What is Bobath?

Okay, here goes my 1st ever blog! My original aim was to present the main topics of discussion about the evidence (or otherwise) for the Bobath concept as they appeared in the icsp discussion (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 ) and to let all contributors make their points in a wider forum. However this has fallen 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. You can always go back to the original icsp thread to check it out.

So here is the 1st topic What is Bobath?

 On 1st October the British Bobath Tutors Association (BBTA) posted a response to neurology network ICSP thread discussion on their website. This (in italics) is the parts that relate to the current definition of the Bobath Concept

We have read with interest the various opinions and discourse put forward and would like to clarify our perspective on some aspects of the discussion threads. Perhaps it would be most helpful to direct contributors and readers to the most recently published papers on the contemporary Bobath concept by Vaughan-Graham et al 2014. The first paper reviews the knowledge base in relation to a contemporary Bobath concept and outlines the ‘cornerstones’ as being;

  • Integration of posture and movement with respect to quality of task performance
  • Selective manipulation of sensory information to positively affect motor control and perception (body schema)
  • Provision of a theoretical framework for clinical practice
  • A focus on a clinically reasoned, inclusive, individualised approach, exploring potential for positive functional change

 

In short, Vaughan-Graham et al describes the Bobath concept as an inclusive, individualised, problem-solving, living concept based on a systems approach to motor control, with particular emphasis on movement analysis and motor recovery from the perspective of the integration of postural control, task performance and contribution of sensory inputs.  The concept is based on contemporary theories of motor control and motor learning.

We sincerely hope that some of the issues raised in the discussion threads have been addressed here. More information is available at www.bbtauk.org.

This is a summary of my reply referring to the Vaughan-Graham paper posted on 4 Oct, 2015

The Vaughan-Graham paper gives a new definition and list of underlying assumptions (now called “conceptual perspectives”). The Bobath concept is now defined as “an inclusive, individualized, problem-solving, living concept based on a systems approach to motor control, with particular emphasis on movement analysis and motor recovery from the perspective of the integration of postural control, task performance and contribution of sensory inputs”.

 The theoretical Foundations of Bobath from Figure 2 of the paper are:

  1. An inclusive, individualized, remediation focused problem-solving approach
  2. Based on contemporary theories of motor control, neuromuscular plasticity and motor learning
  3. To optimize activity and participation thereby improving quality of life

The ‘key aspects of clinical practice’ are:

  1. Movement deficits are limitations in the range of motor patterns normally available to healthy individuals
  2. Movement analysis and treatment is based upon the integration of postural control and task performance, and the control of selective movement for the production of coordinated sequences of movement
  3. Sensory information from multiple sources plays a fundamental role in motor control
  4. Facilitation, including manipulation of the environment and therapeutic handling, is a skilled aspect of intervention
  5. Favours motor solutions that optimize quality/efficiency of movement
  6. Movement quality should be one determinant of effectiveness

Although the jargon has changed a little from earlier definitions, but is no less impenetrable, the generic nature of the definition and ‘perspectives’ has not.  They could just as easily be applied to any other flavour of neuro physio. Only perspective #7 is specific to Bobath. So is Bobath really just every-day neurological physiotherapy with facilitation?

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5 thoughts on “What is Bobath?

  1. I sent this via a direct message on twitter to ask for some advice and I’m sharing on here for further thoughts/support and to let you know what happens in some places still…
    Hi! I work in acute neuroscience and the rehab physio’s are away to run a 3 wk bobath course which I’m under a bit of pressure to go to! My colleague in acute stroke (and bobath trained) and is adamant I should go. Am I missing the point by not being a bobath physio? I have done masters modules in neuro, believe in EBP but still find that locally most are believers of bobath. I suppose I lack the ability to speak up against the tide 😳! Anyway, just checking your opinion…..

    Liked by 1 person

    1. It is fascinating to wonder why Bobath training is still being funded and so zealously encouraged, I believe it is an ingrained habit of practice that reflects very poorly upon our profession. It is therefore helpful to get a more objective (outside physio) view on what treatments and training should be encouraged and used.

      An excellent example here is the RCP Guidelines for Stroke 2016. The problem for the followers of a Bobath approach is that Bobath is not mentioned in the RCP guidelines. But then things get even worse for Bobath:-

      1.8 Treatments not mentioned in this guideline

      “Clinicians can apply the general rule that if an intervention is not mentioned in this guideline, then it is not recommended for use, and commissioners are not obliged to obtain it for the populations they serve.” (They then say that some new/novel treatments can be considered but with certain restrictions, this obviously does not apply to Bobath.)

      This indicates that:-
      1. The NHS should not pay staff to take time off work to run or attend Bobath courses.
      2. The NHS should not fund fees for Bobath courses.
      3. The NHS should not fund therapists to use Bobath methods.

