EBP and CPD. Alternatives to Bobath Courses

In early September a contributor on the icsp discussion asked what alternatives there were to ‘Doing a Bobath Course’? Here is a summary of the suggestions:

Contributor 1 suggested that Universities offer a variety of evidence based courses. Depending on where you are based, are available to NHS staff via LBR contracts. Nottingham and Oxford are two that I know off the top of my head.

Another contributor recommends Nottingham University’s 30 credit MSc level module in Movement Science in Stroke Rehab, which is part of a full neurorehab MSc, but you can complete it as a stand alone module. She says it was excellent. It was well run, evidence based and completely transferrable straight to clinical practice (including other neuro conditions). It was challenging to complete; the course days ran mostly at weekend, but you do have to do a presentation and MSc level essay. However, it had a huge influence on my clinical practice, my teaching of others and the outcomes for my rehab patients.

RogerM suggests looking at the Stroke-Specific Education Framework (SSEF) website (http://www.stroke-education.org.uk/). They have searchable courses and you can filter them to those relevant to physio. However, most of the courses are not exclusively focussed on physios (but maybe a good thing?). They also have a handy “job role profile” with the level of knowledge and skills needed for different physio staff bands. Another possible source of courses is Harrison education (http://www.harrisontraining.co.uk/) who do a course on how to do CIMT and other topics. I think there were also a couple of courses advertised in the last issue of Frontline

I posted that: I agree that there are evidence-based alternatives to Bobath courses. But it isn’t a matter of Bobath against motor relearning (although I have heard many good reports about the Motor relearning module at Uo Nottingham).   Several universities offer modules (if not whole masters programmes) in evidence-based neurological physiotherapy or rehabilitation.  Which, I assume, will look at the overall evidence for different types of interventions (with varying practical elements), rather than advocating and teaching a specific approach. Don’t be limited to looking in your locality – many CPD opportunities are offered by distance learning now-a-days so you don’t have to physically attend the Uni.  Also it isn’t always necessary to ‘go on a course’ to learn/ work out how to deliver EB interventions. Many researchers publish details of how to deliver the interventions they have been testing, so that they can be implemented into clinical practice – which is the whole point of the research in the 1st place!

A couple of examples: Janice Eng in Vancouver has developed excellent exercise programmes for people with stroke – for the upper limb (GRASP) and the lower limb (FAME) which can be delivered in hospital or community settings.  She and her team have completed gold-standard quality RCTs which has demonstrated their effectiveness. The manuals/ instructions about how to run the programmes are available from here http://neurorehab.med.ubc.ca/fame/  and here http://neurorehab.med.ubc.ca/grasp/ .  Also my team and I recently developed and tested a framework for the MDT use outcome measures in stroke rehabilitation and to structure MDT meetings. The details of how to apply that are available here https://www.escholar.manchester.ac.uk/uk-ac-man-scw:230101.

We have also recently published a RCT of patient-led therapy during in-patient stroke rehabilitation which contains sufficient detail to deliver the intervention and you can always contact me if you want more details. (NNR 2015; 29;9; 818-826)

Another place to look is in the original papers. Many (but not all, it has to be acknowledged) provide sufficient detail give sufficient detail to apply the interventions. The treadmill and electro-mechanical training and TENS trials are good examples. It is considered a matter of good research practice now-a-days to report the detail of the intervention and how it was applied. This is often impossible within the word limit of a scientific paper so authors make them available on their websites, in on-line supplementary material and/or by contacting them directly. So if you are interested in implementing an EB intervention and are not sure how to do it, then contact the authors.  It may be that the intervention then needs to be adapted to meet your local situation – that’s where the much discussed clinical experience and judgement comes in. There is an important debate to be had about how far these interventions can, and should, be ‘tweaked’ before they are no longer the intervention described. But that’s for another day….

Finally, manufacturers / providers of equipment such as FES, Saeboflex, treadmills etc, etc worth their salt will provide training in how to use them effectively. If they don’t, don’t buy them! It is only human nature that they will spin the evidence in the best possible light, so I’d read up on it independently before deciding whether to purchase. But they should be able to support you to use their stuff effectively and make those tricky pragmatic decisions about how to implement.



5 thoughts on “EBP and CPD. Alternatives to Bobath Courses

  1. Thanks again for your publication, very useful!!. In my opinion, one of the best things the Bobath courses have is the opportunity to practice with real patients during the course. This a good way to integrate the theory part into the practical part and to have the opportunity to discuss about the problems you can find practicing the theoretical assumptions. I think all the courses should have this, because we are practical professions, but many courses are done only sitting on a chair watching power point presentations or practicing between students, which is of course not the same than to practice with patients. It’s true that many of us will have the opportunity to practice when we come back to our works after the course, but then, if we find problems or we have doubts, we won’t have the teacher with us to explain where the problem comes from, to give us new ideas or variants.

