Thoughts on the BBTA’s thoughts

The BBTA (British adult Bobath tutors) have posted another clarification of the Bobath Context on their website. In keeping with this blog, I thought I’d give my thoughts from an EBP perspective. I suspect I’d infringe the copyright and get my knuckles wrapped it I copy and pasted the BBTA post here so I’ll summarise it as I have with the icsp posts. But you can find the whole thing in its entirety here http://www.bbta.org.uk/news/bobath-concept-clarifications-and-context.

The BBTA bits are in plain text and my bits are in italics

The BBTA posts starts off by saying that they wish to respond to “continued inaccuracies on social media regarding the Bobath Concept and to reinforce and clarify some important points”

They refer us to the two scoping reviews by Vaughan-Graham et al, and explain who the BBTA are and what they do. We have discussed at length in previous blogs (see ‘What is Bobath?; How to do Bobath? Part 2 A big Misunderstanding; Part 4. Motor learning and neuroplasticity; Part 5. The Facilitation Thing; Part 6 Compensation, motor control and muscle activity). https://sarahtphysioblog.wordpress.com/2015/10/13/what-is-bobath/

https://sarahtphysioblog.wordpress.com/2015/10/13/how-to-do-bobath /

https://sarahtphysioblog.wordpress.com/2015/10/21/does-bobath-work/

 The next section of the BBTA post is called ”Discussion and debate” and they complain about recent postings on Twitter that they find disrespectful and unprofessional. And they bring to our attention the newly updated HCPC standards (#2.7 to be exact) which says that social media should be used appropriately and responsibly.

Readers of the evidence based neuro physio blog and preceding icsp discussions will know that it is nothing new in being accused of being unprofessional when expressing views with which others disagree and makes them uncomfortable https://sarahtphysioblog.wordpress.com/2015/10/26/ebp-and-professionalism/). Then, as now, I invite the BBTA to explain what they find unprofessional, I am would be quite happy to apologise and retract whatever is unprofessional, if my actions can be shown to be so. I’ve never had a response over the years and I don’t expect I’ll get one now. Because

  • it is not unprofessional or disrespectful to have a view that differs from yours
  • it is not unprofessional t or disrespectful o express that view
  • it is not unprofessional or disrespectful o question the status quo
  • it is not unprofessional or disrespectful to objectively and critically examine physiotherapy practice and highlight short-comings where they exist
  • it is not unprofessional or disrespectful to make suggestions about how physiotherapy could or should progress
  • it is not unprofessional or disrespectful expect others, especially others who claim to have particular expertise, to be justify the claims that promote (and sell).

 

It IS unprofessional to continue to use interventions that have been superseded by effective ones, however sincerely one believes/feels/‘sees’’ or has a gut instinct that it is a good thing and they like doing it.

As has been noted before in these discussions, it probably human nature to hit out at those who do not support what an individual holds dear and it is challenging to acknowledge that practice is no longer fit for purpose and needs to change, especially when one has invested and gained much from the old practice. But that is what professional practice is all about. I think that all too often folk are unable to distinguish between a disagreement and an argument. It should be perfectly possible for adult professionals to undertake the former without the latter. It is not a personal criticism or affront to an individual for someone to express different views.

The BBTA goes on to say that they welcome considered questions and discussion but that this should be well informed, factual, clear, concise and professional. And that BBTA members would not comment on research studies unless they were well informed about the research study.

A wise approach, it would be all too easy to trip up if one does not really know what one is talking about and ending up looking a bit of a Charlie. Luckily I do know a lot about Bobath, and am in a position to comment. As highlighted previously, I am a fully Bobath trained, former aspiring BB tutor and have been researching the Concept and testing its underlying beliefs for ~25 years. My comments are always based on the most contemporary literature (cf the Vaughan-Graham and other papers from BB tutors in the last few years; the BBTA’s Bobath Concept book and the BBTA website) and backed up with factual detail. Interestingly I have published more papers on the subject than the BBTA members put together so I’m as qualified as anyone to comment.

