis as a tool, can be used with every type of neuro-disability. It involves ‘observation, analysis, interpretation, experimentation, outcome measurement’ (Figure 1, Mayston 2008). A unique aspect of Bobath is the close experimental relationship between assessment and treatment (Bobath B 1978, Bobath B 1990). In other words Bobath practitioners aim through ‘trial and error’ to find what makes a new skill or part of a skill, possible or easier to achieve. They do this using the client’s own active or active assisted movements. Uniquely developed specialised handling to reduce hypertonia is used where appropriate, but this is not ‘passive’, and to describe Bobath as ‘passive handling’ Table 1 (Novak et al) is inaccurate.

The Bobath approach is holistic, covering all areas of daily life and includes advice and carer training regarding handling, equipment and other modalities.(Bobath & Bobath 1984). This is reflected in Nancy Finnie’s well-known illustrated book ‘Handling the young child with cerebral palsy at home’, first published in 1968, the third edition published in 2009. Finnie was a physiotherapist and one of Mrs Bobath’s early protégés, who worked and taught with Dr and Mrs Bobath for many years. Nancy Finnie dedicated her early editions to Berta Bobath and acknowledged her years of invaluable experience to them both. Her practical and parent friendly book, remains a standard volume on paediatric therapists bookshelves.

Mayston writes “Bobath (1990) stated that ‘the emphasis in treatment is now on the active participation of the patient with the therapist…’. The current emphasis on active participation was an integral part of the Bobath Concept even back then.” The Bobaths themselves did not claim that the Bobath approach was the only one ‘on the market’. Mayston (2008) refers to Karel Bobath, who in his speech of response on receipt of the Harding Award in 1975, said that ‘there are other methods and ways of treatment and that these should be explored’ (Bobath 1975). Additionally Mayston quotes Berta Bobath who, in at least two publications (Bobath 1970; Bobath 1978), explained that other techniques described by other workers may also need to be used at certain stages of treatment.

Mayston notes that Mrs Bobath’s other important statement, can be found in the Introduction to the third edition of the book ‘Adult Hemiplegia: Evaluation and Treatment’ (Bobath, 1990): ‘We all learn and change our ways of treatment according to our growing knowledge and experience. . . for better or for worse. Such changes are good and necessary and will continue. But the Concept from which they have evolved should remain intact . . .’ According to Jay Schleichkorn (1992), Mrs Bobath attributed the continuing positive impact of NDT (Bobath) to ‘ I think I learned all the time; I changed it according to what I learned….it wasn’t static’.

Due to the heterogeneous nature of cerebral palsy, Bobath ‘therapy’ involves using personalised combinations of specific analysis with clinical decision making and empathetic advice. So therapy sessions may vary from therapist to therapist, and each session may be different, depending on the needs, priorities, and responses of the client and their carer at that time. This can make comparisons of Bobath ‘therapy’ difficult and confusing as noted by both Novak et al and Mayston in their papers.

The effects of many localised interventions such as botulinum toxin, are not sufficient on their own, but are usually optimised by physiotherapy. The effective outcomes of such localised interventions, are also much easier to measure as they work at only one level of the ICF, than of an analysis tool such as Bobath, which may be applied over several domains of the ICF..  .

As Mayston (2008) also writes ‘it is also important to bear in mind that aspects of the Bobath approach could be useful, and a lack of evidence does not mean that empirical strategies that seem to work should be discarded. Rather, the challenge is to provide the evidence for their efficacy.’

As Bobath tutors and practitioners, we constantly strive to improve our standards of training and treatment, so that Bobath practitioners are a credit to the name of NDT-Bobath. Berta and Karel Bobath have provided a lasting legacy which we would be foolish to discount.

