The Bobath Recommendation in the New UK Stroke Guidelines 2023

Hello again, it’s been a while. A lot has happened since my last blog post and I thought it might be time for an update. The big news is that the UK (and Ireland’s) Clinical Guidelines for Stroke have been updated, as many of you will know. I am the ACPIN and CSP representative on the Intercollegiate Working Group for Stroke which oversee the process and I led the motor recovery group. There are a lot of changes which will really make a difference to practice and ultimately to people with stroke’s recovery. Full details are here – National Clinical Guideline for Stroke (strokeguideline.org)

The new recommendation I wanted to highlight here is headline news is :

Therapy Approach: People with impaired upper limb movement, mobility or balance after stroke, should be offered exercise and repetitive task practice as the principal rehabilitation approach, in preference to other therapy approaches including Bobath.

Last week I presented “What’s New in the Stroke Guidelines 2023” to ACPIN (the UK special interest group for neuro physios) via an online webinar. People put questions or comments in the Chat and I tried to answer them all but we ran out of time. So I thought I would post answers to the questions and comments here. As you may have guessed, the Bobath recommendation caused quite a stir, so I’ll start there.  

This recommendation is based primarily (but not exclusively) on two recent systematic reviews with meta-analysis which compared the effectiveness of Bobath with other interventions. One covered the lower limb and the other, the upper limb impairments and activity limitations/disability/function. Both found that task-specific training was more effective than Bobath. Links to the papers are here.  

https://pubmed.ncbi.nlm.nih.gov/33069609/ https://pubmed.ncbi.nlm.nih.gov/36529640/

Both are high quality reviews led by the Stroke Ed Collaboration team and colleagues. Yes, I am one of the ‘et al’, am proud and honoured to be involved. The method follows gold standard guidelines for systematic reviews, including an independent statistician. They were published the Journal of Physiotherapy, which is the highest impact (ie most prestigious) physiotherapy journal; they only publish the good stuff.

Up until now, the evidence has been at the level where one is only able to say that no one approach is any better (or worse) than another. But now we know the task specific training is more effective than Bobath.  At the ACPIN presentation some people welcomed that news, while others said they were horrified and, as ever some looked for reasons to dismiss it.  

Here are the questions and comments that were posted in the Chat of the ACPIN webinar and my replies, which I didn’t have opportunity to give at the time.

1. Task-specific practice is part of Bobath

Comments /Question for the audience:

“But task specific practice is used within The Bobath Concept”.

“Doesn’t Bobath make task practice become more efficient, rather it being a separate entity?”

“I would be interested to know what they class as purely ‘bobath’ and what is ‘task practice’ as for me they are incorperated [sic] together.

So what is meant by “Bobath”?

Me: This quite a common ‘misconception’ of Bobath; people say it includes all sorts of things, especially when there is a suggestion we should use something instead of Bobath and there is evidence suggesting the other thing is effective. This is probably related to the uncertainty about what Bobath actually is. As you will know from previous posts, the Bobath tutors led by Dr Julie Vaughan-Graham have published many papers trying to answer this issue. There have been at least fourteen papers trying to work it out, including a systematic review: I reviewed this paper (and many of others by Dr VG et al ) in detail in a previous post https://sarahtphysioblog.wordpress.com/2020/03/24/contemporary-bobath-a-definition/ so I won’t go over old ground, but the tutors define Bobath as

“An inclusive, individualised, remediation focused problem-solving approach based on contemporary theories of motor control, neuromuscular plasticity and motor learning which aims to optimize activity and participation thereby improving quality of life”.

None of which distinguishes it from any other aspect of physiotherapy. All physiotherapy is inclusive, individualised, problem-solving, based on contemporary theories and focused on activity and QoL. As detailed in the previous posts, the only thing that is actually unique to Bobath is the use of facilitation.  

It’s good the tutors say Bobath focusses on activity and participation but after that they get forgotten. Later on the same paper they list the ‘key aspects of [Bobath] practice’ which are all about impairments (eg postural control, alignment, selective movement). No mention of activity or participation when it comes to actual practice. This is reiterated in a later publication, where the tutors presented a couple of case studies which are intended to illustrate how contemporary Bobath is delivered. Again, I have reviewed this paper in detail here:   https://sarahtphysioblog.wordpress.com/2020/05/04/case-studies-to-illustrate-how-bobath-is-applied/

In that paper, the tutors present two patients and describe the Bobath assessment and treatment plan. Both patients have activity and participation–related goals. So that’s good, but that is pretty much the last mention of activity or participation, or the goals. The assessment and treatment plan are all about the impairments – and a very narrow slice of motor impairments at that. There is no assessment of weakness; RoM; sensation; balance (other than saying it is ‘reduced’); reflex activity or co-ordination for example. There is nothing in the assessment about mobility or the upper limb function (ie the patients’ goals) and nothing in the treatment plan about the patient practicing activities or tasks.