The BBTA would do well to take their own advice and include specific, concise examples and detailed facts in their writing. It does do a great deal to enhance credibility. So what is it they find unprofessional or disrespectful? What are the continued inaccuracies, misconceptions and contradictory comments? Come on BBTA, put up or shut up

In the next section of the post BBTA seek to identify the key elements of the Bobath Concept which, essentially, repeats their previous posts to clarify aspects of the Bobath Concept. I refer you to the previous blog posts that have covered these issues ‘What is Bobath? and ‘How to do Bobath? (Parts 1-6!)’ and ‘Does Bobath work’? https://sarahtphysioblog.wordpress.com/2015/10/13/what-is-bobath/

https://sarahtphysioblog.wordpress.com/2015/10/13/how-to-do-bobath /

https://sarahtphysioblog.wordpress.com/2015/10/21/does-bobath-work/

They also raise some issues about the new points about the research ….. They say that BB is an individualised response-based treatment approach. It is not a compilation of exercises that can be universally applied to a group of clients, which they feel explains the “difficulty investigating the Bobath concept using traditional experimental designs such as the Randomised Controlled Trial”.

We’ve done the whole individualisation thing before (https://sarahtphysioblog.wordpress.com/2015/10/27/individual-patients-assessment-expertise-and-the-bobath-concept/ ) so I won’t repeat it here. The fact that Bobath is individualised is no barrier to using a RCT design to evaluate it efficacy and effectiveness. All complex interventions are individualised and many RCTs of them have been successfully completed. RCTs are not an inappropriate design to evaluate BB, it is just haven’t given the results the BB tutors want.

Then they point out that BB is often the conventional treatment/ usual care/ control provided in a trial, as BB is the most commonly used treatment approach in neuro-rehabilitation. They feel that BB hasn’t been subjected to the same scrutiny as the experimental group. Thus they “question whether BB has been investigated or has it just been compared to an experimental group”?

Hoorah, something we agree on! Indeed, Bobath is the most common used treatment approach at present (but that doesn’t make it right) and, yes, BB is often the conventional or usual treatment to which new interventions are compared. Nothing wrong with that. It is needed to see if the new treatment is likely to be an improvement over the status quo and thus whether one should change practice. A wide range of interventions have been tested in this way and found to be superior to BB. But it is incorrect to say that BB (ie the control intervention) has less scrutiny that the intervention arm. It is a fundamental element of trail design quality that both arms undergo the same testing and evaluation regime. Trial is unlikely to be funded, published in good journals or included systematic reviews if they did not.

They go on to quote Vaughan-Graham et al (2015b) who conclude that RCT designs [testing BB] have “serious methodological flaws regarding treatment fidelity and measurement” and that “Aspects such as theoretical framework, therapist skill, quality of movement measurement and individualized interventions require careful consideration in the design of Bobath studies”. From this they opine that the results of many studies should be treated with caution and recommend that future studies improve fidelity and effectiveness.

As is so often the case in statements from Bobath tutors, there is insufficient detail to clearly understand the point being made, or to justify/ support it. There is no detail about the methodological flaws to which they refer. They do list some relatively minor methodological issues but do not identify the papers to which they refer, nor explain what the flaws are, nor the effect on the robustness of the results.

In a previous blog post I have explained about different types of bias and how evaluations need to negate these sources of bias https://sarahtphysioblog.wordpress.com/2015/11/02/when-should-evidence-change-practice-part-3-levels-of-evidence/ The main sources of bias are randomization; having a control; blinded allocation and assessment; use of effective outcome measures. Not the issues listed by the BBTA (theoretical framework, therapist skill, quality of movement measurement). These are more a matter of the detail in the reporting. The detail one can include in a journal article is constrained by a pretty stringent word count limit. However with the advent of open access and e-publishing it is now possible to add this detail in supplementary materials (if the editor allows it), and reporting is becoming much more detailed.

With regard to the lack of detail about the theoretical framework of Bobath or having skilled therapists delivering it, the Bobath tutors might reasonably be expected to look inwards. After all, they are the ones providing the framework and training the therapists. It is their shortcoming if it isn’t clear what Bobath is, how it should be delivered, or if the therapists cannot deliver it properly.  

The only issue that could be potentially serious is the use of robust outcome measures. Obviously, one has to measure the right thing to show an effect! They state that the outcome of choice to show that BB works is quality of movement. The only problem is that when the BBTA worked with Sheila Lennon to test the effect of Bobath on movement quality in gait, they found that BB treatment had no effect on movement quality (see ref below). Furthermore, movement quality is a curious choice of primary outcome as previous statements about Bobath have asserted that the aim of BB is to improve function (details in https://sarahtphysioblog.wordpress.com/2015/10/13/how-to-do-bobath-2/).

