How to do Bobath? Part 1 Quality or function?

Not the snappiest of titles I’m afraid, but there has been a lot of discussion in the icsp threads (found here http://www.csp.org.uk/icsp/topics/rationale-evidence-bobath-neurological-physio and http://www.csp.org.uk/icsp/topics/novak-review-casts-doubt-efficacy-bobath-should-we-embrace-or-ignore-it ) from physios who use Bobath about: what Bobath is, or isn’t, what it aims to do, how and why. Fair to say, I think, that there is considerable uncertainty, despite the earlier posts about the definition of Bobath. So I have tried to collect together the relevant discussions and to chunk them into easily digestible pieces . I hope this makes sense and represents everyone reasonably. You can always go back to the original icsp thread to check it out. If Ive screwed up, I’m happy to be shown the error of my ways. Unfortunately I can’t directly attribute the discussion to the person posting (unless they have specifically said that I can) because that would fall foul of the terms and conditions of icsp and their copyright rules, so I have to summarise the contributions in my own words. I have tried to do this as openly and even-handedly as I can.

 

Quality or Function, which is the question?

1.It’s all about the quality

Grannie Jackie started off by saying they felt quality of movement (rather than function) is the essential thing that should be measured to evaluate the effects and effectiveness of Bobath.

RogerM and SarahT disagreed, summarising the results of the only study to-date on the effect of Bobath on quality of movement ((Lennon et al. Disability and Rehabilitation 2006:28;873-881). In this study, patients who were cherry picked as having good potential for improvement in gait and were given therapy until their therapist believed they had reached their full potential (on average 17 weeks, with range of 8 to 35 weeks). All the therapists were trained to advanced level of Bobath (one was a tutor). Quality of gait (kinematics and kinetics of the gait, ie the gait movement pattern) was measured in a movement analysis lab before and after rehab. The conclusion was that Bobath had no effect on quality of gait.

Furthermore Sarah T contended most strongly that the aim of physiotherapy, of whatever brand, is to improve patients’ function, and thus should be the primary outcome for trials and in clinical practice. ‘Quality’ of movement (whatever that is, a consensus on a definition has never been reached) is a secondary, if not spurious, issue. It is widely assumed by many therapists that impairments such as ‘quality of movement’ are directly related to function so that if one improves the patients’ impairment, they will automatically have more / better function. There is abundant evidence that this is not so. The relationship between impairment and function is often weak, and many patients are able function because they use abnormal movement patterns and compensations, not in spite of them. For example in the Lennon et al paper described above, the most treatment target was an “inability to accept and transfer weight and an inability to selectively move the pelvis and the hemiplegic lower limb”. The therapists hypothesised that improving these impairments would improve the kinematics (movement patterns) of the hip, knee and ankle, and the kinetics (weight transfer) of both legs, and consequently would improve mobility (function). They didn’t. Even in this best case scenario, there were no changes in the movement patterns or weight transfers.  There is no strong methodological explanation for this. It is a good quality study of a complex issue – the treatment just did not improve ‘quality of movement’. There were some improvements in function – which is good.  But however these were achieved, it wasn’t by improving the quality of, or normalising the movement patterns – which rather refutes the concept/ theory/ rationale for Bobath.

 

  1. No, no, function is the important thing

Contributor 6 knew Dr and Mrs Bobath and was able to draw on their recollections and archive notes from Bobath courses in the preceding decades. She clarified that Bobath practitioners don’t teach an exercise per se. They show, assist, ‘facilitate’ an activity, and then modify either their handling or the activity to alter the outcome. However Bobath is not just about specialist handling/ facilitation. Dr and Mrs Bobath’s focus and priority was quality of movement to achieve a longer term functional outcome. Mrs Bobath always insisted that ‘unless you stimulate or activate your patient in the way in which new activities are possible, you have done nothing at all’ (Archival material Bobath Centre 1965, publ in NDTA Network 2005). She felt that the important changes to achieve were the ease with which one [presumably the patient, but it may refer to the therapist doing something to the patient] performs a task, or speed or endurance of performance. Other important changes include range movement (active or passive). Specialised handling/ facilitation is designed to influence and reduce increased tone can be used to achieve this.