Of course it’s difficult to get a clear idea of how a physical process is carried out from a written description, but there are a good few examples of the Bobath tutors delivering Bobath, and explaining how others should use it in practice on YouTube. Here are just a few examples from the BBTA

Activating the hand – YouTube

Taking a backward step – YouTube

Developing Scapula Stability; Asymmetrical Forward Lean sitting – YouTube

Strengthening Quadriceps for sit to walk transition – YouTube

While you are watching, count how many active movements the patient/demo person actually makes themselves, and how many repetitions the ‘patient’ makes of any activity or functional task. What do you see? By and large, the patients are sitting, lying, or, frankly strange positions while they are facilitated or mobilised. These are essentially passive movements or, at best active assisted. The number of active movements the patient makes is very low, and the repetitions of any activities are negligible. You would be generous to get the number of repetitions into double figures, but we know that people with neurological need to make tens of thousands (ie hundreds+ per day) to make long-term changes to their function.

So no, Bobath does not incorporate task-specific training/practice. 

2. Never mind the evidence, what about my experience?

Comments /Question for the audience: In my many years of clinical experience treating patients with principles of The Bobath Concept it is very effective. What about our clinical experience? 

Just because we can, does not mean we should. Is not our clinical experience and knowledge of any importance?

But that is just the studies, what about our clinical experience?

Those who have experienced the transformation in their practice from being on a Bobath course and seen the difference in their patients, I hope, will not be bamboozled into accepting these “studies” at face value

Me: This has come up before. Dr Vaughan-Graham and other Bobath tutors wrote a whole paper about how their ‘wisdom’/experience trumps theory and evidence and is the main basis of their clinical reasoning. I made a detailed review of the paper here. https://sarahtphysioblog.wordpress.com/2020/04/13/278/  so I won’t repeat all the whys and wherefores.  This was also discussed at length in the icsp discussions about Bobath which were the precursor for this blog.  A summary is here or you can find it be searching the neuro section of icsp for ‘Bobath. https://sarahtphysioblog.wordpress.com/2015/10/26/ebp-and-professionalism/ andhttps://sarahtphysioblog.wordpress.com/2015/10/27/individual-patients-assessment-expertise-and-the-bobath-concept/

The issue here isn’t really about Bobath, it is about one’s understanding of the Professional Code of Conduct. One element of which is to be aware of the evidence and to use it. Here are the relevant rules from the CSP  

4.4.1 Contribute to developing physiotherapy through building the evidence base of physiotherapy practice and implementing new evidence ….. 

4.4.4. Respond to developments in research and the evidence base that may raise questions about the safety or efficacy of specific elements of physiotherapy practice

4.4.5 Engage with developments in research and the evidence base that present new clinically and cost-effective ways to respond to individuals’ needs

So professional practice means implementing evidence. It is about recognising when the evidence shows our practice is no longer fit for purpose and needs to change. I do understand how difficult this is, especially when one has invested and gained much (particularly in terms of role and status) from the old practice; I’ve been there myself. But that is what professional practice is all about.

Is not our clinical experience and knowledge of any importance? Yes, of course it is. But the role of experience and clinical skill is to work out how to apply the evidence to meet individual patients’ needs, not to pick and choose which bits of evidence one wants to take any notice of.

3. Trashing the evidence

Comments /Question for the audience: I took apart these studies: unfortunately there is such a thing as “garbage in, garbage out” review/meta analysis. And each of these individual studies had a different (and sometimes hardly explained) set of therapy inputs. Very hard to tell what actually took place sometimes. A couple of very ancient studies. One where Bobath input ended up being as good as being put into a very expensive robotic gait trainer (the patient gains didn’t carry over for the 3 months afterwards but the results at the time were the same or better!)  So, once you have ignored the content of the studies themselves, in terms of quality, but then lumped their findings together in a neat “forest” then yes it looks like one thing is better or worse than another, but look a little closer and the whole foundation crumbles. Those who have experienced the transformation in their practice from being on a Bobath course and seen the difference in their patients, I hope, will not be bamboozled into accepting these “studies” at face value. Look closer and decide for yourself