The BBTA then refers to some recent studies. So let’s have a look at those papers (references at the end.

1st off, they bring up a small (n=24, 12 in each group) RCT comparing CIMT and BB (Huseyinsinoglu et al 2012). They quote part of the conclusion in the abstract that says “CIMT and the Bobath Concept have similar efficiencies in improving functional ability, speed and quality of movement in the paretic arm among stroke patients with a high level of function”. But they miss out the next sentence that says “CIMT seems to be slightly more efficient than the Bobath Concept in improving the amount and quality of affected arm use”. Ooopsy.

They also point out that the CIMT group received more therapy (3hrs per day) than the BB group just received 1 hour, speculating that the outcome would have been different if BB had been delivered in the intensity. Possibly. But then BB is never delivered for 3 hours per day, is it? The main defining feature of CIMT is the intensity of task practice (which is probably the ‘active ingredient’). In contrast, Bobath features low intensity non-task related practice. So if comparing dose matched interventions one would not be testing ‘real Bobath’.

Next up is Brock et al (2011) – a small (n=24) pilot trial. The groups received 6 x1 hour treatment sessions over two weeks (so dose matched) of either BB plus ‘structured task practice’ OR ‘structured task practice’ alone. So they weren’t examining BB on its own; they were testing BB + structured practice. Gait was measured before and after treatment, so only the immediate effects of treatment were examined, not whether any benefits continued into the long-term. They measured gait speed, endurance and balance and found that both groups improved. There were no differences between the groups in the change in endurance or balance, and greater improvement in gait speed in the group who received BB+ structured practice than those who received structured practice alone.  

The BBTA then copy the part of the conclusion that says “In patients with moderate to severe stroke, who are able to walk with supervision, interventions based on the Bobath concept, in conjunction with task practice, may be more beneficial than structured task practice alone for improving gait velocity” and ask whether it a combination of treatment approaches is more effective than any one approach alone. No, is the answer. One very small pilot study has shown a positive result in 1/3 outcomes. That is no reason to do anything other than a properly powered trial with measures of immediate and long-term effect.

They also suggest that perhaps consideration should be given to factorial designs to determine rehabilitation effectiveness. Yes, it is a possibility. A factorial design is rather nifty. It essentially tests whether combinations of interventions work alone or in combination. So it would be a suitable design to test whether BB plus something else worked, and worked any better than BB alone. But why would one want to do that (or more pertinently, why would someone fund it)? There is good evidence that exercise and task specific practice are effective, and more effective than BB, why would anyone want to spend their money on testing a combination? Just do the ones that work.  

In the next section The BBTA talk about trunk restraint in relation to BB and compensation. They mention a trial by Michaelsen et al (2006) which showed better outcomes in terms of UL function when training happened while the trunk was restrained, than when it was not (nothing about BB). They also refer to a systematic review of trunk restraint by Seng Kwee et al (2014) which found that trunk restraint moderately reduced upper extremity impairment in chronic strokes, but there wasn’t enough evidence to draw a conclusion about the impact on function. They directly quote snippets of the text. As neither paper is about BB and I’m struggling to understand how they contribute to the point the BBTA are making (or indeed what the point is). I think the BBTA have reinterpreted the finding that trunk restraint reduces impairment to say that the trunk restraint prevents ‘compensation’ (which it does in the trunk, but not the upper limb) and are extrapolating this to justify BB’s aim to prevent movement they consider to be ‘compensation’. Which it doesn’t, of course. The papers are nothing to do with BB.

The BBTA then pose a rhetorical question: “To optimise upper limb recovery should the trunk be restrained? Or, alternatively perhaps consideration should be given to the rehabilitation of the trunk to improve necessary dynamic stability for functional recovery of the upper limb”.

Yes probably, to the former (although the endorsement would be much stronger if a positive effect on function was reported). No to the latter. The papers provide no evidence what so ever to support “rehabilitation of the trunk to improve necessary dynamic stability for functional recovery of the upper limb”. There is no rationale to support its consideration.

The final aspect of this section of the BBTA post refers to some CIMT trials which showed that the functional gains seen in CIMT are produced by patients using compensatory strategies (strengthening the evidence that compensatory strategies are good thing, they enable people to function). Plus a couple of studies that have combined trunk restraint with CIMT and showed improved impairments, movement patterns and function. Unfortunately, the BBTA get in a bit of a tangle, and have misquoted the papers, saying that they show worsened outcomes. They don’t. They show improved function by using compensatory movement. Ooopsy, again.  

