Case studies to illustrate how Bobath is applied.

So, here we have the last review of the series of papers about Contemporary Bobath. As you can see from the title, the paper aims to illustrate how Bobath is practiced (which the authors are now rather grandly referring to as the Model of Bobath Clinical Practice or MBCP) using two case studies.

Michielsen M, Vaughan-Graham J, Holland A, Magri A & Suzuki M (2019) The Bobath concept – a model to illustrate clinical practice, Disability and Rehabilitation, 41:17, 2080-2092, DOI: 10.1080/09638288.2017.1417496

here is the link to the paper Case studies of how Bobath is applied

The introduction summarises what Bobath is about. It repeats the content of the papers I have reviewed previously so I won’t go through it all again. Throughout this commentary I’ve added my thoughts in italics.

The introduction explains how the MBCP came about. It was produced by the Education Committee of the International Bobath Instructors Training Association (IBITA) and the resulting model was endorsed by the AGM of IBITA.

Then two clinical cases are presented to illustrate how Bobath is applied.

Case 1 is 58-year-old man with an incomplete C6/7 spinal cord injury (we don’t know how long ago) which is noted to cause spastic paraparesis with truncal weakness and bladder and bowel dysfunction.

The assessment presents social history as ‘personal factors’ and environmental factors’ . The patient is right-handed; works as a freelance mechanic; enjoys archery; lives with wife and adult son; is independent in all ADL “although walking is effortful and restricted”. No details of walking aids or other assistive devices or in what way the walking is restricted. Nor is there any information about housing/living conditions; extended ADL; driving; work needs – ie activity or participation. Also no details of ‘other medical history’. One might assume that he doesn’t have any but it should at least be noted.

Patients’ Goals are to walk longer distances, over uneven terrains, with less effort; reduce back and knee pain; participate in outdoor archery

Physical Assessment

This starts with a list of Tasks/movement assessed: Quiet stance; walking, stand-to-sit and Sit-to-Stand; reaching in standing

Then a section on Facilitation. There is a list of the movements and ‘alignments’ that have been facilitated during the assessment. There is nothing about why these movements were facilitated or what affect the facilitation is thought ot have. There is mention of strengthening the musculature and ‘creating’ movement, as well as a lot of very dense jargon where it is really difficult to what it meant.  So it may be that they believe that facilitating these movements during the assessment is sufficient to increase strength nad motor skill.

• Handling to realign lower limbs prior to facilitation of stand to sit
• Facilitation of selective trunk extension (multifidus and transversus abdominus) in sitting with upper limbs placed with light touch support, prior to the postural transition from sit to supine [There is a lot of empty wordage and jargon here – “postural transition from sit to supine” is that lying down, then??]
• In supine, selective strengthening lower limb musculature and core.
• Creation of crook lying [what the heck is ‘creation of crook lying’?] with distal facilitation (foot)
• Facilitation of supine to side lying for further strengthening of lower limb musculature. Supine to side lying means rolling, doesn’t it? Really?? You think practicing rolling strengthens the lower limbs in someone who can walk?
• Supine and side lying were also used to “activate and develop selective synchronous activation of the lower limbs and core musculature”. What on earth does this mean? Any one gonna try to explain what “activate and develop selective synchronous activation” means? It’s beyond me
• Facilitation back into standing and stepping.

A strange list of positions are used  (STS; sitting with UL support; supine; crook lying; side lying; standing, stepping). I can understand standing and stepping (although presumably single leg stance should be in there given that the only reported findings are for SLS). But given the patient wants to improve walking endurance and outdoor mobility, why are they faffing about in lying? No assessment of walking impairments or activity over than limited weight transfer in SLS.

Then the outcome of the Functional movement analysis is presented. There are no data or information about how these conclusions have been drawn eg – no objective measures; no actual data, no assessment of impairments or activity levels. Given the history of incomplete spinal cord injury, one would expect an assessment of

• each myotome and dermatone – ie strength and sensation/ proprioception/ temperature
• reflexes/ spasticity. As the patient was introduced as having a spastic paraparesis, it is important to know which muscles are spastic, how much and how much it affects function
• autonomic symptoms
• passive range of movement (active range of movement is a function of strength) at all joints
• pain (note the goal to reduce back and knee pain).

There is also no assessment of

• Walking or functional mobility (note, the goal to improve walking endurance/distances and outdoor mobility)
• upper limb impairments or function (note the C6/7 injury and goal to do archery)
• Given that the Bobath tutors claim to improve patients’ perception, then one would expect this to be assessed too .

