Does Bobath work?

The issue that set the icsp discussions off in the 1st place was a systematic review by Novak et al (DM&CN 2013: 55; 10 epub 21/08/13) which used the GRADE methodology to review and summarised the evidence for many treatments for children for CP. They concluded that there was strong evidence that the following physical interventions were effective and should be used: bimanual training, botox, casting, CIMT, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after Botox and pressure care). They also concluded that the evidence showed Bobath was ineffective and should not be used (along with Craniosacral therapy, hip bracing, hyperbaric oxygen and sensory integration).

Then the 2nd thread started with the aim to discuss the rationale and evidence for Bobath (in adults).  There have been two main elements within that thread re: the evidence of efficacy for BB. Firstly there were the studies that tested the underlying assumptions of the Bobath Concept – and how they don’t support BB.   Then there has also been a discussion of larger trials that compared BB with other interventions. I think it is safe to say that we have pretty much said as much as there is to be said about the former in How to Do Bobath Parts 1-6 (although very happy to receive further thoughts, ideas, questions). So it’s time to turn our attention to the trials.

On 1st October SueArmstrong posted a comment about the discussion thread on behalf of the British Bobath Tutors Association (BBTA) which they also published on their website.  In the section that relates to the effectiveness of Bobath, Sue refers to a paper by Vaughan-Graham et al (D&R 2015:37:21;1909-1928) which reviews intervention studies of Bobath, but does not give any details. So I’ve had a look. The paper puts much emphasis on which version of the Bobath concept was used and only includes papers published from 2007-2012, but …. 12 experimental design studies that investigated the effects of Bobath were identified. In all but 1, Bobath was the control condition that was compared to ANOther treatment. Of these 12, 6 studies showed that the alternative treatment was superior to Bobath, in the others both groups improved with no differences between them. This indicates that Bobath is less effective than many interventions and no more or less than others. Crucially none of them can show that Bobath was superior.

SueArmstrong then refers to the well-known ‘Kollen paper’ (Kollen et al The Effectiveness of the Bobath Concept in Stroke Rehabilitation What is the Evidence? Stroke 2009;40:e89-e97)which shows that the Bobath Approach is no better, or worse, than other approaches. She then goes on to highlight the section in the paper where the authors say how the BBTA are working with universities, developing MSc modules and claims to back up their CPD courses with present-day knowledge of motor learning, control etc, etc. And that they approve the use of ‘adjuncts’ (which have a much stronger evidence base than Bobath). However, they don’t include the section that followed which describes how the Dutch Bobath tutors have abandoned Bobath in preference to evidence base treatment approach.

The Netherlands has adopted a different perspective. Over a period of 18 months, all 22 Bobath instructors have adopted evidence-based practice based on the Dutch Physical Therapy Guidelines for Stroke. It is their view that in line with the lack of evidence as well as major changes over time in our understanding of underlying mechanisms about stroke recovery, which do not concur with the obsolete and constantly changing assumptions used to explain the Bobath Concept, a new evidence-based approach was warranted. Therefore, in effect, a new approach based on evidence-based guidelines and the improved understanding of mechanisms underlying adaptive motor relearning and mechanisms of functional recovery after stroke replaced the Bobath Concept”.

I would advocate the same. Although ‘the Kollen Paper’ is the systematic review most often quoted by Bobath advocates, it is not the only one to consider the effectiveness of Bobath. Over 10 years ago, Van Peppen et al reviewed the evidence for physical therapy after stroke (Clin Rehab 2004;18:833-862). They found strong evidence for therapies focusing on functional training such as CIMT, treadmill training, aerobic exercise, external auditory rhythms during gait and FES for subluxation. No evidence or insufficient evidence was found to support the use of ‘traditional neurological treatment approaches’ (Bobath).  In the same year as the Kollen paper, Langhorne et al reviewed physiotherapy treatments for motor recovery after stroke (Lancet Neurol 2009; 8: 741–54). They concluded that CIMT, EMG biofeedback, mental practice with motor imagery, and robotics improved recovery of arm function, while repetitive task training, biofeedback, and training improved transfers or balance, and physical fitness training, high-intensity therapy (usually physiotherapy), and repetitive task training improved walking speed. Bobath is referred to as ‘neurophysiological approaches’, the effects of the neurophysiological approaches on function were not significant and their effectiveness was termed ‘unknown’.