References

  1. Bain K & Chapparo C (2012) The impact of neurodevelopmental treatment on the performance of daily living tasks by children with cerebral palsy. Dev Med Child Neurol 54: Concurrent Free Papers (s5): 51.
  2. Bobath B and Bobath K (1958) Principles of treatment. Bobath Manuscript
  3. Bobath B  (1970) Adult Hemiplegia: Evaluation and Treatment. 1st edition. Heinemann
  4. Bobath K and Bobath B (1984) in Scrutton. MacKeith Press
  5. Bobath B Adult Hemiplegia (1990) Evaluation and Treatment. 3rd edition. Oxford: Butterworth Heinemann
  6. Bower E (2009) Finnie’s Handling the Young Child with Cerebral Palsy at Home, Elsevier
  7. Finnie N (1968) Handling the Young Cerebral palsied Child at Home Heinemann
  8. Knox V (2002) Evaluation of the Functional Effects of a Course of Bobath Therapy in Children with CP: a Preliminary Study DMCN 2002 44: 447-460
  9. Mayston M (2004) in Scrutton MacKeith Press
  10. Mayston M (2008) Editorial: Bobath Concept: Bobath@50: mid-life crisis –What of the future? Physiotherapy Research International 13:131-136
  11. Schleichkorn J (1992) The Bobaths a Biography of Berta and Karel Bobath Therapy Skill Builders
  12. Schmidt R and Lee T (2005) Motor Control and Learning, a Behavioral Emphasis. Human Kinetics 5th Edn.

 

*Acknowledement: Evi Sideri Senior Bobath tutor and the Spanish Tutors Organisation, who linked and used the references in paragraph 4 for their presentation at the EBTA Congress in Madrid 2010.                                      

 

 


The Bobath Concept Today

Dr Margaret Mayston, first published in Synapse 2001 

Dr. Mayston gained her Diploma in Physiotherapy in Melbourne, Australia in 1973 and, following a completion of a conversion course, was awarded a Bachelor of Applied Science (Physiotherapy) in 1981. She has extensive clinical experience, initially working at the Royal Children's Hospital, Melbourne and then as a Senior Bobath Tutor at the Bobath Centre. In 1990 she gained her Master of Science degree in Human and Applied Physiology from King's College, London, whilst continuing to work part-time as a senior clinician at the Bobath Centre.

In 1996 she was awarded a Doctor of Philosophy from University College London. Her PhD focussed on two main areas, that of the mechanisms underlying mirror movements in development and pathology, and the mechanisms underlying co-contraction of antagonistic muscle pairs in development and pathology.

Dr. Mayston has two main areas of research currently, firstly the changes in the control of hand movements during development and in various pathologies, and secondly the neural control of antagonistic muscles pairs, both in healthy children and adults and in children with cerebral palsy. A variety of neurophysiological techniques are used including EMG, transcranial magnetic stimulation, cutaneomuscular reflex and stretch reflex testing in addition to cross-correlation analysis of EMG signals. Dr. Mayston's work has been published extensively.


Any discussion of the Bobath Concept requires a common understanding of what the Bobath Concept is. In an interview almost twenty years ago, Bobath explained it this way: '... A whole new way of thinking, observing, interpreting what the patient is doing, then adjusting what we do in the way of techniques - to see and feel what is necessary, possible for them to achieve. We do not teach movements, we make them possible ...' (Bobath, 1981). It was also made clear that Bobath was not a method or technique, not limiting, but fluid; was not rigid but changing, and still changing. The Concept can be summarised as follows: It is primarily a way of observing, analysing and interpreting task performance. This also includes the assessment of the client's potential, which was considered to be that task or those activities which could be performed by the person with a little help, and therefore possible for that person to achieve independently where possible. Of course the Concept also involves the use of various techniques, and Bobath always advocated that the therapist should 'do what works the best' (Bobath, 1978). In the present day, this should mean, that therapy is based on sound evidence when it is available, while recognising that currently much of what therapists do has not been evaluated. This does not mean that these therapy strategies should be discarded, but does mean that they require investigation and possibly an alternative explanation of their effect. There is evidence to support some of what therapists do, but there are still many unanswered questions. For the Bobath therapist, there is also the dilemma of what it means to be a Bobath therapist. A study by Davidson and Waters (2000) showed that 88% of neurological physiotherapists in the UK use the Bobath approach. But, it depends on when you trained, where and who with. I very much doubt that those 88% of the therapists surveyed would explain or clinically apply the Bobath Concept with any degree of similarity.

