DOI 10.

1515/ijdhd-2012-0110      Int J Disabil Hum Dev 2013; 12(3): 363–367

Emilia Mikołajewska*

Changes in Barthel Index outcomes as result of

poststroke rehabilitation using NDT-Bobath method
Abstract in regular community life, learn, work, etc. [1, 2]. In post-
stroke patients, performance of ADLs is compromised, and
Background: Poststroke patients need effective rehabili-
one of the aims of poststroke rehabilitation is to restore
tation because of limitations in activities of daily living
the patients’ best possible functioning in ADLs. Particular
(ADLs). The aim of the study was to assess the results of
attention is directed to looking for more effective ways of
ADL rehabilitation of patients after ischemic stroke who
doing the ADLs. The aim of this study was to assess the
underwent NDT-Bobath therapy for adults method using
results of poststroke rehabilitation based on the neuro-
selected items of the Barthel Index.
developmental treatment – Bobath (NDT-Bobath) method
Methods: The investigated group consisted of 60 patients
for adults in ADL restoration using selected items of the
after ischemic stroke who participated in the program of
Barthel Index. The NDT-Bobath method for adults is one of
rehabilitation: 10 sessions of the NDT-Bobath therapy for 2
the leading methods used in poststroke rehabilitation [3–
weeks (10 days of the therapy). The measurement of the ADLs
11]. This method is not only a set of exercises but a whole
using selected items of the Barthel Index were performed in
concept that includes disability analysis and assessment
every patient on admission (before the therapy) and after the
of functional deficits and their causes. Particular attention
last session of the therapy to assess rehabilitation effects.
is paid to “direct” stimulated use of the affected side. The
Results: Results among patients involved in the research
uniqueness of the NDT-Bobath method lies in its attempts
were as follows: recovery, 30 cases (50%); no measurable
to integrate both the affected and unaffected sides of
changes, two cases (3.33%); relapse, not stated.
the body. Neuroplasticity plays the most important role.
Conclusions: Observed statistically significant and favora-
Patient-oriented therapy, problem-solving approach, and
ble changes in the health status of patients, described by
cause-to-goals analysis are used to plan the proper inter-
Barthel Index outcomes, confirm the effectiveness of the
NDT-Bobath method. vention. The main theoretical assumptions and therapy
rules are not quite simple: the newest Polish book in the
Keywords: activities of daily living (ADLs); Barthel area of the NDT-Bobath method in the neurorehabilitation
Index; ischemic stroke; NDT-Bobath; physical therapy; of adults has 232 pages and yet is considered basic [11].
rehabilitation. Despite its wide use, there is lack of studies in the
area of outcomes of poststroke rehabilitation using the
NDT-Bobath method [10] including ADL rehabilitation
*Corresponding author: Emilia Mikołajewska, PhD, Rehabilitation (1, 2, 12–17). Almost every research in this area is consid-
Clinic, The 10th Military Clinical Hospital with Polyclinic,
ered valuable, as each increases knowledge and improves
Powstańców Warszawy 5, 85-681 Bydgoszcz, Poland,
E-mail: e.mikolajewska@wp.pl clinical practice in neurorehabilitation.

Introduction Patients and methods

Stroke constitutes a huge medical, social, and financial

problem. Fifteen million people experience stroke world-
wide each year, with 5 million resulting to death. Of all
stroke cases, 80%–85% constitutes ischemic stroke. The
effect of the stroke depends mainly on area of the brain
where it occurs and the extent of brain injury. About 50%
of poststroke patients have limited independence, need
the help of another person in accomplishing activities of
daily living (ADLs), and/or are unable to participate fully
Patients
The study was carried out in 60 patients after ischemic stroke. The study
group was established based on the following inclusion criteria (con-
firmed by medical records): age, older than 18 years; time after cerebro-
vascular accident (CVA), from 6 weeks to 3 years; diagnosis, ischemic
stroke. The size and anatomical involvement of infarct varied among pa-
tients, and the general extent of involvement of motor areas and tracts
was not described. The patients’ profiles are presented in Table 1.
The study was accepted by the appropriate Bioethical Com-
mittee. The subjects gave written informed consent before entering