      This is all negative but we as a profession must follow our CSP code of conduct and use methods that have a good objective evidence base and are therefore recommended in national guidelines. Our commissioning groups are obliged to fund training in these methods, which they cannot do if they have already spent the budget on courses that are not recommended and they are not obliged to fund.
      Where I worked our stroke consultant was asked to approve funding for a Bobath course and he blocked it on the grounds that it was ineffective, it is a shame that we have to rely on another profession to take an objective view of physio practice/training.

      To quote from a discussion on iCSP by “Chris”:-
      “As HCPC registered physiotherapists we are duty bound to offer the best evidence based treatment to our patients. I do wonder where one stands on the matter of professional registration for those who refuse to set aside their Bobath treatment strategies in the knowledge that better evidenced practise exists elsewhere. It’s important to remember we were all physiotherapists first before we studied Bobath and it should be used or discarded in line with the evidence base like any other treatment modality.”

      Jb8205 from your point of view I think you can make a very positive point that you (and others) should receive training in the modalities recommended in national guidelines before any Bobath training is considered.

      However, I know from my own experience it can be very lonely and difficult to be the non-Bobath therapist. It is hard to discuss Bobath without being seen as criticizing (professionally and personally) the majority of your colleagues, who you respect as individuals, and with whom you share / handover patients.

      We need to increase the level of education on this subject and as such I did a lecture to our local ACPIN group on evidence based neurophysio and why we still use Bobath, I can send you the powerpoint of the talk if you think you could use it.

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      1. Hi Rmepsted
        Do you mind sharing the slides with me? I share Jb8205’s experience at my work too. Perhaps i could do a presentation to my colleagues as well.

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  2. Hello S2Sda & JB8205
    I have just uploaded the PowerPoint re Bobath vs EBP file to a discussion started a few days ago on the neurology section of iCSP. (The discussion is titled peer pressure and Bobath so it’s easy to find). Feel free to use it however you like (if you change it too much take my name off and substitute your own). There are notes with additional information at the bottom of many of the slides. I hope to get the file onto this blog as well, if that is possible, so that therapists not in the CSP can access it..
    Best wishes
    Roger

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  3. New publication examines the clinical reasoning of Bobath instructors.

    I have just come across an article that provides an in-depth analysis of the clinical reasoning used by Bobath instructors (1).
    The authors (one a Bobath instructor) discuss the role of scientific evidence based practice and comment that although it can demonstrate the efficacy of particular interventions that these are not necessarily applicable to all individuals. They then discuss the “why” process of thoughts that a therapist uses as they apply their intervention to an individual. They call this clinical reasoning and rightly point out that it is a vital part of the whole process. They complain that rehabilitation research has become dominated by scientific approaches and that the role of clinical reasoning has been largely ignored. This they say has produced a widening chasm between research and practice.
    I agree with a lot of the above but believe there are some significant omissions in this study.
    Firstly, the authors state “Although the effectiveness of the Bobath concept has been widely investigated, clear descriptions of Bobath interventions are lacking and the clinical reasoning process is undocumented.” This statement omits to mention that the numerous investigations into the effectiveness of Bobath conclude that it is less effective than the alternatives. This is why it is not recommended in national guidelines and is criticised in reviews (2-4). These reviews recommend a range of specific interventions but do not recommend the following of any named concepts or approaches.
    Secondly, they describe the clinical reasoning process of Bobath instructors in depth but to my mind it is no different to that used by any experienced therapist. I cannot see anything that makes it uniquely Bobath, other than it is largely confined to the Bobath methods and concepts. Bobath trained therapists do not have a monopoly on clinical reasoning.
    This is the fundamental flaw in this paper; we all agree advanced clinical reasoning skills are a good idea and help us adapt generalised interventions to an individual. But we need to combine clinical reasoning with treatments with a good objective evidence base, i.e. recommended in reviews and guidelines. The problem for Bobath based therapists is that their methods are not recommended.
    In summary, this paper demonstrates that followers of this approach can be easily lead into an in-depth analysis of what they do whilst ignoring the objective evidence that better interventions exist. Where is the clinical reasoning in using a suboptimal approach in the first place? I believe there is no reason for a scientific evidence based approach to result in what the authors describe as the ever-widening gap between research and practice. This divergence exists because the evidence based has moved and the Bobath concept has not.

    Refs
    1 Vaughan‐Graham & Cott (2016) Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors, J. Eval. Clin. Pract., doi: 10.1111/jep.12641.
    2 RCP (2016) National Clinical Guideline for Stroke. available at :- https://www.strokeaudit.org/Guideline/Full-Guideline.aspx
    3 Novak et al. (2013) 55 885-910. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev. Med. Child Neurol. Available at :- http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pd
    4 Kollen et al. (2013). A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev. Med. Child Neurol 55 885-910. Available at :- http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pd

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