Bobath under fire
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Issue: 06 January 2010
A debate about the Bobath concept is inflaming passions across Europe, Daloni Carlisle talks to people on both sides of the dispute
As inflammatory statements go, this from a group of neurorehabilitation physiotherapists might rank up there with the greats: ‘Evidence-based guidelines rather than therapist preference should serve as a framework from which therapists should derive the most effective treatment.’
It was made in a 2009 systematic review of evidence for the Bobath concept and published in the academic journal Stroke1 (see panel: What’s the evidence?). It concluded there was no evidence Bobath was better than any other treatment – although there was no evidence any other treatment was superior to Bobath either.
Its final conclusion – Bobath should be put aside, hides within it an accusation that has inflamed passions on both sides of the North Sea and contains echoes of a similar row in the US: that Bobath therapists do not base their treatments on evidence and are acting on personal preference.
There is now a growing body of research and opinion saying Bobath is out of date and obsolete, not least because of emerging data from neurosciences2 and should be abandoned in favour of an evidence-based approach. There is an equally convinced group of Bobath tutors and practitioners who defend the concept vigorously and ask: what else do we have that’s better?
In between are the agnostics who think there is room to keep Bobath and update it. Talk to people involved in the debate and the strength of feeling is obvious on each side. Words like ‘rift’, ‘complex’, ‘minefield’ and ‘sensitive’ rub up against ‘potentially far-reaching international consequences’ and ‘more than my job is worth to talk about this publicly’.
The Netherelands moves on
Professor Gert Kwakkel, chair of neurorehabilitation at the VU University Medical Center in Amsterdam, is one of the authors of the Stroke paper. He cites it as further evidence to support the 2007 decision by physiotherapists in the Netherlands to abandon Bobath in favour of a new evidence-based guideline approach.
Called ‘neurorehabilitation-stroke’, it is based on an improved understanding of the mechanisms underlying adaptive motor relearning and mechanisms of functional recovery after stroke and includes metrics for measuring change. Over the last two years, 18 of the 22 Bobath teachers in the Netherlands have retrained using the new approach, with the remaining four deciding to stand down. A similar approach to Parkinson’s ‘neurorehabilitation-Parkinson’s’ is in the pipeline.
In Prof Kwakkel’s view, Bobath is obsolete. The understanding of how patients recover from stroke has changed radically since 1948 and while Bobath has taken this on board, it has been done so selectively, say Prof Kwakkel and other academics.
Prof Kwakkel is not alone in criticising Bobath therapists for this. In a 2006 letter in Physiotherapy Research International, Margaret Mayston, senior lecturer at University College London and a Bobath tutor and consultant, wrote: ‘The Bobath concept is now so diverse that it can be difficult to know where it came from and what it is: there are so many derivatives of it that it could be considered a disservice to Dr and Mrs Bobath to continue to practise under the Bobath name.’3
But Prof Kwakkel’s key criticism is Bobath therapists are not measuring their impact on patients. ‘Their problem is that they talk about quality of motor control and motor performance, but they do not understand how to measure quality,’ he says. ‘But observation is not an appropriate way to say this works. You need to make it transparent for the world.’
This is echoed in the US where the debate rages over Bobath therapy in children. Diane Damiano, a physiotherapist in the department of neurology at Washington University and vice president of the American Academy for Cerebral Palsy and Development Medicine, made the same point in a 2007 editorial in Development Medicine and Child Neurology.
She wrote: ‘Many therapists purport that they use an “eclectic” approach, and pick and choose techniques from multiple sources, as if there were a therapy method buffet table. Medical science however, demands that we seek the best approach, and does not support a practice where individuals can do whatever they want regardless of the support for these personalised decisions.’4
Should UK embrace change?
Prof Kwakkel says therapists in Germany and Belgium are set to follow the Netherlands’ example and the question must now arise: what about the UK? Should we follow suit?
