Toward a Future Where Clinical "Tacit Knowledge" and Scientific "Explicit Knowledge" Intersect — Report on the 15th Annual Meeting of the Japanese Bobath Association

Introduction

In clinical rehabilitation settings, interventions performed by skilled therapists based on subtle changes in a patient's response have often been passed down as "tacit knowledge" rooted in "experience" and "intuition." On the other hand, modern medicine strongly demands Evidence-Based Medicine (EBM), making the presentation of "explicit knowledge" in the form of scientific evidence indispensable.

The 15th Annual Meeting of the Japanese Bobath Association, held in 2026, featured the main theme "Connecting Clinical Practice (Tacit Knowledge) and Science (Explicit Knowledge) - Proposals from Neurorehabilitation -," and hosted passionate discussions on reconstructing these two forms of knowledge not as opposing structures, but as mutually complementary relationships.

This is a personal report on attending the conference.

Part 1: Neuroscience Unravels "Recovery" and the Visualization of "Clinical Knowledge"

What are the therapist's "hands" causing? (Keynote Lecture)

In clinical practice based on the Bobath concept, the process of handling—where the therapist touches the patient's body and makes fine adjustments to the intervention while observing movement—is extremely important. However, this has also been a prime example of "tacit knowledge" that is extremely difficult to verbalize or share objectively. The lecturer is challenging the visualization of this tacit knowledge through advanced research using fMRI and exoskeleton robots.

A skilled therapist's handling does not simply passively substitute for the patient's movement. It is performed by exquisitely adjusting the direction, magnitude, and timing of force so that the patient can actively organize their own movement. The lecture introduced attempts to quantify the therapist's "intuition" by capturing immediate changes in brain activity and electromyographic activity during interventions using fMRI research. It was emphasized that this is not for the purpose of replacing tacit knowledge with explicit knowledge itself, but is an important process for deepening the understanding of a patient's potential for recovery from a neuroscience perspective and enhancing the quality of clinical judgment.

Approaches to "True Recovery" from the Perspective of Brain Science (Special Lecture 1)

Regarding functional recovery after central nervous system injury, the lecturer provided an overview from the cutting-edge neuroscientific perspective of changes in local brain activity and brain networks. In recent years, advances in image analysis technology such as fMRI and fNIRS have revealed that the recovery of motor function and ADLs (Activities of Daily Living) after a stroke is deeply involved with the "reconstruction of brain networks," including not only the lesion site but also the remaining motor cortex and related areas.

What is important in rehabilitation is to distinguish between simple "Compensation" and "Restitution" that involves the reorganization of the neural system. The lecturer pointed out that sufficient repetition, appropriate difficulty setting, and expanding opportunities for use in daily life are essential as "motor learning" to promote adaptive neuroplasticity. Including the combined use of neuromodulation technologies such as non-invasive brain stimulation and BMI (Brain-Machine Interface), the content strongly made one realize that the realization of tailor-made rehabilitation according to the brain state of individual patients is just around the corner.

The Future of Pediatric Neurorehabilitation: Beyond Critical Discussion (Special Lecture 2)

In recent years, the Bobath approach (NDT) in the pediatric field has been subjected to harsh criticism from the standpoint of promoting EBM, such as being "passive and not encouraging problem-solving." The lecturer faced the history of critical discussion on NDT, starting with the 2013 systematic review by Novak et al., head-on and calmly organized the current issues.

The powerful message that we should break out of the traditional Bobath shell and evolve into a multi-professional collaborative intervention system that focuses on activity and participation became a heavy question not only for the pediatric field but for all therapists.

Part 2: Deciphering the "Quality" of Gait and Movement with the Eyes of Science

In the general sessions, there were many reports proving "qualitative changes" in movement as objective data using the "Model of Bobath Clinical Practice (MBCP)," a framework for clinical reasoning, and the latest motion analysis equipment.

Capturing the Moment of Tripping: The Chain of Postural Control and Compensatory Movement (General Session)

Regarding "tripping," a major cause of falls during walking, we objectively compared and analyzed the characteristics of whole-body posture that occur prior to tripping using three-dimensional motion analysis. As a result of extracting and analyzing data on near-falls due to tripping, it was revealed that in trials where tripping occurred, the forward tilt of the thorax and pelvis significantly increased prior to the trip, and the step length of the non-paretic side decreased. In other words, it was not that balance was lost after the foot caught on something, but that the trunk tilted forward (flexed posture) at a stage prior to that, making it difficult for the center of gravity to move forward. It was suggested that to compensate for this state where propulsive force is difficult to obtain, compensatory movements of the lower limbs, such as increased plantar flexion of the paretic ankle and sudden knee flexion of the non-paretic side, were triggered, resulting in tripping. This report strongly indicated the importance of analyzing not only the movement of the paretic lower limb but also the "trunk alignment (postural control)" that precedes it.