Sarah T noted how Contributor 6’s post highlighting what was important in the Bobath Concept emphasised facilitation, handling, doing things to passive patients (“unless you stimulate or activate your patient in the way in which new activities are possible, you have done nothing at all”) and promoting changes in impairments – muscle tone, range of movement and ease of effort, speed, endurance. This is borne out by the 18 case studies on the BBTA website from students of Bobath courses ((http://www.bbta.org.uk/poster-presentations-bobath-concept). These almost exclusively involve therapists trying to alter the muscle activity by facilitating very specific and limited ranges of movement (usually passively, occasionally active -assisted). There is precious little patient activity or function going on. All of which contrast with the claims that Bobath is all about function, encouraging the patient to be active rather than just using facilitation techniques to treat impairments (which almost certainly don’t promote neuroplasticity or motor learning).

 

  1. What is meant by function? The ICF is a useful way to think about things

Contributor 7 picked up on the references to impairments, activity etc and felt we should clarify how function was defined. She refers to the International Classification of Functioning or ICF (International Classification of Functioning, Disability, and Health: Children & Youth Version: ICF-CY. World Health Organization – 2007)) and uses that classify the outcomes in a recent study previously quoted by Contributor 6. She notes that the focus is measuring on ‘body structures and function’ (or impairments), activity and participation were not assessed. She asks “So what”? She feels that an intervention is only truly useful if it has an impact on the client’s every-day life.

Sarah T agreed that the ICF was a valuable way to consider the aims of therapy and the effects it may have. She gave some examples of each level of the ICF:

Body structures and functioning (AKA as impairments are (as it says on the tin) aspects of body functioning and structure. So this includes tone, strength/weakness, pain, sensation and the like. Then there is activity (AKA disability), I would postulate, is what we mean when we refer to function. It is about the activities someone can (or cannot) do in everyday life. So mobility, dressing, bathing, cooking, shopping etc are activities. Then there is participation (which used to be called handicap) which is about someone’s ability to fulfil their roles (schoolchild, spouse, employee etc). So going to school is participation, being able to write is an activity and having the grip strength to hold a pen or the dexterity to use a mouse are impairments.

 

4. How does the ICF inform treatment?

Sarah T: The issue comes in treatment planning and evaluation. Participation and activity in everyday life are difficult to measure and treat as we aren’t with patients in their everyday lives (or not often). So we tend to assume there is a linear relationship between impairments, activities and participation. Ie, That as a patient becomes stronger or more co-ordinated they will automatically become (more) able to write /use a keyboard and then will be able to cope/perform better at school (for example). This is on the assumption that if we focus on the impairments (such as tone or strength, then the activity/ participation will look after themselves.  But those relationships are actually pretty weak and there isn’t a direct relationship between one and the other. This quite complex because there IS a relationship between impairment and activity; between lower limb strength, gait speed and mobility levels, for example – the stronger a patient is, the faster they can walk and the more generally mobile they are. Indeed mobility level can be reasonably accurately predicted from walking speed.

So that’s good, BUT endless research has shown that there isn’t an automatic transfer from improvements in one ICF domain to another. So mobility (for example) will only improve if the patient practices walking in all the environments and ways in which s/he needs to walk. Walking outdoors will only improve of the patient practices walking outdoors, fast enough to keep up with everyone else, for long enough to get where they want to go, to be able to adapt their gait to negotiate obstacles, change direction etc. One may well need to treat the impairments (strength, cardiovascular fitness/endurance, speed and/or range of movement) first (or simultaneously) to achieve get to the speed/ endurance/adaptability they need to perform the activity – but they also have to practice the activity in context/ environment they need to operate – or any changes won’t carry over.