More recently, Pollack et al have published a major update for their 2007 Cochrane Review of rehabilitation approaches for ‘the lower limb’ after stroke. The original review found no differences between approaches and recommended that research (and practice) should focus on specific interventions rather than ‘approaches’. This updated review (in 2014,

http://www.cochrane.org/CD001920/STROKE_physical-rehabilitation-approaches-for-recovery-of-function-balance-and-walking-after-stroke ). Their main conclusion re ‘approaches’ is unchanged (ie don’t use them, use specific interventions that we know work instead). Importantly, they add that it appears a treatment dose of 30 and 60 minutes per day, five to seven days per week is needed. And that treatment in the acute/ sub-acute stage sis more effective than later after stroke. They state that “evidence indicates that physical rehabilitation should not be limited to compartmentalised, named approaches, but rather should comprise clearly defined, well-described, evidenced-based physical treatments, regardless of historical or philosophical origin”. So the advice is the same. STOP using ‘approaches’ and start using the interventions which we know work.

There is a good range of interventions with evidence of both efficacy and effectiveness now – use those: other Cochrane reviews have found that electromechanical gait, training, treadmill training, circuit training, physical fitness training, repetitive task training, CIMT, mirror therapy and FES are effective (http://onlinelibrary.wiley.com/cochranelibrary/search ).

So in conclusion, I return to one of the very 1st questions posed in this discussion, which has still not be addressed, let alone answered: why would a professional who uses evidence based practice continue to use an approach which is, at best, unproven, rather than specific interventions which have strong evidence of effectiveness?  The issue facing our professional is no longer which interventions should be used, but how they should/ could be implemented in to practice. Shifting towards exercise and intensive tasks-specific practice of functional tasks (the EB interventions) as the focus of our therapy provision involves a whole scale re-organization of how services are delivered (the oft mentioned paradigm shift) but the nettle needs to be firmly grasped.

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3 thoughts on “Does Bobath work?

  1. I have just posted this into the iCSP discussion but thought I would send it here too! I have just read your latest blog (amazing btw) and I have another question. Why do Senior therapists advocate or allow members of staff to attend courses that have NO EVIDENCE BASE? The cost to the NHS must be extraordinary.

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  2. A very good question Kelly! I know this doesn’t exactly give you an answer, but alternatives to Bobath courses have been discussed on the icsp thread so today’s blog is summary of the suggestions made.

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  3. Hi Sarah
    I am not sure this is now the right place to commend but I thought I’d try anyway.
    I participated in the icsp discussion in 2015, commenting that although I don’t classify myself as a Bobath therapist I still thought I had learned a lot in the Bobath courses. I signed off with ‘dutch and sensible’
    I have now moved back to the Netherlands and have recently completed a course in ‘haptonomic moving and handling’. It concentrates on making contact with the person you want/need to move (for transfers) and invite them to be an active participant. It was a great course, making you think again how you approach your patients. And this is where I found a great overlap with the handling skills I had learned in the Bobath courses and in years of practice afterwards. Make your patient an active participant, where needed with hands on facilitation and knowledge of normal movement, before you start all your evidence based exercise therapies.
    Haptonomic moving and handling is not evidence based but the results are great, even getting someone up from the floor without hurting your back or lifting. It is based on feeling so evidence is hard to come by.
    I now realise what I have been doing all those years with my CVA patients, getting great results with active therapies. Instead of working the Bobath way, I worked with the haptonomic principles and knowledge of normal movement, but the base for both ways was laid during Bobath courses. No regrets!

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