Quantifying Fall Risk from "Floor-Level Movements" (General Session)

Regarding "floor-level movements (sitting on the floor and standing up)," which are directly linked to independence and safety in daily life, we quantitatively compared healthy individuals and stroke patients with hemiplegia using the Floor Transfer Test (FTT) and the Sitting and Rising Test (SRT). In hemiplegic patients, compared to healthy individuals, a prolongation of movement time and a decrease in scores were clearly confirmed. Furthermore, among hemiplegic patients, those with a history of falls showed significantly longer FTT execution times and lower SRT scores compared to patients without a history of falls. Floor-level movement is a multifaceted complex task that includes not only muscle strength but also balance control, coordination, and even psychological factors such as fear of falling. This presentation suggested the possibility of objectively capturing qualitative changes in movement strategies by quantitatively evaluating floor-level movements and utilizing them for new evaluation and intervention strategies aimed at fall prevention.

Walking on Slopes and Sensory Feedback from the Feet (General Presentation)

To achieve outdoor walking, we conducted task analysis of slope walking and cross-stepping (FSST). Slope walking requires the reversal of mechanical tasks: centripetal propulsion generation during ascent and centrifugal shock absorption during descent. In this case, limited ankle mobility and insufficient sensory feedback from the soles of the feet led to reduced propulsion during the stance phase and trunk instability.

As a result of focusing on selective ankle inversion/eversion control (foot core system) and activation of intrinsic muscles during intervention, centripetal proprioceptive information from the feet improved. This enabled compensatory postural control in response to environmental changes, demonstrating not only a reduction in FSST time but also a remarkable improvement in the 'quality of walking' through dynamic stability.

Measuring 'Walking Strength' Rather Than 'Walking Speed' (General Presentation)

A presentation that tracked changes in trunk acceleration indices of stroke patients in the community phase using a 3-axis accelerometer (AYUMI EYE) was highly suggestive in terms of the 'consistency' between data and clinical observation.

Throughout the intervention, walking speed itself did not show a clear change. However, dramatic time-series changes occurred in the trunk's anterior-posterior acceleration (RMS). It decreased after the 4th intervention from the initial state, and then rose again after the 5th intervention.
At first glance, this appears to be contradictory data with fluctuating values, but the initial state involved 'useless compensatory wobbling' more than twice that of healthy individuals. Through intervention for core stability based on MBCP, the unnecessary swaying was stabilized (reduced) to a level equivalent to that of healthy individuals by the 4th session.
Then, with that stable trunk as a foundation, the strength to firmly push off the floor with the paralyzed leg was added during the 5th session, causing the acceleration to rise again as dynamic forward propulsion.

This was a groundbreaking study that visualized the 'qualitative improvement process of walking'—which cannot be measured by speed alone—by linking the patient's subjective feeling of 'being able to push the floor with the paralyzed leg' with the therapist's observations and acceleration data.

'Trajectory Bulge' and Turning Strategy in TUG (General Presentation)

Regarding the Timed Up and Go (TUG) test, which is widely used to evaluate mobility, we delved into the qualitative aspect of 'movement trajectory' using a markerless motion analysis device, rather than just the completion time.

During turns before the intervention, the patient's movement trajectory deviated significantly, drawing a large curve outward, and the cumulative bulge increased. The cause of this 'bulge' was that the center of gravity of the body was taking a detour outward as a result of insufficient segmental rotation of the trunk and compensation through lateral flexion toward the non-paralyzed side. Additionally, the fact that the 'head and gaze,' which should act as the steering wheel for turning, remained facing downward was also a factor hindering smooth rotation.

Through rehabilitation, trunk extension and segmental rotation improved, and 'rotation starting from the head' appeared prior to turning. This made it possible to control the movement with the feet while tilting the body axis inward, reducing the cumulative bulge before the turn and achieving an efficient center-of-gravity movement route. This study brilliantly proved through markerless analysis how intervention based on clinical reasoning can reduce useless compensatory movements and elicit predictive and efficient movement strategies (quality of walking).

Part 3: The Philosophy of 'Handling' and Clinical Reasoning (Symposium)

In the symposium, top runners in the adult and pediatric fields engaged in a profound discussion on the process of verbalizing clinical 'tacit knowledge' and reconstructing knowledge.

Turning Clinical Discomfort into Questions

The lecturer explained the importance of not simply applying 'explicit knowledge'—evidence—to the patient in front of you in adult rehabilitation, but rather generating 'questions' from the patient's context-dependent reactions and continuously updating hypotheses.

Instead of dismissing reduced support during the stance phase of walking as mere 'muscle weakness,' it should be reinterpreted through a complex system involving sensorimotor experience, postural control, and interaction with the visual and vestibular systems. In this context, handling becomes not a unidirectional operation, but a sophisticated clinical act for verifying hypotheses and engaging in dialogue with the patient's system. Verbalizing tacit knowledge (using frameworks such as MBCP) and refining it into 'shareable knowledge' while oscillating with science is the expertise required of therapists from now on.

