Individual patients, assessment, expertise and the Bobath Concept

I think we are approaching the point that we have all said as much as there is to say about the evidence for, or against Bobath. But there are couple of discussion points I wanted to share with the wider audience. Several contributors have alluded to the reason/ excuse (depending on your point of view) that one can’t use EB interventions or implement research findings is because their patients are individuals for whom one cannot generalise. Research findings shouldn’t be applied to them because their uniqueness means that an exploratory assessment process and novel treatment regime must be worked out for each one using clinical reasoning based on a hypothetico-deductive model.  Here is a couple of examples:

Contributor 1. “My patients aren’t research subjects but a complex, diverse population of people from a wide range of ages, backgrounds and diagnoses.…. The important thing is that every patient is an individual and no 2 patients will ever present in exactly the same way…..  Any research has to limit itself to looking at a very specific group of individuals which makes it hard to generalise results and conclusions to the greater population.

Contributor 2: When dealing with two human beings, even if they have the same condition, they respond to that condition in the context of their environment, culture, personal beliefs etc….So every time, we, as therapists come to treat a person we create a hypothesis that we think will work with that child, with that family.

I’ll come to the nature of the research designs used in tomorrow’s blog. But let’s consider the ‘unique patient’ angle. It is, of course, ‘Motherhood and Apple Pie’ to say that every individual is an individual, of course they are. Who could claim otherwise? And we aim to accommodate their needs and preferences within a treatment/ rehabilitation plan. But it is their personalities, social situation, life experiences and other medical history that impact on their individuality rather than their pathology, impairments, and to a lesser extent, activity limitations. Actually, if one thinks logically, the impairments and basic activity limitations caused by a pathological process (the stroke or CP, etc) are pretty stereotyped. For example, hemiplegic gait is hemiplegic gait. There is a very broad range to the severity of impairments that limit mobility, but they are just a spectrum. The underlying mechanisms causing the problems are the same.

Like much of physiotherapy, Bobath assessment is based on hypothetico-deductive reasoning (it says in the book). That is, the notion that one’s assessment aims to produce  a hypothesis about the cause of each individual  patient’s problems and how to fix them. Then one tests out the hypothesis during on-going assessment and treatment. This is based on the work of Schon (reflective practice) and Kolb (learning circles) and it is the way that novices work. You can see students using it; they laboriously work everything out from scratch, are clumsy, don’t ask questions in an effective way, repetitive themselves, do unnecessary, irrelevant stuff, go up blind alleys, get it wrong etc. That’s why they make obvious mistakes; because it isn’t obviously a mistake to them. This isn’t how experts work. Experts use mastery in action (AKA mastery in practice, or pattern recognition). This is when one is able to use experience, knowledge and skills to recognise problems that one has seen and successfully treated before, understand the underlying mechanism/ cause and implement successful treatment without further ado. See Schon’s original literature on reflective practice for further details. At the risk of sounding totally geeky, it is a good read. One should only need to use hypothesis driven decision-making if dealing with a particularly complex or unusual situation which one has not come across before. Even then, one should be able to use experience to work quickly and effectively through the ‘knowns’ to get to the ‘unknowns’.

The ability to use specialist knowledge and experience to make skilled judgements is one of the hallmarks of a professional, and of an expert. So why is Bobath focussing on using hypothetico-deductive reasoning and pushing their practitioners to continue to work as novices? Many BB advocates have espoused the expert assessment skills achieved from attending the BB courses and using the Concept. But this is an non-sequitur, if one is doing a BB assessment as intended one is acting as a novice. Surely if the BB courses are to develop expertise , then practitioners should taught be to develop pattern recognition skills and knowledge. The problem may be that to do that, one has to be able to clearly articulate (and justify) what the patterns are, and what to do about them, which BB practitioners seem unable to do.  Weird.

It isn’t as if there aren’t any patterns to be recognised. For example, if someone comes to see me with hemiplegic gait, I know that the primary underlying impairment is weakness, particularly isometric strength of the hip extensors and abductors during stance phase; concentric strength of the hip flexors, plantar flexors during push off phase of swing, and the dorsiflexors during late swing and heel strike. Shortening or tightness of the hip flexors, hamstrings and plantar flexors may well be limiting range of movement. Sensory impairments and spasticity may contribute to limitations (in those that have them) but are rarely the limiting factors. I often recognise the nature and cause of their problems as they come in to the clinic  (I do some private work). The assessment is to confirm that (or otherwise). I will, of course, assess them to ascertain the extent of their impairments and limitations, how it impacts on their daily life, and their goals for treatment.  But I won’t be working out what on earth the problem might be as I go. Hypothesis driven reasoning only kicks in if the findings of the assessment don’t match the expectation. And then only about the bits that didn’t fit with the explanation – the ‘unkowns’.

Having completed the assessment, I know that most effective, evidence-based way to treat hemiplegic gait is with walking aids/ AFO/FES; exercise and task specific practice (circuit training or strength training with a treadmill or electro-mechanical gait trainer, depending on level of severity). I also know that there will also probably need to be some locality based training in their own home/ community to build confidence, motor skill and know-how (routes, where the loos are, what support is available etc) within their own environment and to encourage social networks. As mentioned before, the skill of an expert isn’t having magically clever handling skills, the expertise is in knowing how to apply and adapt evidence based treatment and local knowledge as appropriate for patients’ level of ability and personal circumstances. That’s the unique bit.

Can a BB practitioner summarise what they do, how and why in this manner? They should be able to if they are an expert. It does the credibility of any branch of physiotherapy a great injustice to suggest that a hypothesis driven approach is needed every time. To anyone with a cynical turn of mind, it would appear that we don’t know what we are doing and are making it up as we go along.

 

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