The answer from the British Bobath Tutors’ Association, which represents 17 Bobath tutors who teach in the UK and internationally, is an emphatic no.
Referring to the Stroke paper, Paul Johnson, a BBTA member and lead physiotherapist in the NHS, says: ‘We recognise this is a systematic review of the current evidence, but it is limited. We do not see on the basis of that paper that there is any reason to change practice in the UK.’
BBTA points out its courses are full and still in demand, despite the existence of a range of alternatives. Paul Johnson says: ‘From an educational perspective, we recognise there are many approaches used by therapists in the UK and we fully recognise the Bobath concept forms part of them. The specific focus of the Bobath concept is around the application of movement analysis skills as a basis for developing clinical reasoning processes.’
In other words, Bobath teaches therapists to look at the individual in front of them, analyse their needs and select the appropriate therapy. ‘We are trying to help people to use the evidence,’ says Paul Johnson. ‘But there is a difficulty for people taking pure forms of evidence and applying them to patients.’
Mary Lynch-Ellerington, BBTA member, adds that this ability to select the right treatment for the right patient rather than follow a rigid protocol defined for a diagnosis reflects UK physios’ autonomous status and strong continuing professional education ethos.
‘This is something that does not exist in Europe where therapists are still required to carry out a doctor’s prescription,’ she says. ‘I would hate, and that is the right word, to go back to treatment of diagnosis and set protocols for every patient.’
The BBTA has taken on board the need for a better evidence base for Bobath, and in the autumn of 2009 published a new work outlining the theory behind Bobath and its clinical practice, which they hope will provide the theoretical basis for moving forward.
Evidence for change
Others support more radical change and point to the range of guidelines and systematic reviews already published. Sarah Tyson, reader in rehabilitation at the University of Salford, cites a 2004 review of 128 randomised controlled trials and 28 controlled clinical trials in stroke rehabilitation, which found strong evidence for the effectiveness of therapies focused on functional training of the upper limb, such as constraint-induced movement therapy and treadmill training with or without body weight support. There was no evidence in terms of functional outcome for a range of other interventions, including traditional neurological treatment approaches.5
She says: ‘If we are looking purely at the evidence, then I would say yes, we should have similar changes in practice implemented in the UK as seen in the Netherlands.’
Her reading of the growing body of evidence leads her to say: ‘The implications are that exercise and intensive practice of functional tasks “work”, while traditional approaches such as Bobath do not, and that other treatments which include exercise and intensive practice interventions, such as treadmill training, work better than Bobath. I would suggest it is hard to justify continuing to use Bobath nowadays, when the evidence to support other treatments is so much stronger.’
Others are less convinced of the need for wholesale change, a stance that perhaps recognises that the investment – emotional, cultural and financial – in Bobath is just too large and that the UK lacks the insurance-based healthcare system that has in part driven change in the Netherlands, where the government funded the retraining of Bobath tutors.
Sheila Lennon, senior lecturer in rehabilitation sciences at the University of Ulster and a co-author on the Stroke paper, says UK therapists should be wary of throwing the baby out with the bath water, pointing out that although it showed no evidence that Bobath was more effective than other treatments, it was no less effective either.
But change is needed, she adds, including more quality trials. ‘I personally feel we need to implement evidence-based techniques and get away from a guru mentality and use research in combination with clinical expertise and the wishes of patients and carers.’ Like many, she is looking to ACPIN, the Association of Chartered Physiotherapists Interested in Neurology, for a lead.
Mixed approach
Dr Margaret Mayston, president of ACPIN, agrees with Dr Lennon, that things are changing here, but that the UK is not ready for a wholesale rejection of Bobath. Rather than throw out Bobath, she advocates a mixed approach.
‘I don’t think we should do what the Dutch have done, which is modify Bobath so much they cannot call it Bobath anymore. We should define what Bobath is, say what is successful, explain it in terms of current scientific knowledge and then add other things that work.’