A Continuum of Relationships Beyond 'Handling or NOT'

In response to criticism of handling in the pediatric field, the lecturer raised a fundamental question. Just as appropriate handling performed consciously or unconsciously by parents in daily childcare serves as a scaffold for a child's development, a therapist's handling is also by no means a 'unidirectional passive operation.'

As symbolized by the words of the Bobaths, 'He guides us and we guide him,' handling is a 'two-way dialogue' through the body. In recent years, there has been a movement to view the child as an active subject and reinterpret handling using terms such as 'coordination,' 'incorporation,' 'sense-of-agency,' and 'intention.' The perspective of re-perceiving touch as a 'collaborative continuum of relationships' born through the body and intention, transcending the dualism of whether or not to perform handling, will be an extremely important paradigm shift in neurological rehabilitation.

Part 4: The True Purpose of Rehabilitation—Behavioral Change and Self-Efficacy (Public Lecture)

At the public lecture held at the end of the conference, two stroke survivors shared their perspectives on where the 'true value' of rehabilitation lies.

Immediately after the onset, what patients face is not merely physical paralysis, but a profound sense of fear and loss regarding 'what will happen to my life.' In that darkness, what saved them was not just advanced technology, but the presence of a therapist who 'thought with them and shared the joy of small successes.'

What left an impression was the episode where a therapist's remark, 'Rehabilitation is a game where you win if you do it,' transformed into intense hope for the patient that 'if I work hard, I might be able to change.' The body may recover through exercise therapy, but the heart recovers through human connection and the 'weight of words.'

A small routine of writing down movements performed with the left hand every day eventually became an 'automatic amplifier' that nurtured confidence, giving rise to self-efficacy, such as 'I might be able to do a little' or 'Maybe I can do it alone!'

Rehabilitation during the living phase after discharge, while carrying anxiety, is not merely functional recovery, but a process to regain 'a life (role) that is uniquely their own,' such as bathing, housework, and hobbies. How the interaction with the therapist draws out the patient's motivation, promotes behavioral change, and leads to the discovery of a reason for living. We must never forget that scientific measurement and the exploration of biomechanics all exist for this ultimate goal of 'moving the patient's life forward.'

Conclusion — The Future of Rehabilitation Spun by 'Posture and Attitude'

The 15th Annual Meeting of the Japanese Bobath Association presented a clear answer to the grand theme of bridging 'tacit knowledge' and 'explicit knowledge' by ending the confrontational structure of 'experience vs. science.'

The essence of handling that we tried to visualize with fMRI, the qualitative shift toward the 'strength' of gait captured by AYUMI EYE, and the 'recovery of the heart through words' spoken by the survivors. These are all connected.

As a summary of this entire conference, please allow me to introduce a passage from the book by neurophysiologist Dr. Kaoru Takakusaki, which I always keep in mind and cherish in my daily clinical practice.

Furthermore, Dr. Takakusaki states, 'In all movements, postural control is accompanied, and unless there is preceding postural control, the intended movement cannot be executed.'

I feel that everything discussed at this conference is concentrated in the truth of these words.

The acquisition of 'powerful propulsive force from efficient postural control' in gait and movement shown in the general presentations is not merely a correction of mechanical alignment. It is the very process of rebuilding the foundation for converting the patient's intention to 'want to move' and 'want to move forward,' which is governed by higher brain functions such as the frontal lobe, into actual movement.

And the 'sharing of intentions and two-way dialogue through handling' pointed out by the lecturer at the symposium, and the budding motivation of 'maybe I can do it alone!' brought about by the 'weight of words' spoken by the survivors at the public lecture. These were truly the moments when the patient's 'attitude,' that is, their 'mental activity,' changed positively.

In other words, when we 'intervene in postural control' in our daily clinical practice, we are not simply correcting the tilt of the body or muscle tone, but are deeply involved in the patient's 'posture for living' and their very 'attitude toward facing life.'

Science (explicit knowledge) objectively unravels the complex neural networks behind posture and movement and provides reliable signposts. However, it is none other than the eyes and hands (tacit knowledge) that therapists have cultivated in the clinical field that translate that scientific knowledge into the diverse context of each patient, draw out 'intentions' from both the body and mind, and promote behavioral change so that the person can regain their own 'posture and attitude for living.'

While valuing evidence, carefully engaging in dialogue with the 'posture that conveys intention' emitted by the patient in front of you, and continuing to update hypotheses.
I am convinced that the 'constant back-and-forth between science and clinical practice' is the key to opening up the future of neurorehabilitation and the most valuable legacy that the Bobath concept should pass on to the next generation.
I feel that Bobath therapists who continue this kind of journey are often thanked and chosen by their patients (though it is difficult to turn the reason for this into data).

It was a conference where there was laughter, tears of emotion, and a lot of learning.
I would like to thank everyone I was able to meet on-site, those involved in the operation, and everyone who gave lectures and presentations.

※ This conference report is based on personal impressions and does not represent the views of the affiliated organization or the academic society.