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364      Mikołajewska: Changes in Barthel Index outcomes as result of neurorehabilitation

the study in accordance with the recommendations of the Bioethi- Table 2 Barthel Index – part of the test [18].
cal Committee, acting on the rules of good clinical practice and the
Helsinki Declaration. Activity Score

Transfers (bed to chair and back)

 unable, no sitting balance 0
 major help (one or two people, physical), can sit 5
Methods  minor help (verbal or physical) 10
The patients underwent 10 sessions of NDT-Bobath therapy for 2  independent 15
weeks (i.e., 5 days per week, for a total of 10 days). It will be easy to Mobility (on level surfaces)
compare results of further studies and experiences of clinical prac-  immobile or < 50 yards 0
tice. Each session lasted 30 min.  wheelchair independent, including corners > 50 yards 5
Patients were treated according to the NDT-Bobath method by an   walks with help of one person (verbal or 10
internationally certified and experienced therapist. The international physical) > 50 yards
certification in the NDT-Bobath method for adults was required to pro-  independent (but may use any aid; e.g. stick) > 50 15
vide an easier comparison of professional qualifications in the NDT-Bo- yards
bath method, as recommended by Paci [10], and includes the following: Stairs
– International Bobath Instructors Training Association (IBITA)-  unable 0
recognized basic course, “Assessment and Treatment of Adults  needs help (verbal, physical, carrying aid) 5
with Hemiplegia – The Bobath Concept”   independent 10
– IBITA-recognized advanced course, “Assessment and Treatment Total (0–40)
of Adults with Neurological Conditions – The Bobath Concept” Guidelines: The assessment can be used to determine a baseline
– EBTA-recognized NDT-Bobath basic course, “Assessment and level of functioning and can be used to monitor improvement in
Treatment of Children” ADLs over time. The items are weighted according to a scheme
developed by the authors. The person receives a score based on
The measurement of the ADLs, where available, was performed twice whether they have received help while doing the task. The scores
in every patient using selected items of the Barthel Index in the areas for each of the items are summed to create a total score. The higher
of transfers, mobility, and stairs (Table 2), on admission (before the the score the more “independent” the person. Independence
therapy) and after the last session of the therapy, to assess the effects means that the person needs no assistance at any part of the task.
of rehabilitation. If a person does about 50% independently then the “middle” score
A selected part of the Barthel Index consists of three items meas- would apply.
uring patients’ daily functioning in the area of ADLs and mobility:

moving from wheelchair to bed and back, walking on level surface,

Table 1 Patients’ overall profile. and going upstairs and downstairs. The reliability of the test is “val-
id” according to studies [19–21].
Criteria n (%) The possible results were generally defined as follows:
– Recovery: After therapy, there was a measured significant
Side of paresis, n (%) 30 (50)
difference (favorable change) compared with the result at the
 Left
beginning of the therapy.
 Right 30 (50)
– Relapse: There was a measured unfavorable change compared
Sex, n (%)
with the result at the beginning of the therapy.
 Females 30 (50)
– Recovery: There was no measured significant difference
 Males 30 (50)
compared with the result at the beginning of the therapy.
Age, years
 Min 42
 Max 86
 SD 10.3
 Mean 65.7
Statistical analysis
 Median 68 The results are expressed as mean, median, maximal value, minimal
Age brackets, n (%) value, and standard deviation (SD). The results were statistically
 38–47 years 2 (3.33) analyzed using the Wilcoxon’s test. A probability p< 0.05 was con-
 48–57 years 13 (21.67) sidered statistically significant. The statistical analysis of data was
 58–67 years 13 (21.67) performed using the Statistica software (StatSoft, Tulsa, USA).
 68–77 years 27 (45)
 78–87 years 5 (8.33)
Time after CVA, n (%)
 6 weeks to 6 months 20 (33.33) Results
  > 6 months to 1 year 13 (21.67)
  > 1 year to 2 years 14 (23.33) The results are presented in Tables 3–8. This study has
  > 2 to 3 years 13 (21.67)
focused on the determination of changes in three areas