When therapists attending the paediatric course at the Bobath Centre are asked what Bobath is, the reply usually concerns the use of techniques of inhibition of abnormal tone and movement patterns, facilitation of more normal movement, and possibly stimulation in cases of hypotonia or muscle inactivity. These techniques should not be considered to be Bobath, and yet for most therapists these techniques are Bobath. Given the diverse understanding of the Bobath Concept, it seems important to ask this question: Is Bobath a relevant therapy approach in the year 2000? It might be: but only if it is based on current scientific evidence; is actively finding ways to produce such evidence; and additionally an agreement to leave old ideas, such as the inhibition of spasticity, in the past. We need to have the courage to challenge our current practice and clinical reasoning. With this in mind, several of the assumptions underlying the Bobath Concept need to be re-evaluated. The following questions are intended in part to address some of the current issues facing therapists.

Is tone relevant? Bobath proposed that the main reason for reduced functional ability resulted from abnormalities of tone e.g. spasticity was thought to be due to abnormally increased tonic reflex activity and therefore could be inhibited. It is necessary to define what normal tone is in order to understand any deviation from that norm. 'Tone is the resistance offered by muscles to continuous stretch' (Brooks 1986) '...at complete rest a muscle has not lost its tone although there is no neuromuscular activity in if (Basmaijan & De Luca, 1985). Normal tone can be defined as a slight constant tension of healthy muscles (Kandel, Schwartz and Jessell, 1991). "A state of readiness' (Bemstein 1967).

These definitions suggest that tone comprises both neural (e.g. Proprioceptive reflexes, and arousal level of the CNS) and non-neural (e.g. visco-elastic properties of muscle) components. Commensurate with this idea, any abnormal tone will also demonstrate neural and non-neural changes. For many years, spasticity has been clearly defined by Lance (1980) as a velocity-dependent increase in stretch reflexes with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neurone syndrome. The UMN which consists of positive symptoms (exaggeration phenomena such as hyperreflexia, extensor plantar response) and negative symptoms (functional deficits such as weakness, loss of dexterity) was described by Hughlings-Jackson (1954), and subsequently explained by Burke (1988) and Carr and Shepherd (1998). When viewed in this context, spasticity is often only a small component of the movement disorder, and in some cases can even be of functional value to the client, e.g. standing. We should conclude from the preceding discussion that spasticity and hypertonia are not the same. Spasticity is a part of hypertonia and of course they co-exist, but velocity dependent hyperreflexia does not usually in itself explain the clients movement disorder, and therefore simply reducing spasticity is not the solution for providing effective, evidence-based intervention.

Therapists can reduce hypertonia, but can they by handling inhibit spasticity? The term inhibition was introduced by Bobath as a physiological explanation for the effect of handling on spasticity, based on the assumption that spasticity resulted from exaggerated/released, abnormal tonic reflexes and subsequently abnormal tonic reflex activity (Mayston 2001a). Although on passive movement spasticity is shown to be present by evidence of hyperreflexia, on voluntary movement there is usually an inability to generate sufficient electrical activity in the muscle (lbrahim et al 1993). Inhibition physiologically is defined as a decrease in transmitter release, a way of moulding excitation and shaping the firing of action potentials, and is present at all levels of the CNS. But suggesting inhibition is a physiological explanation for what therapists achieve by handling is not scientifically correct. Therapists are effecting changes in both inhibitory and excitatory synapses simultaneously, but their 'inhibition' also affects visco-elastic properties of muscle and by improving muscle length can gain a better biomechanical advantage for more efficient muscle action for the performance of functional tasks. Handling via stretch will of course affect and reduce muscle spindle firing and resultant abnormal reflex activity, but for any lasting effect of spasticity to be obtained the therapist must enable the client to perform more effective, efficient functional activity.