Then they use this mis-interpretation to suggest that “this could be one of the reasons impacting on results leading to a much more cautious Cochrane Review (2015) on ‘Constraint Induced Movement Therapy’ (CIMT)”.

No. It isnt. The updated review finds evidence of a beneficial effect on impairment and function but limited evidence of an effect disability in every-day life, which was not the focus on the previous review. Essentially, the bar has been raised. This review is in contrast to another published by Gert Kwakeel (a name I am sure you all know) and colleagues in 2015 which showed that “….CIMT is beneficial for motor function, arm–hand activities, and self-reported arm–hand function in daily life both immediately after treatment and at long-term follow-up. The type of CIMT, timing, or intensity of practice do not seem to affect patient outcomes”. Pay your money and take your choice

And finally we arrive at the BBTAs “Last thoughts…” which are that “It is time for rehabilitation research to move beyond the RCT and acknowledge the many other forms of evidence that are available” This is because RCT only provide “generalised evidence, whereas the clinician is providing intervention for a specific individual”.

We’ve been here before with the individualisation thing (see above) and the value of trials thing (https://sarahtphysioblog.wordpress.com/ parts 3 and 4). There are, indeed, many types of research design other than RCTs to answer important questions (which is why I am a mixed methods researcher). BUT a RCT is the only way to tell whether a treatment is effective, or not. The skill of the professional is to apply the appropriately evidence for individual patients, not to reject the evidence and the methods used when it produced inconvenient truths. RCTs tells you what to do, clinical reasoning is about how you do it for each individual

The BBTA finish by saying that they encourage informed and respectful dialogue and invite comments. So I’ve emailed this to them to put up on their website. Let’s see if they do.

 

References:

Seng Kwee Wee 2014 Trunk Restraint to Promote Upper Extremity Recovery in Stroke Patients: A Systematic Review and Meta-Analysis Neurorehabilitation and Neural Repair1–18

Huseyinsinoglu BE 2012 Bobath Concept versus constraint-induced movement therapy to improve arm functional recovery in stroke patients: a randomized controlled trial. Clin Rehabil. 2012 Aug; 26(8):705-15. doi: 10.1177/0269215511431903. Epub 2012 Jan 18.

Brock 2011 Does physiotherapy based on the Bobath concept, in conjunction with a task practice, achieve greater improvement in walking ability in people with stroke compared to physiotherapy focused on structured task practice alone? A pilot randomized controlled trial Clinical Rehabilitation 25(10) 903–912

Vaughan-Graham et al (2015a) The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part I: conceptual perspectives Disability & Rehabilitation, 37:20 p.1793-1807 DOI: 10.3109/09638288.2014.985802

Vaughan- Graham et al (2015b) The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part II: intervention studies perspectives. Disability & Rehabilitation, 37:21 p.1909-1928 DOI: 10.3109/09638288.2014.987880

Lennon et al. “Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke.” Disability and rehabilitation 28.13-14 (2006): 873-881.

Michaelsen et al 2006. Task-specific training with trunk restraint on arm recovery in stroke randomized control trial. Stroke, 37(1), pp.186-192.

Woodbury et al. Effects of trunk restraint combined with intensive task practice on poststroke upper extremity reach and function: a pilot study. Neurorehabil Neural Repair. 2009;23:78-91.

Wu et al. Constraintinduced therapy with trunk restraint for improving functional outcomes and trunk-arm control after stroke: a randomized controlled trial. Phys Ther. 2012;92:483-492.

Wu et al. Pilot trial of distributed constraint-induced therapy with trunk restraint to improve poststroke reach to grasp and trunk kinematics. Neurorehabil Neural Repair. 2012;26:247-255.

Kitago et al. Improvement after constraint- induced movement therapy: recovery of normal motor control or task-specific compensation? Neurorehabil Neural Repair. 2013;27:99-109.

Massie et al. The effects of constraint-induced therapy on kinematic outcomes and compensatory movement patterns: an exploratory study. Arch Phys Med Rehabil. 2009;90:571-579

Corbetta et al. “Constraint‐induced movement therapy for upper extremities in people with stroke.” status and date: New search for studies and content updated (conclusions changed), published in 10 (2015).

Kwakkel et al. “Constraint-induced movement therapy after stroke.” The Lancet Neurology 14.2 (2015): 224-234.

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