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 Mikołajewska: Changes in Barthel Index outcomes as result of neurorehabilitation      365

of ADL (moving from wheelchair to bed and back, Table 5 Results depend on the side of the paresis.
walking on level surface, going upstairs and downstairs)
Right, n (%) Left, n (%)
that were observed as a result of the therapy conducted
according to the NDT-Bobath method in a group of Number of patients 30 (100) 30 (100)
patients after ischemic stroke. These elements are often Recovery 13 (43.33) 16 (53.33)
Relapse 0 (0) 0 (0)
impaired as a result of the stroke. There were observed
No changes 2 (6.67) 1 (3.33)
statistically relevant changes reflecting recovery as the
result of the therapy using the NDT-Bobath method. The In the group of patients with right-sided paresis, recovery was
statistically significant (p= 0.001), with the mean recovery increasing
observed changes reflect the recovery in the areas of
from 32.0 (median, 35.0) in the first examination to 35.8 (median,
ADL. The results found in the patients (n = 60) involved 40.0) in the second examination. In the group of patients with left-
in the study were as follows: recovery, 30 cases (50%); no sided paresis, recovery was statistically significant (p < 0.001), with
measurable changes, 2 cases (3.33%); relapse, not stated. the mean recovery increasing from 31.3 (median, 32.5) in the first
For the purposes of statistical analysis, the whole examination to 36.0 (median, 40) in the second examination.
group was divided into two groups using median age (68
years).
Table 6 Results depend on sex.

Female, n (%) Male, n (%)

Discussion Number of patients 30 (100) 30 (100)

Recovery 16 (53.33) 7 (23.33)
The results of the therapy using the NDT-Bobath method Relapse 0 (0) 0 (0)
No changes 2 (6.67) 3 (10)
showed statistically significant changes in the health
status of patients in the selected items of the Barthel Index. In the group of women, recovery was statistically significant
These changes in three areas of ADL (moving from wheel- (p<0.001), with the mean recovery increasing from 29.5 (median,
30.0) in the first examination to 34.0 (median, 40.0) in the second
chair to bed and back, walking on level surface, going
examination. In the group of men, recovery was statistically significant
upstairs and downstairs) were favorable. The results are (p=0.001), with the mean increasing from 33.8 (median, 40.0) in the
very good, considering the short period of rehabilitation first examination to 37.8 (median, 40.0) in the second examination.
(2 weeks, with 10 sessions) and the mean age of patients
(65.7 years).

The most favorable results of the therapy were

achieved by patients with the following prognostic signs:
– Therapy was started between 2 and 3 years after CVA,
Table 3 Results for whole group of patients.
which suggests the effectivity of the method during
Barthel Index the late period after CVA, especially in transfer
outcomes, n (%) activities.
– Age between 78 and 87 years, which suggest the
Number of patients 60 (100)
Recovery 30 (50) effectivity of the method in older patients, especially
Relapse 0 (0) in transfer activities.
No changes 2 (3.33) – Women showed the biggest change in this group, as
observed in mobility on level surface areas.
– Left-side paresis.
Table 4 Statistical analysis of the results for whole group of
patients. The next stages of therapy should provide better results,
but there is a need for longer rehabilitation. Unfortu-
n Mean Median Min Max SD nately, there is lack of research on the use the NDT-
First examination 60 31.7 32.5 0.0 40.0 10.1 Bobath method for adults to compare the outcomes
Second examination 60 35.9 40.0 5.0 40.0 7.3 of the study. A systematic literature review of 15 clini-
cal trials performed by Paci [10] demonstrated that the
In the whole group, the recovery was statistically significant
(p < 0.001), with the mean recovery increasing from 31.7 (median, results show no evidence of the effectiveness of the NDT-
32.5) in the first examination to 35.9 (median, 40.0) in the second Bobath method, but this conclusion is widely discussed
examination. and needs additional studies. Paci [10] stated that it is

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Table 7 Results depend on age.