    Liked by 1 person

  2. I agree, the ‘practical element’ is one of things that many folk value most about a Bobath course. As you say, the opportunity to integrate theory and practice, discuss it with fellow learners and get feedback from experts are all useful, and are known to make important contributions to skill acquisition. Whether all courses need this, and whether the format used in a Bobath course is the only way to gain this is debatable. The bit I really object to is the way the patients are treated. They are used as objects for attendees to practice on. I’m sure I won’t be the only one who has observed the tutors encouraging (nay, instructing) attendees to “have a play” with the patients. The patients are almost always required to undress as a matter of course (often unnecessarily), they are never given an explanation about what is being done to them, or why, let alone asked for their permission/ consent. I presume that the patients give some sort of consent before they take part but I wonder how much they have really given informed consent. Do they really know what will be done to them and have a choice about it? The whole process hardly fits with Bobath’s claims to be holistic and patient-centered.
    How else could it be done? Using videos (recorded or real time) (this is what they tend to use on movement science courses); skype, email, twitter, facebook or other online methods of discussion to get real-time feedback; case studies; reports of real-life patients; treatment records with objective measures (have you ever seen objective measures used in a Bobath demonstration?); ‘paper patients’; group discussion, and problem-solving. All of these can be used to provide the effective aspects of learning without using patients.
    As we have discussed in previous posts, it is very debatable whether what is practiced in Bobath actually has any effective connection with their theoretical ‘assumptions’. The teaching methods above are very effective (if delivered properly) to work out how to promote neuroplasticity, motor learning and understand the implications of the systems model of motor control, how to effectively manipulate task and environment, organise exercise, promote activity and task practice, understand and adapt treatment to patients’ needs and develop clinical reasoning without exploiting patients and using them as lumps of meat. The effective ways of delivering effective neurological physiotherapy needs a good working brain much more than handling skills.


  3. I read this post with interest, I’ve run a couple of courses looking at taking a movement science / hypothesis oriented approach to gait analysis in neurological patients (I did my MSc at Nottingham and agree with the praise for the movement science module) and have used patient videos instead of patient volunteers as I share your concerns about using “live” models. An additional concern that I’ve had from a few courses I’ve attended before is that the discussion how to manage the impairments observed in the patient volunteer runs the risk of creating unrealistic expectations for the volunteers – It may be positive for the course leader and delegates to throw around lots of treatment ideas in the knowledge that not all of these would necessarily be feasible, appropriate or effective for the specific patient but for the patient this may not be quite so clear. Using video allows discussion around the type of problems seen rather than the specific patient without running the risk of ignoring the patient or discussing them in what may seem an overly negative or unrealistically positive way. The other big benefit of video is that the patients don’t fatigue or get bored and you can analyse movement to your heart’s content!

    Generally course participants have appreciated being able to repeat the video multiple times and discuss amongst themselves without being conscious of the patient being present, however a fairly regular comment on the course evaluations is that it would be good to also have patient models on the course to apply what we’ve covered so there is undoubtedly a desire for this type of course setup. The next time I run the course I have been requested to include patient volunteers. I’m planning to take informed consent for what the patient is happy for us to observe and discuss in relation to them, and am only using the volunteers for assessment, keeping discussions around the findings and what potential treatment plans could be outside of the patient sessions. Your blog has reinforced those thoughts!

    I would also say that I think researchers could do much more to disseminate details of their interventions – it’s very easy to provide additional material in online appendices to articles now, and no reason why this couldn’t include video and other multimedia covering how the interventions were carried out.

    Enjoying all of the posts- it’s good to have strong and vocal advocates for evidence based neuro physio!

    Liked by 1 person

  4. Fridays post about how patient models are treated on Bobath courses has caused a bit of a stir! I can’t copy and paste the main reply because of the icsp copyright rules so I will have to attempt to summarise.

    An anonymous contributor posted, stating that Friday’s post was a lot of nonsense and she took exception to my comments, which bear absolutely no resemblance to what actually goes on. She hosts Bobath courses in her trust and they are a huge success with great learning achieved, great patient results, great skill acquisition. The patients give fully informed consent with information sheets, discussion with their normal therapist, and chosen NOK, consent is regained every single day verbally, to check the patients are entirely happy and they are free to withdraw at any time. Patients are NEVER undressed or exposed. She has never heard any tutor invite therapists to ‘play’ with a patient, certainly not….and at every stage during demonstrations full and clear explanations are given to the patient during the session. In fact any talking during the demonstration is done so politely and professionally, always including the patient and giving the patient a good understanding of what was going on at all times. So all that I have said is simply untrue. She asks why I am being so scathing and offensive with my dreadful claims, which she considers are possibly litigious. She is shocked about this ‘outburst’ and asks what my problem is. The courses are extremely professionally and therapeutically delivered.