Muscle weakness is secondary to the problems of abnormal tone.

For all their working life, the Bobaths considered that muscle weakness was a secondary problem to that of abnormal tone in the management of the neurologically impaired person. They assumed that when hypertonia was reduced the client would have near normal activity with which to function. This may be potentially true, but any person will know that disuse and lack of opportunity to activate muscles results in atrophy and weakness. More significantly, the person with an UMN lesion will most likely lose some of their voluntary drive onto the motoneurone pools in the spinal cord resulting in a lack of activation of muscles for action, despite exhibiting hyperreflexia at rest. Even those with significant velocity dependent hyperreflexia encounter difficulty in generating sufficient voluntary activity, rather than being limited by an exaggeration of abnormal muscle activity on attempts at self-generated activity.

Recent evidence suggests that weakness is a problem for the neurologically impaired adult and child (Bourbonnais & van der Noven 1989; Giuliani 1992). While therapists can work to increase strength by the use of activity, repetition and weight bearing, it has been shown that when used appropriately, strengthening can improve function and does not increase spasticity (Miller and Light 1997; Damiano and Abel 1998). This evidence suggests that therapists must direct more attention to the role of muscle strength and ways of improving it, for the rehabilitation/habilitation of the neurologically impaired person, of course with the proviso that the individual has sufficient muscle activity to participate in a strengthening regime.
Bobath proposed that working for normal movement patterns would lead to function. "This idea has been misinterpreted by some to the extent that it is thought that the person with neurological impairment can become normal if only they receive the 'right' therapy and do not make themselves spastic by overactivity or activity too early. Firstly, the CNS is highly task oriented in its organisation (Flament et al 1993; Ehrsson et al 2000), therefore movement patterns will not automatically lead to function – the function must be practised in the correct context. Secondly, there is no evidence to suggest that stopping a client from moving will stop the development of spasticity. My experience of working with Mrs. Bobath was that the therapists role was to help the person function in the best way possible, helping them to counteract any unwanted increase in tone, not to stop them moving. While certain activities are not encouraged in some cases, the idea of stopping a client from moving, especially if they are motivated to do so, cannot be supported on financial, moral or scientific grounds.

Although learning movement patterns might be a part of the re-learning process, clients need the opportunity to practise functional, meaningful tasks if therapy is to be effective.

Related to this question of compensation. If the CNS is damaged, there will of necessity be a compensation by other parts of the system, which can be either positive or negative, and can be shaped by experience. Compensation means to take the place of that which is lost, but is understood in a variety of ways. For example, the person with hemiplegia will have to compensate with the sound side for the loss of function on the affected side if recovery is less than optimal. The person with spastic diplegia will overuse their upper body and limbs to compensate for the lack of useful activity of their lower limbs. The critical questions to ask are the following: how much of that compensation is necessary and how much can be avoided by training the affected body parts to function more effectively. It has long been part of the Bobath approach to restrain use of the less affected body parts manually during a therapy session to try and activate the affected body parts, e.g. hold back the sound arm to force the use of the affected arm, providing there is activity for the person to work with. For the person with diplegia, it might mean activating the legs without overuse of the upper body and arms e.g. to sit to stand without pushing on the arms. Support for this idea is found in the recent work of Taub (Taub et al 1993; Taub and Wolf 1997), described as Constraint Induced Therapy, or forced use. One of the basic ideas underlying the Bobath Concept is that each person with a neurological lesion has the potential for improved functional performance - this is one way that it might be achieved for clients who meet the criteria for inclusion in such a regime. I very much doubt that therapy can make a person normal - if so, their CNS had the potential for recovery and they would have been normal anyway (whatever normal is!). The CNS if damaged has to compensate, it is the therapists' job to guide the persons recovery so that they can achieve their maximal functional potential within the constraints of the damaged CNS. How soon and how much is unclear, but Tardieu (1988) states that a muscle must be stretched for six hours a day in order for length to be maintained; the clients receiving forced use therapy were trained for at least three hours a day. The work of Nudo (1996) and colleagues indicates that specifically training activity can enhance behavioural recovery and reduce the loss of secondary areas around the infarct. Forced use of the lower limbs by treadmill training has also been shown to be effective in improving function for both adults and children (Hesse et al 1994, Schindi et al 2000). The caveat is of course, that the person can only enter this kind of regime if they have sufficient activity to utilise. Forced use in clients who have little or no activity may drive negative changes in the CNS and result in further loss of neural tissue around the original lesion site.