38–47 years, 48–57 years, 58–67 years, 68–77 years, 78–87 years,
n (%) n (%) n (%) n (%) n (%)

Number of patients 2 (100) 13 (100) 13 (100) 27 (100) 5 (100)

Recovery 0 (0) 6 (46.15) 7 (53.85) 13 (48.15) 4 (80)
Relapse 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
No changes 0 (0) 0 (0) 1 (7.69) 1 (3.70) 0 (0)

In the group of patients younger than 68 years, recovery was statistically significant (p = 0.001), with the mean recovery increasing from
33.6 (median, 35.0) in the first examination to 37.5 (median, 40.0) in the second examination. In the group of patients older than 68 years,
recovery was statistically significant (p = 0.001), with the mean recovery increasing from 29.5 (median, 30.0) in the first examination to 34.1
(median, 40.0) in the second examination.

Table 8 Results depend on time after CVA.

6 weeks to > 6 months to > 1 year to > 2 to

6 months, n (%) 1 year, n (%) 2 years, n (%) 3 years, n (%)

Number of patients 17 (100) 12 (100) 17 (100) 14 (100)

Recovery 10 (58.82) 5 (41.67) 5 (29.41) 10 (71.43)
Relapse 0 (0) 0 (0) 0 (0) 0 (0)
No changes 1 (5.88) 0 (0) 1 (5.88) 0 (0)

In the group of patients treated within 6 weeks to 6 months after CVA, recovery was statistically significant (p = 0.005), the mean recovery
increasing from 30.0 (median, 30.0) in the first examination to 35.0 (median, 40.0) in the second examination. In the group of patients
treated within 6 months to 1 year after CVA, recovery was statistically significant (p = 0.043), with the mean recovery increasing from 34.6
(median, 40.0) in the first examination to 37.9 (median, 40.0) in the second examination. In the group of patients treated within 1 year to
2 years after CVA, recovery was statistically significant (p = 0.043), with the mean recovery increasing from 35.0 (median, 40.0) in the first
examination to 37.4 (median, 40.0) in the second examination. In the group of patients treated within 2 to 3 years after CVA, recovery was
statistically significant (p = 0.008), with the mean recovery increasing from 27.1 (median, 30.0) in the first examination to 33.6 (median,
40.0) in the second examination.

necessary to perform further investigations to develop
outcome measures concerning the goals of the Bobath
approach (motor performance and others). One of crite-
ria of the study is the therapist’s deep knowledge of the
NDT-Bobath method for adults, as confirmed by inter-
national certificates and several years of experience [10,
11]; this was required because only the outcomes of the
NDT-Bobath method performed by certified and experi-
ence therapists can be objectively compared. The author
has reviewed publications in the PubMed (US National
Library of Medicine) database, but very little research
is conducted in the aforementioned area. There was no
review on the subject, and there were only six articles
with the specified keywords “Bobath+adults+ADL” and
one research in Chinese investigating the effects of early
rehabilitation on ADLs within 1 month after the first
stroke [22]. This was impossible to compare their results
with the present study because of a different range of
time after CVA.
The main limitation of this research is the lack of a
control group. In most cases, a research without a control
is insufficient. However, despite this study’s lack of a
control group, the results presented here is an important
step toward a better understanding of ADL rehabilitation
of adult stroke survivors using the NDT-Bobath method.
Further studies should add a control group using another
rehabilitation method or solely using the NDT-Bobath
method to compare the results and examine the effective-
ness of method.
No doubt, there is a need to provide further studies in
the area, as independent sources of knowledge are nec-
essary to estimate the effectiveness of the NDT-Bobath
method for adults in the ADL recovery of poststroke
patients. Based on this study, there is a need for further
research using a control group and to provide better
evidence.
In conclusion, the results showed that the NDT-
Bobath method for adults is an effective in the ADL reha-
bilitation of adult patients after ischemic stroke. There
were statistically significant and favorable changes in the
health status of patients in terms of ADL outcomes meas-
ured using parts of the Barthel Index.

