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 5. The Facilitation Thing
The Bobath tutors say that facilitation is a key feature of BB and always has been. They make many statements about facilitation including that it:
- involves the use of afferent information to effect improvements in motor performance
- aims to provide appropriate afferent information approximating that usually experienced during performance of the motor task.
- involves specific manipulation of afferent inputs inclusive of somatosensation, vision, vestibular, and auditory in order to bring motor systems to threshold.
- enables the Bobath clinician to specify the sequences of movement and specific muscle activity that will produce efficient task performance.
- is intended to enable the individual to have an experience of movement that is not passive but one that they cannot yet do alone
- is used to enable successful movement and task performance with regard to aspects such as postural orientation, components of movement, functional sequences of movement, recognition of the task, and motivation to complete the task.
Which sounds marvellous. Who wouldn’t want to use something that enables patients to move and do things in the way they did before they had their stroke? The problem is that there is no evidence that facilitation does enable patients to move and do things etc, etc, or any of the other things listed above. The limited evidence available suggests that it doesn’t have an effect on movement. The Lennon et al study showed that facilitation did not affect motor performance, movement sequences etc, etc. Hesse et al (Electroencephalogr Clin Neurophysiol 1998;109:515–22) looked at the effect of facilitation on gait in a one-off session, which showed that patients showed some minor changes in gait pattern while facilitated but any effect had worn off half an hour later.
So what little evidence there is, does not support the hypothesis/ belief that facilitation improves motor or task performance. There is no evidence that facilitation manipulates any type of afferent information, nor that manipulating afferent information affects motor performance in a functional way. Now you may well be thinking that the lack of evidence may just be because the research hasn’t been done (after all, lack of evidence isn’t evidence of lack of effect). But why isn’t there any evidence? The Bobath-ers have been using their concept for decades and claim to use objective outcome measures and to be active in research. So why has no evidence of the effect of their treatment ever been published? It wouldn’t even need to be high-powered trial evidence. Even a decent case series or two; detailed small N studies or some before and after reports would be a start. At least that would be something on the first couple of layers of the evidence pyramid. But no, nothing, zilch. Why?
Next blog is all about compensation