"These are only a few of the considerations for the Bobath therapist in the light of changes in our understanding of the control of movement and changes in the clinical presentation of clients. It is essential to continuously read the available literature and to review our mode and frequency of therapy intervention. Carr and Shepherd (1998) have contributed much by their aggressive encouragement that we read the literature and act upon it. Their motor learning approach to optimise functional performance is of value in clients with a reasonable level of ability. But what about the less able client, and is the emphasis on training and bio-mechanics sufficient? It should be noted that their ideas for motor re-learning are predominantly based on data from healthy individuals. It is not known if those same principles can be directly applied to the neurologically impaired person.

I would like to propose some factors that we might take into account when planning an intervention programme:
 

  • Muscles need to be at the best length for activation. It is known that muscles generate the most efficient active force at a mid-length. For this reason alone it would seem important to gain alignment. This may involve muscle stretching to achieve length, perhaps we could call it tone reduction, the judicious use of equipment and/or orthoses. Sustained muscle stretch may also prepare for more efficient muscle activity by reducing the effect of hyper-sensitive muscle spindles.
  • The muscle needs sufficient activity to generate force for action. In the case of reduced drive onto the motoneurone pool, there might need to be stimulation of muscle activity through the use of weight bearing, resistance, sensory stimulation in appropriate postures and patterns to enable the person to have a sufficient basis for the training of functional tasks. Splinting and orthoses may also be indicated to gain alignment, or a good weight-bearing base for improved proximal and truncal activity (Mayston 2001b).
  • This activity needs to be translated into functional, meaningful goals for that person. Bobath advocated specific preparation for specific function, which is another way of staling this principle of translating activity into function. There needs to be opportunity for practise for leaming/re-leaming to occur, either by the individual or with the help of carers.
  • Goals need to be realistic according to the client's potential and appropriate to the environment encountered during daily life.
     

These principles integrate with the main ideas of motor learning theory, which requires the active participation of the client. This is not new. Bobath in the 1960s stated that 'unless you stimulate or activate your patient in the way in which new activities are possible, you have done nothing at all. So the handling techniques as such are only the very first step in treatment, though they are very important' (Bobath, 1965).

Secondly, motor learning emphasises the need for practise, also advocated by Bobath though perhaps less rigorously, by stressing the importance of home activities for the client. Thirdly, learning requires that there be meaningful goals, relevant to the client. This aspect of motor learning is now important, and at the Bobath Centre goals are set in collaboration with the client and their family (at least for each child) and their achievement is monitored using a variety of outcome measures.

ln summary, the Bobath Concept states that each client has the potential for improved function and that we should work with our clients doing 'what works the best'. This requires an ongoing knowledge of current scientific motor control and rehabilitation literature, and courage to put old ideas in the past. Of course it is important to have a Centre which honours the contribution made by Bobath to the progression of the field of neuro-rehabilitation. However, if Bobath is considered as inhibition of spasticity and the facilitation of normal movement as proposed in the Bobaths' working years, it might be preferable to leave the name in the past. This is an idea, not a solution, to the current controversy which surrounds the Bobath Concept in this new century.