Also we need to be bear in mind that impairments do not prevent activity/function. Many patients are able to function despite, or sometimes because of, their impairments. That’s what compensation is all about: Compensation is a good thing. It is the automatic way the body-brain adapts to achieve a goal/ activity. Our professional challenge is to work out how to manipulate the tasks and environment to enable the patient to be as active as possible and to learn how to move/ function as well as possible. Professionally, we need to be able to judge when the activity aim should be achieved by pushing performance (ie impairments) to as close to normal as possible or when to enable activity by encouraging compensating and adaptation. I would suggest that the legacy of Bobath is that we have tended to focus too much on the former. In doing so we have inadvertently made our patients more disabled/ less active than they could be in our mistaken belief that by normalising impairments will automatically carry over into improvements in activity and that ‘normal’ or ‘quality’ movement is needed to function/ be active.  Which isn’t saying that we shouldn’t work on impairments at all (especially if it is the impairment that is limiting the function) or try to improve someone’s movements towards becoming’ more normal’. I’m suggesting we have given it more prominence than is helpful for many of our patients.

Then, there is participation which is actually what our patients are interested in. They want to be able to get on with their lives rather than fretting about their tone or movement patterns. In fact, impairments are often a relatively minor concern.  For example, a patient may want to improve their dexterity so they can use a mouse so they can play computer games, or they may well be just as happy to use a different type of mouse that is easier to use. It is being able to play that is important, not the mouse or how they use it. And this is so often missing from physiotherapists’ mind-set. In all my research (Sarah T’s) with physiotherapists about their clinical reasoning, defining the content of physiotherapy, working out what to measure and how, participation has never figured. We focus on impairments (excessively) and then activity, but rarely get as far as participation

 

Advertisements

One thought on “How to do Bobath? Part 1 Quality or function?

  1. Thank you Professor Tyson for starting this blog and for clearly bullet pointing the facts you believe we physiotherapists know. I shall try and comment on each bullet point.
    1. I agree.
    2. Reflex activity is a very important component of motor control.
    3. I do not like the paper (? Title) that first introduced the idea of having positive and negative aspects of an upper motor neurone legion. My personal hypothesis is that selection of compensatory stability is the main disabling factor in an upper motor neurone legion. Encouraging or allowing patients to persistently use compensatory stability only leads to abnormal movement and spasticity.
    4. I agree. There are however two types of stretch reflexes – the muscle spindle stretch reflex and the type IV propriorceptor nerve ending situated in fascia. It is the latter reflex which is the relevant reflex.
    5. Now-a-days a minority of stroke patients are spastic. I disagree all patient have some degree of spasticity when they compensate. I do however agree with you that in Mrs Bobath’s earlier days more patients were spastic. and weakness is greatest contributor of limited function. I disagree compensation is the greatest contributor to limited function.
    6. I disagree. Asymmetry has a strong relationship to function. Where patients select compensation they usually also select some form of unnatural asymmetry. It is much better to get folk doing something and then train them to get better at it, than to stop folk doing something. Patients need to focus on quality function and not abnormal compensatory spastic movement. Stopping patients from practicing walking in the early days is a small price to eventually regaining a good gait with normal postural reflexes and overall better quality function in both the trunk and affected arm.
    7. Patients learn what they practice. I agree. But patients do need to learn quality function and not abnormal compensatory spastic function. So it is not effective to treat a patient’s tone, quality of movement, soft tissue length or immobility, selective movements, core stability, components of movements, etc, etc, etc and then hope that this will automatically carry over to the patient being able to do more. I disagree. By working at quality non compensatory function the patient’s core stability, tone and tissue length etc will easily and automatically improve. To get good “carry over” patients need to practice quality function in between physiotherapy sessions.
    8. Exercise is only effective where patients work at quality non compensatory function.
    9. I agree but activity needs to be all about non compensatory quality function throughout the 24 hour day. Bobath can only be truly effective where compensation is avoided.
    I hope these comments help Sarah Tyson. Will you be allowing contributors to use pseudonyms? If so may I change my name from Contributor 1 to Granny Jackie.
    Best wishes Jackie

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s