How to do Bobath? Part 2: A big misunderstanding

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 I’ve messed 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. Inevitably this involves quite a bit of editing and tbh I’m not really clear where a summary of the discussion ends and a new post on the topic begins. I have tried to be as open and even-handed as I can; happy to receive feedback.

In this chunk, which follows on from the previous post about whether function or quality of movement are Bobath-ers primary objective. We consider the some Bobath tutors historical perspective.

Contributor 6 stated that function was always Dr and Mrs Bobath’s focus and gave priority to ‘quality of movement’ to achieve a longer term functional outcome. She felt it was a common misunderstanding that quality of movement was treated at the expense of function. She had known Dr and Mrs Bobath and was able to draw on their recollections and archive notes from Bobath courses in the preceding decades. She explained that Mrs Bobath taught neuroplasticity, observational assessment/ analysis, clinical reasoning, the importance of functional alignment and motor learning and incorporated them into the Bobath Concept long before any of these terms had been coined.

This notion of Bobath practitioners misunderstanding what Bobath is all about is also reiterated by the BBTA and IBITA. In their ‘Vaughan-Graham paper (Top Stroke Rehabil 2009;16(1):57–68) they include many specific statements about what Bobath is, or isn’t, about. They say that: “A misinterpretation of the Bobath concept is the assumption that perfect alignment of body segments and postural control are required before engaging in task performance. The use of task-directed movement during treatment does not presuppose independent postural control. By changing the environment and providing an appropriate external support, the individual can perform complex motor tasks that in turn can improve postural control and selective movement. Alternatively, directly addressing alignment of body segments (macro) of tissue (micro) and postural control may improve efficiency of complex motor tasks.

Sarah T agreed that if Bobath advocated that practitioners should not prevent activity/ function until the quality of movement was right, then there is, indeed, very widely misunderstood. How did that misunderstanding occur and became so common?  Presumably it was something about what is taught and the way it is taught. It is simply untrue of Bobath tutors to say they never advocated preventing a patient from functioning if their quality of movement was not normal, or that they should not use assistive devices (like walking aids and AFOs), or use strengthening exercises.  She, and thousands of others, have sat at the feet of the Bobath gurus, read the books and paid for the courses where we were told exactly that.

May be Bobath has ‘evolved’ and now recognizes that their previous beliefs were ineffective. In which case, it would be much more credible to just say so, and demonstrate how it has changed by publishing (ie opening up to peer review) the detail of the theory it is drawn from, the evidence connecting the new theory to the way Bobath is operated and its effects. The current approach appears to claim that Bobath was right all along, and knew about neuroplasticity, motor learning, the value of exercise, assistive devices, etc, etc all along and taught it, but the people attending courses and using it in every-day practice was just too dim to appreciate it, then continuing with the same treatment techniques but using new buzz words.

To be fair, the Bobath tutors have attempted to explain their rationale about what Bobath is now-a-days (in the ‘Vaughan-Graham papers’ Top Stroke Rehabil 2009;16(1):57–68 ) and the ‘Bobath Concept book’ (now uploaded in pdf on the icsp in the ‘Why is there no Bobath research?’ thread), But the paper and the book are essentially a list of the Bobath tutors’ views. They claim to draw from contemporary theories (motor control, neuroscience, motor learning, biomechanics etc, etc) but don’t give an information about which theory they are using; how it is being used; how it is operated within the concept (ie what practitioners actually do); and what effect it has. All of which is really necessary for credibility. Just saying something is happening now is not enough – give us the details, so that fellow professionals can understand it and make their own mind up about it. .

More thoughts about the evidence for, or against the assumptions of Bobath in the next post ….

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