    Here’s my reply

    Hello Anonymous PT Band7 and Mum
    There are two main issues in your post; how patients are treated on Bobath courses and a more general issue about professionalism, EBP and practice development. I’ll deal with the 1st one 1st, and the 2nd one later
    You are right, it is a good while since I was involved with Bobath courses, and it may well be that things have changed. I hope so. I’m glad you feel that the Bobath courses you run at your trust are a great success, I expect they are in many ways but…. Do you really know the patients are getting great results? Are they really able to do more in their everyday life than they could before? How do you know? When they gave informed consent was it really explained to them that they wouldn’t be getting extra treatment, but would be there for the tutors to demonstrate, and the attendees to practise the techniques they were learning, not to give the patient the treatment that would benefit them most? As RogerM points out, do they really know that the techniques practised on them aren’t ones that are known to be effective, but ones with (at best) very limited evidence that they would do them any good?
    Obviously I have no reason to doubt your view that in your world everything is absolutely fabulous. All I can say is that in my experience, it is not. You say that my observations and views have “no basis in any evidence”, which is surprising. It should be obvious by now that I don’t really do things without evidence. Let’s start with the Bobath book. If you look at the photos therein, you will notice that nearly all the patients are semi-dressed, with no good reason. The men are nearly all topless; there are photos of women with their underwear on show (p132, p160); photos with tutors touching intimate areas, presumably attempting to facilitate the pelvis and hips but do the patients really know that? (p109, p110, p134, p140, p142) In one set of photos the therapist has her hands up the patient’s shorts (p197,p198)!!. Is that really necessary and appropriate?
    Let’s have a look at the BBTA website. Granted, most of the photos in the gallery are of participants facilitating each other but there are a few of patients. There is one rather spectacular photo of a topless patient (male) with his trousers round his ankles. Presumably he did give full consent for identifiable photos of him in that undignified position to be put up on the web with anyone to have free access. All the ‘posters’ (students assignments from the basic courses, presumably the best ones) have photos of patients receiving their Bobath treatment. Two show patients who are normally dressed (proving it is possible to treat and assess while dressed), the others are semi-dressed to a greater or lesser degree. Less than half the students have ensured the patients are anonymised/ non-identifiable. Many are shown in undignified positions with their treating student touching them in places/ways that would not normally be acceptable. One poster involves a (fully identifiable) lady photo’d in a backless hospital gown, with incontinence pads in full view. So much for patients always coming 1st and never being undressed or exposed.
    Tbh, in years gone by I would probably have responded to my post with a similar degree of indignation to you. The scales fell away from my eyes when the trust I worked in hosted a Bobath course and some of my patients were dragooned in to attending as patient models. I was, of course, agog to see how they got on and what difference it made. Fear not, I was terribly professional and did not share my view s with them. The course coincided with my annual leave so I didn’t see my patients for a couple of weeks after the course ended. When I asked how they got on, they complained there was a lot of sitting around waiting, they got cold as they had little clothing on and they weren’t looked after. One spent so long waiting to ‘go in’ without being offered any refreshments he had a hypoglycaemic attack and had to be taken to A&E. They said “the lady” (the tutor) spent a lot of time talking about them to “the girls” (the attendees). Then “the girls had a go at them”. They didn’t really know what had been done to them. The most common replies were along the lines of “stretching me out” and “being massaged”. “Did it help? Are you able to do more now?” I asked. The replies were along the lines of ‘Not really’. A couple said they felt they had had a good “going-over” and “a stretch” and that “they felt looser for a few days but it was back to normal now”. Those who kept attending (several dropped out) felt that overall they didn’t regret taking part as ‘the girls’ meant well and tried hard, and “After all, they were only learning”.
    I hope that explains “what my problem is”. It is easy to both give and take unintended impressions from email correspondence and I am sorry if you consider my post a “scathing and offensive outburst” to be dismissed as “a lot of nonsense” without consideration. My observations are merely factually describing my experiences. If you find it offensive to hear views that differ from your own, uncomfortable truths and for experts to be held to able to justify themselves and expected to practice what they preach. Then the problem is with you.
    More on professionalism tomorrow


  5. Hi Ben
    I agree, researchers could do much more to disseminate details of their interventions – it’s very easy to provide additional material in online appendices to articles now, and no reason why this couldn’t include video and other multimedia covering how the interventions were carried out.
    The opportunity to add supplementary material to publications is a relatively new one, nad one that we could and should be using more. It’s not always as straight forward as it may seem as one has to consider the copyright limitations attached by the journal when one hands a paper over for publication. However, as I am discovering (!) there is much that can be done to make information about how to deliver interventions available now-a-days. I think expectations and outputs are changing, not least driven by the need to demonstrate impact. There’s a lot more that can be done but the possibilities are endless.


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