The debate is set to run and run and should interest not just those in neurorehabilitation, but also provoke interest more widely, highlighting as it does the clash that can happen when research and clinical practice are at odds, when cherished beliefs are challenged as in the extent to which physiotherapists have actually taken on board what it means to base their practice on evidence. FL
REFERENCES
Kollen B et al. ‘The effectiveness of the Bobath concept in stroke rehabilitation. What is the evidence?’. Stroke (2009), 40:e89
Oujamaa L et al. ‘Rehabilitation of arm function after stroke. Literature review’, Annals of Physical and Rehabilitation Medicine (2009), 52:269
Mayston M ‘Editorial: Bobath concept: Bobath@50: mid-life crisis – what of the future?’, Physiotherapy Research International (2006), 11:183
Damiano D ‘Pass the torch, please!’, Development Medicine & Child Neurology (2007), 49:723
Van Peppen R PS et al. ‘The impact of physical therapy on functional outcomes after stroke: what’s the evidence?’ Clinical Rehabilitation (2004), 18:833
What’s the evidence?
In 2009, a group of Netherlands and UK physiotherapists and researchers published a systematic review of randomised, controlled trials to evaluate the available evidence for the effectiveness of the Bobath concept in stroke rehabilitation. Their argument was although it is the most popular treatment used in stroke rehabilitation, the Bobath concept has never been proven to be superior to alternative approaches.
Researchers carried out a systematic literature search in March 2008 and studies in which the effects of the Bobath concept were investigated were classified into the following domains: sensorimotor control of upper and lower limb; sitting and standing; balance control and dexterity; mobility; activities of daily living; health-related quality of life and cost effectiveness.
The next step was to measure the strength of the evidence in the literature retrieved. Independent researchers rated it using the Physiotherapy Evidence Database scale and derived a best evidence synthesis that was used to determine the strength of evidence for the effectiveness of the Bobath concept and for its superiority over other approaches. This approach whittled down an initial list of 2,263 studies to a final 16 involving 813 patients suitable for inclusion in the review.
The researchers found no evidence for the superiority of Bobath on sensorimotor control of upper and lower limb; dexterity; mobility; activities of daily living; health-related quality of life and cost effectiveness. Only limited evidence was found for balance control in favour of Bobath.
They concluded the Bobath concept was not superior to other approaches, but equally there was no evidence available yet for the superiority of any approach. However, the review identified many methodological shortcomings in the studies and called for further high quality trials.
Bobath: a brief history
The Bobath concept emerged in the post-World War II period in the UK as awareness of the need for rehabilitation generally was increasing. It was first published in 1948 and now, more than 50 years later, it is the most popular approach for treating neurologically impaired patients in the western world.
It was developed by husband and wife Dr Karel Bobath and Berta Bobath, a doctor and physiotherapist, respectively, who shared an interest in understanding the problems of adults and children with neurological conditions. The main aim of treatment is to encourage and increase the patient’s ability to move and function in as normal a way as possible by encouraging more normal postures. Therapists assess the patient, observe their movements and develop a treatment plan. It is a hands-on approach, with the therapist directing the patient’s movements.
Bobath therapy has changed over time, incorporating new scientific knowledge. Karel and Berta published their concept for the last time in 1990, a year before they died.
Useful resources
The Royal College of Physicians’ National Clinical Guidelines for Stroke was updated in 2008 and includes a section on rehabilitation. It does not contain the latest (2009) reviews of the effectiveness of Bobath
The evidence-based stroke rehabilitation guidelines and flow chart developed by the Royal Dutch Society for Physical Therapy are available to download in English here
Meadows L et al (ed), Bobath concept: theory and clinical practice in neurological rehabilitation. Wiley Blackwell, October 2009
Hesse S ‘Treadmill training with partial body weight support after stroke: A review’, NeuroRehabilitation (2008), 23(1):55
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