When should evidence change practice? Part 1 Change over time
The discussion on icsp kicked off in February (Yes really!) when RogerM posted a review by Novak et al who had undertaken a systematic review using the GRADE Methodology. GRADE is a well-respected method to pragmatically overview the state of evidence on a topic so that clinical practice can be informed. In Novak’s case, the aim was to identify which interventions had sufficient evidence of effectiveness to recommend (or to recommend they should not be used) for children with cerebral palsy. It demonstrates that task specific strength training, exercise, orthoses, casting, aquatic therapy, biofeedback, CIMT, treadmill and Botox are effective and should be used. And that Bobath (along with cranio-sacral therapy and some others) is not effective and should not be used.
The review concludes “Consequently, there are no circumstances where any of the aims of NDT/Bobath could not be achieved by a more effective treatment. Thus, on the grounds of wanting to do the best for children with CP, it is hard to rationalize a continued place for traditional NDT within clinical care”.
Not surprisingly that caused a bit of a stir and a Children Bobath tutor replied saying that “It is not in the interests of our clientele to allow one systematic review, the value of which has been significantly undermined, to undo many many years of hard work. As has been said often ‘the absence of evidence is not evidence of its absence’”.
However RogerM gave a historical perspective highlighting how over the last 10 years or so the evidence had moved from “no clear evidence” to prove, or disprove, Bobath to “there is evidence to recommend other specific interventions (such as exercise, task specific practice, Botox) ” and eventually, to the current situation where we can say that Bobath is not effective and recommend that iti should not be used.
“In 2001 Butler and Darrah concluded that there was no clear evidence that NDT/Bobath was superior to the alternatives. They called for more research and particularly research into alternatives to NDT. This is very much my point, we have come since 2001 when there was insufficient evidence to categorically recommend or disprove the efficacy of particular treatments; there has been much more research. The first stage of this was that some specific treatments to now be regarded as “proven” or recommended. In general this recommended list is similar regardless of who writes it ….[they all] recommend the following:- Task specific strength training and exercise, orthoses, aquatic therapy, biofeedback, CIMT, Intensive partial weight bearing treadmill. These are the things we should be doing] See the Cincinnati Children’s Hospital Best Evidence Statements which also provides very useful practical guidelines on how and when to use these interventions.
The important point is that NDT/Bobath is not recommended by any independent source…. More recently the level of evidence has increased and reviewers now feel that they can state that Bobath is ineffective. As far back as 2008 Webb concluded that “there was good quality evidence (level 1 and 2) that did not provide support for the effectiveness of NDT/Bobath”. Novaks conclusions are an extension of this, they may be disputed but they are part of a similar trend in stroke rehabilitation research.
I supported RogerM’s opinion saying:
As a profession we could go on for ever swapping references and arguing the toss. Obviously those who have invested much, gained elevated status and make their living from teaching and practicing NDT/Bobath are unlikely to be early adopters to change. But the inconvenient truth is that there is now a strong body of evidence that some specific interventions (such as Botox, exercise, intensive practice of functional tasks) are effective for neurological rehabilitation in adults and children, while there is a growing body of evidence that Bobath is not. At best one can say the evidence from trials of ‘the Bobath concept’ show it isn’t definitely worse than something else, but then it doesn’t show it is better either. However it is worth noting that for many of the trials demonstrating the effectiveness/ superiority of specific interventions over the control, Bobath based therapy was the ‘usual care’ delivered as the control intervention – so the specific interventions are better. So why would a professional practicing evidence based care choose to use something that might work but probably doesn’t rather than interventions that do? The challenge facing our profession isn’t which interventions to use, but how to change our practice to integrate the ones that have been shown to work in to everyday clinical life.