Me:  Wow, I’ll take these points one at a time

• I took apart these studies: unfortunately there is such a thing as “garbage in, garbage out” review/meta analysis.
  • Me: a rather harsh verdict on several years of cutting edge clinical science using gold standard methodologies but everyone’s entitled to their opinion
• And each of these individual studies had a different (and sometimes hardly explained) set of therapy inputs
  • Me: well yes, they would. Given that physiotherapy input of any type is individualised to the patients’ abilities, needs and preferences and the local context then you would expect that. That is a positive, not a criticism.
• Very hard to tell what actually took place sometimes
  • Me: Agreed, it is an issue for all so called complex interventions which are individualised to people’s presentation and needs, and the local context, and where the interaction between patient and professional is a factor. However it isn’t a barrier to effectively conducting a trial to see if it worked.
• A couple of very ancient studies
  • Me: Ahh, the arrogance of youth! I’m of an age where I realise that just because something was done a while ago, it does not mean it was poor quality or the results are not relevant.
• One where Bobath input ended up being as good as being put into a very expensive robotic gait trainer (the patient gains didn’t carry over for the 3 months afterwards but the results at the time were the same or better!) 
  • Me: So, one study indicated the immediate effect of Bobath was ‘as good as’ (ie no different) or better than robotic gait training [Im not sure how the results could so that but I’ll let that go for now], but by three months the effect was lost. You forgot to mention the other 8 trials which did show task-specific training was more effective. I think you may not have fully understood how meta-analysis works; the data from all the trials are pooled (whatever the findings) to get an overall result. So in effect, the data suggesting Bobath may be no worse than task-specific training were outweighed by the data showing task specific training was more effective.    
• So, once you have ignored the content of the studies themselves, in terms of quality
  • Me: the reviews didn’t ignore the quality of the trials, it was assessed and reported using the Pedro scale. We also did sensitivity analyses as part of the statistical plan to check whether the trial quality influenced the outcome; it didn’t.
• But then lumped their findings together in a neat “forest”
  • Me: Another rather harsh description of a highly complex and sophisticated, scientifically robust analysis that required a senior academic biostatistician to complete, but hey ho. NB its Forrest plot, not forest. Named after the person who invented it, not the collection of trees
• then yes it looks like one thing is better or worse than another, but look a little closer and the whole foundation crumbles.
  • Me: On the contrary, however closely one looks, one finds a very thorough, methodologically robust piece of work which produces evidence at a level to change practice. Task-specific practice is more effective ie produces better results for our patients than Bobath. I understand this is difficult to hear for someone who is invested in Bobath, but why would anyone adhering to their professional code of practice to provide evidence-based care and to fully inform patients about the treatment offered, not provide the more effective care?

What next?

Over the years, many people have expressed their frustration about the lack of CPD and courses to learn more about how to actually use the evidence-base to deliver more effective neuro physio. That was why I started this blog, as I wanted to start a discussion about the evidence and how to use it (as the name suggests!) but somewhere along the way it got side-tracked by the Bobath thing. Now we know definitively that we should be using exercise and task-specific training, and not Bobath I want to focus more helping people deliver this. Also I have retired from academia so I have more freedom to do the teaching that is needed, rather than fulfilling the University’s priorities.

So I have set up a teaching platform to deliver that training. It’s called (rather grandly) the Evidence Based Rehabilitation Academy (EvBRA, www.evbra.podia.com ). Its tag line is ‘helping you to deliver evidence-based neurological rehabilitation’.  It’s all online, with courses (lectures and practical tasks) that you can complete whenever and wherever suits you. I can set up online interactive courses too if there is sufficient interest (just let me know if so).

So far there is a one day course on the main motor impairments (that’s weakness, spasticity and contractures), the evidence surrounding them and how to treat them, with an emphasis on the principles of exercise and how to prescribe it in neurological conditions. It’s called “Why people with neurological conditions have difficulty moving and what to do about it’ – not the snappiest title but it does what is says on the tin! Check it out here https://evbra.podia.com/why-people-with-neurological-conditions-have-difficulty-moving-and-what-to-do-about-it      

I’m just finishing a short (probably a couple of hours) session on the new stroke guidelines, where we can look at the recommendations, how to deliver them and what it means for physiotherapy in more detail. I’ll address the non-Bobath questions raised in the ACPIN presentation too.

Then it will be on to courses on motor relearning/ task-specific training, cardio-respiratory fitness training, running exercise groups and maximising the amount of therapy. All with an emphasis on the evidence and how it can/should be applied in everyday practice. Watch this space! If you have any requests for courses/ teaching sessions you would like to see, or questions/comments just drop me a line on evbra.sarah@gmail.com or DM me on twitter @evbra.