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Conflict of interest statement
Authors’ conflict of interest disclosure: The authors stat-
ed that there are no conflicts of interest regarding the pub-
lication of this article.
Research funding: None declared.
References
1. Muren MA, Hütler M, Hooper J. Functional capacity and health-
related quality of life in individuals post stroke. Top Stroke
Rehabil 2008;15:51–8.
2. Murtezani A, Hundozi H, Gashi S, Osmani T, Krasniqi V, Rama
B. Factors associated with reintegration to normal living after
stroke. Med Arh 2009;63:216–9.
3. Bromley I. Tetraplegia and paraplegia: a guide for
physiotherapists. 6th ed. London: Churchill Livingstone, 2006.
4. Davies PM. Steps to follow: the comprehensive treatment of
adult hemiplegia, 2nd ed. New York: Springer, 2000.
5. Howle JM. Neuro-developmental treatment approach.
Theoretical foundations and principles of clinical practice.
Laguna Beach, CA: NeuroDevelopmental Treatment Association,
2003.
6. Mayston MJ. Problem solving in neurological physiotherapy
– setting the scene. In: Edwards S, editor. Neurological
physiotherapy, 2nd ed. A problem solving approach. London:
Churchill Livingstone, 2001:4–16.
7. Lennon S, Ashburn A. The Bobath concept in stroke
rehabilitation: a focus group study of the experienced
physiotherapists’ perspective. Disabil Rehabil 2000;15:665–74.
8. Lennon S, Baxter D, Ashburn A. Physiotherapy based on the
Bobath concept in stroke rehabilitation: a survey within the UK.
Disabil Rehabil 2001;6:254–62.
9. Bobath B. Adult hemiplegia: evaluation and treatment, 3rd ed.
London: Heinemann Medical Books, 1990.
10. Paci M. Physiotherapy based on the Bobath concept for adults
with post-stroke hemiplegia: a review of effectiveness studies.
J Rehabil Med 2003;1:2–7.
11. Mikołajewska E. Metoda ND-Bobath w neurorehabilitacji osób
dorosłych [NDT-Bobath method in neurorehabilitation of adults].
Warsaw, Poland: Wydawnictwo Lekarskie PZWL, 2011 (in Polish).
12. Bravi L, Stoykov ME. New directions in occupational therapy:
implementation of the task-oriented approach in conjunction
Brought to you by | New York University Bobst Library Technical Services
Authenticated
Download Date | 2/9/15 10:36 AM
Employment or leadership: None declared.
Honorarium: None declared.
Received July 19, 2012; accepted September 22, 2012; previously
published online December 6, 2012
with cortical stimulation after stroke. Top Stroke Rehabil
2007;14:68–73.
13. Daving Y, Claesson L, Sunnerhagen KS. Agreement in activities
of daily living performance after stroke in a postal questionnaire
and interview of community-living persons. Acta Neurol Scand
2009;119:390–6.
14. Hofgren C, Esbjörnsson E, Sunnerhagen KS. Return to work after
acquired brain injury: facilitators and hindrances observed in a
sub-acute rehabilitation setting. Work 2010;36:431–9.
15. Huang YH, Wu CY, Hsieh YW, Lin KC. Predictors of change in
quality of life after distributed constraint-induced therapy
in patients with chronic stroke. Neurorehabil Neural Repair
2010;24:559–66.
16. Jones F. Strategies to enhance chronic disease
self-management: how can we apply this to stroke? Disabil
Rehabil 2006;28:841–7.
17. Nakao S, Takata S, Lemura H, Kashihara M, Osawa T,
Komatsu K, et al. Relationship between Barthel Index scores
during the acute phase of rehabilitation and subsequent ADL in
stroke patients. J Med Invest 2010;57:81–8.
18. Mahoney FI, Barthel D. Functional evaluation: the Barthel index.
Md State Med J 1965;14:56–61.
19. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a
reliability study. Int Disabil Stud 1988;2:61–3.
20. Laake K, Laake P, Ranhoff AH, Sveen U, Wyller TB,
Bautz-Holter E. The Barthel ADL index: factor structure depends
upon the category of patient. Age Ageing 199;5:393–7.
21. Wyller TB, Sveen U, Bautz-Holter E. The Barthel ADL index
one year after stroke: comparison between relatives’ and
occupational therapist’s scores. Age Ageing 1995;5:398–401.
22. Xu BH, Yu RQ, Yu W, Xie B, Huang YX. Effects of early
rehabilitation on activities of daily living and complications in
acute stroke patients. Beijing Da Xue Xue Bao 2004;36:75–8 (in
Chinese, only abstract in English available).