References

Basmaijan, J.V. and De Luca, Carlo J. (1985) Muscles Alive. Their Functions Revealed by Electromyography. Williams and Wilkins Chapter 10 and II.
Bernstein, N. (1967) The Co-ordination and Regulation of Movements. Oxford: Pergamon.
Bobath, B. (1965) Notes on Reflex Inhibiting Postures. Archival material. Bobath Centre London.
Bobath, B. (1978) Course notes, Bobath paediatric 8-week course.
Bobath, B., Bobath, K. (1981) Interview for NDTA. Baltimore.
Bourbonnais, D., Van den Noven, S. (1989) Weakness in patients with hemiparesis. American Journal of Occupational Therapy 43: 676-685.
Brooks, Vernon (1986) Neural Basis of Motor Control. Oxford University Press Chapter 1,8.
Burke, D. (1988) Spasticity as an adaptation to pyramidal tract injury, Advances in neurology Vol 47. Raven Press MY.
Carr, J., Shepherd, R. (1998) Neurological Rehabilitation; Optimizing motor performance. Butterworth Heinemann Oxford.
Damiano, D.L., Abel, M.F. (1998) Functional outcomes of strength training in spastic cerebral palsy. Archives of Physical Medicine and Rehabilitation 79: 119-25.
Davidson, 1., Waters, K. (200) Physiotherapists working with stroke patients: A national survey. Physiotherapy 86:69-80.
Ehrsson, H.H., Fagergren, A., Jonsson, T„ Westling, G., Johannsson, R.S., Forssberg, H. (2000) Cortical activity in precision versus power grip tasks: an MRI study. Journal of Neurophysiology 83:528-536.
Flament, D. Goldsmith, P., Buckley, CJ„ Lemon, R.N. (1993) Task dependence of responses in first dorsal interosseous muscles to magnetic brain stimulation in man. Journal of Physiology (London); 464:361-378.
Giuliani, C.A. (1992) Dorsal rhizotomy as a treatment for improving function in children with cerebral palsy. In: Movement Disorders in Children Ed. Forssberg, H., Hirschfeld, H. 247-254.
Hesse, S„ Bertelt, C.H., Schaffrin, A„ Maiezik, M„ Mauritz, K.H. (1994) Restoration of gait in non-ambulatory patients by treadmill training with partial body-weight support. Archives of Physical Medicine and Rehabilitation; 75: 1087-1093.
lbrahim, I.K., Berger, W., Trippel, M„ Dietz, V. (1993) Stretch-induced electromyographic activity and torque in spastic elbow muscles. Brain; 116: 971-989.
Lance, J.W. (1980) Symposium synopsis In: Spasticity: disordered motor control. Ed. Feidman, R.G., Young, R.R., Koella, W.O. Chicago: Year Book of Medical Publishers; 485-495,1980.
Mayston, MJ. (2001 a) Setting the scene In: Edwards, S. Ed. Neurological Physiotherapy- a Problem Solving Approach 2nd edition. Churchill Livingstone (in press).
Mayston, MJ. (2001b) People with cerebral palsy: effects of and perspectives for therapy. Neural Plasticity (in press).
Miller, GJ.T. and Light, K.E. (1997) Strength training in spastic hemiparesis: should it be avoided? Neurorehabilitation, 9, 17-28.
Nudo, RJ., Wise, B.M., SiFuentes, P., Milliken, G.W. (1996) Neural substrates for the effects of rehabilitative training on motor recovery after ischaemic infant. Science 272:1791-1794.
Schindi, M.R., Forster, C., Kern, H., Hesse, S. (2000) Treadmill training with partial body weight support in nonambulatory patients with cerebral palsy. Archives of Physical Medicine and Rehabilitation; 81: 301-306.
Tardieu, C., Lespargot, A., Tabary, C., Bret, MJ). (1988) For how long must the soleus be stretched each day to prevent contracture? Developmental Medicine Child Neurology 30:31-10.
Taub, E., Miller, N.E., Novack, T.A. (1993)A technique for improving chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74, 347-354.
Taub, E. and Wolf, S.L. (1997) Constraint induced techniques to facilitate upper extremity use in stroke patients. Topics in Stroke Rehabilitation 3: 38-61.