How to do Bobath? Part 4. Motor learning and neuroplasticity

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. I have tried to do this as openly and even-handedly as I can.

In this chunk some of the theoretical beliefs about how Bobath works are considered in the light of evidence. I’ve taken the Vaughan-Graham 2009 paper (Top Stroke Rehabil 2009;16(1):57–68) as a starting point. In the paper there are several statements specifying aspects of the Bobath Concept. I published that list before in the icsp thread a while ago. At the time it didn’t raise a lot of discussion. So I’ve grouped the statements into several sections and will consider how they compare with the evidence. Ive also added some relevant queries, stated beliefs and discussion from the icsp threads and drawn on the Bobath Concept book (pub 2009 – a most illuminating read). There is a sprinkling of references to back up my claims or I have recommended other reading (would hate to be accused of not justifying my claims!) These are by no means a comprehensive indication of the evidence, they are some examples.

 

Part 4. Neuroplasticity and motor learning

The Bobath tutors say: the Bobath concept utilizes present-day knowledge of motor control, the nature of movement dysfunction, neuromuscular plasticity, biomechanics, and motor learning….. The Bobath Concept is part of an active learning process. It assists the patient in problem solving and enables him or her to experience the patterns of movement and success in achieving the task. …… Treatment is focused toward remediation, exploring the individual’s potential to regain abilities through neuromuscular plastic adaptation.

 Neuroplasticity and motor learning are considered two of the main mechanisms by which BB has its effect (ie how it works). It is the mechanisms for all other types of neuro physio too, but we’ll leave that aside for now. In their book, the Bobath tutors have sections on motor learning and on neuroplasticity. They outline the principles of both and highlight some of the conditions needed to promote both, and carry-over into every-day life. These include:

  • Working on meaningful goals/ tasks
  • training in different real-life situations as appropriate and not only in the therapy department.
  • enabling active participation which involves engaging the patient in a problem-solving process [ie the patient has to work out how to perform and to correct the activity themselves]
  • using repetition effectively – varied tasks; varied environments; varied repetitions (random more than blocked practice); whole tasks (more than part task or practicing components);
  • training intensively (the more the better)
  • giving feedback occasional on the outcome (knowledge of results with wide ‘band-width, to use the jargon) more than continuous/ frequent feedback about the way the person is moving (narrow band-width knowledge of performance).

The BB book also includes mental practice, modelling (or demonstration) and guidance [AKA facilitation] as techniques that promote motor learning and neuroplasticity, which is extrapolating some early stage research a bit too far IMHO. However they do note that “excessive guidance [NB: guidance AKA facilitation] or physical devices offering continuous restraint and direct movement reduces the need for problem-solving and does not improve learning.”

All of which is sensible stuff and I agree with !! I can see the headlines now #TysonagreeswithBobathShock, they will be saying that I endorse BB next, Oh wait, they already do!  BUT but, but, but, there is nothing in the book, the courses or the papers they have published to actually connect BB with these principles.  No evidence that Bobath generates motor learning or neuroplasticity, although there is plenty of evidence that other interventions do: The EB ones like CIMT, exercise, electro-mechanical gait-training and treadmill training. It is just stated that they do, presumably we are accepted to take this at face value.  Although that may have been on in the past (for lack of an alternative), it is an insufficient basis for credibility now-a-days. Show us data to demonstrate that BB produces neuroplasticity and motor learning.

Although there is no evidence that BB involves the conditions that promote motor learning and neuroplasticity. There is evidence that it does not involve the right conditions to achieve it. Granted it is very low level but it does come from the horse’s mouth. Think of the Bobath courses you have been on; look at the examples of BB in action in the case studies (presumably the good ones) on the BBTA website (http://www.bbta.org.uk/poster-presentations-bobath-concept); look at the examples of BB in action in their book. How many examples involve meaningful goals/ tasks; training in different real-life situations; an actively engaged patient (them actually doing a meaningful/ functional task for themselves); varied practice conditions; high repetitions; varied practice conditions; knowledge of results; low frequency feedback?

Exactly! None or next to none. How often have you seen the conditions which prevent motor learning – excessive guidance, continuous restraint and directing of movement, abstract rather than functional movements, the patient being passive rather than active, low number of repetitions? Nearly all of them.

In the icsp discussions, contributors wondered whether low repetition/ intensity of practice was a factor in BB’s lack of evidence. She said “I would question the notion of “person centred approach” being used in the same sentence as the Bobaths’ approach.  All the Bobath courses I’ve attended were very much geared towards what the therapist was doing to or for the client, rather than what they [the patient] were generating for themselves within or beyond the treatment”….. The link between repetitive practice and neuroplasticity is well established in Neurophysiology research, and we know a significant amount of repetition is required.  Perhaps 1 reason why NDT/Bobath is not achieving proof of effectiveness or significant change in research trials is insufficient repetition?”

Another contributor agreed, adding that “If you want to learn to walk you need to practice walking; this is how infants learn to walk and how we all acquire new skills. However, in Sheila Lennon’s study ([D& R 2006:28;873-881] where the major aim was to enhance mobility by advanced Bobath techniques;  the patients actually walked for only 7-12% of their therapy time. This concurs with my own experience that Bobath trained therapists can be more interested in applying their complex handling techniques to patients than helping the patient do something useful themselves. The emphasis needs to be more on the patient practicing functional tasks than on ourselves exhibiting high level handling techniques; especially when the best evidence indicates they are are better alternatives”. 

The observation of a gap between what BB says and what they do is further illustrate din some work I did a while ago now, about the how neuro physio therapy is delivered in ‘real life’. Tyson, Connell, Lennon, Busse Clin Rehab 2009; 23;11;1051-1055  D&R 2009: 31:18;1494-150 D&R 2009;31:6;448-457. These showed that Bobath practitioners spent most of their time in therapy sessions ‘preparing’ patients using passive techniques such as mobilisations and facilitating selective movements. There were precious few repetitions, the patient was passive most of the time and the activities were abstract rather than functional.  None of which promote motor learning or neuroplasticity

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