It appears that the Bobath assessment merely involves observation and (presumably) feeling during facilitation while the patient does the tasks listed and then come up with what they think is the problem. Perhaps this is what the Bobath tutors mean when they talking phronesis (see early reviews). Ie the primacy they give to experience over evidence. Perhaps, they feel this justifies the lack of data, or reference to any evidence. They just present what they know/belief to be the issue(s). Wherever they came upon them, the things that the authors consider important are referred to as ‘critical clues’ and listed as:

• Reduced range of pelvic movement and weakness of the extensor multikinematic chain [whatever that is!] impacts on single leg stance, which affects both walking and reaching [no detail on how it impacts]. Given the diagnosis I expect all muscle groups below the injury level would be weak. The key issue is how weak!
• The preserved sensibility/proprioception [how do they know sensibility and proprioception are ‘preserved’ if they haven’t assessed it?] enables independent qualitative practice [what does qualitative practice mean?].
• The activated hand offers information through light touch in relation to postural control [What does this mean? It might just mean that the patient has better balance if he holds on, but god knows what “an activated hand” is].
• Postural Control: Stiffness and weakness limit the selective movement of the pelvis [hips and lumbar spine] for an adequate transfer of the Centre Of Mass above the Base Of Support and prevents appropriate anticipatory postural adjustments of the trunk and lower limbs for feed forward postural control [I think this just means that forward weight transfer in step standing is limited by hip weakness and possibly stiffness – yah that at least is something that I could get my head around and agree with!].
• Selective movement sequences: Inefficiency of single leg stance in gait limits contralateral swing limb advancement and reaching activity in standing. As you don’t usually use single leg stance in reaching, I’m not sure how they come to the conclusion that it is ‘inefficiencies of SLS while walking’ that limits forward reach (ie dynamic standing balance). More likely the weakness (of all muscle groups below the injury level) +/- proprioception limitations and changes in reflex activity limit standing balance, reaching and walking

There are no findings from the assessment of Quiet stance; walking. stand-to-Sit and Sit-to-Stand; reaching in standing which were listed as the ‘tasks assessed’. The findings/critical clues just talk about single leg stance.

The Critical cues from the facilitation assessment are also presented.

• Manual facilitation is essential for hip and pelvic biomechanical components, in order to reduce stiffness and to activate core musculature in a more selective way. This is just a statement of belief. It isn’t related to the patient. It also highlights one of the key things about Bobath that makes little sense and is never explained. How do the Bobath experts think/propose that moving someone around in a passive (or possible active assisted) way (ie facilitating) will ‘activate muscles’ (whatever that means)? Let alone how it will improve strength/weakness (a limiting impairment here) when we know that repetition, specificity, and challenge/ overload are needed to increase strength.
• Verbal Facilitation: Understands verbal commands and translates these into appropriate motor behaviour. Doesn’t this just mean the patient follows instruction?
• Environmental Facilitation: The environment is used to offer light touch as a balance aid and reduces the need for compensatory strategies. In all references to ‘environmental cues’ the authors only mention this thing about light touch being a balance aid. As far as I can tell it just means that holding on to, or leaning on something means the patient can balance better- who knew?

Then there is the ‘Movement diagnosis’: Perhaps this is meant to be the findings from the assessments ie what they think is the problem. It’s hard to tell as there is no link between the assessments (the tasks, movement analysis and facilitation listed above) or any actual data to see what is limited/normal/abnormal. Anyway, however it happened, the therapist/authors decided their diagnosis was    

• Limited pelvic tilt, lower limb malalignment and extensor weakness impacts on antigravity competence that is crucial for functional walking. Wtf is antigravity competence? Is it being upright? Clearly the patient is competent at ‘antigravity’ as he is able to stand up and walk!
• The absence of an efficient single leg stance limits stance stability and progression through stance and contralateral swing limb advancement. Hmm, as the patient can already walk, it is inaccurate to say that single leg stance is absent (although it is probably impaired of course). I would imagine the ‘inefficient SLS’ is due to weakness of the hip abductors and extensors so that there is increased hip flexion and adduction during single stance. I would also need to check out the range of hip flexors and plantarflexors which may be tight and limiting hip extension and dorsiflexion in late stance. Also need to assess reflex activity of the plantarflexors which may well be spastic and preventing plantarflexion in late stance phase. Progression of the swing leg may be due to ‘inefficient’ SLS of the other leg but may also be due to weak hip flexors and plantarflexors and dorsiflexors which limit population and toe clearance.
• Back and right knee pain related to mal-alignment of the lower right limb (not that pain has been assessed at all).

Then comes the Working hypothesis/plan

• Increasing range of pelvic tilt to facilitate core and anticipatory postural adjustments of the trunk. Hmm, It looks like the authors are hypothesising that being able to tilt the pelvic more will improve anticipatory postural adjustments (ie balance reactions). Which doesn’t really ring true, does it? I don’t really understand what ‘facilitating the core’ is, or how being able to tilt one’s pelvis would help. But I do know that someone with this diagnosis would need to increase strength of the lower limb, plus RoM and reflex activity (if necessary) and practice balance reactions in standing and walking in a safe environment to improve his balance and mobility.
• Scapula setting as a part of core training to reduce neck and shoulder over-activity. Eh up, where has this come from? No previous assessment/ report of scapular (setting or otherwise); and no Ax/reports of neck and shoulder over-activity (or anything other aspect of the neck and shoulder).
• Improving lower limb alignment and strength as well as foot and calf activation will enhance ground reaction forces and propulsion. That’s true. Not that ‘foot and calf activation’ (whatever that is) has appeared previously as an abnormality in the assessment or featured in the critical clues of what is important. So why treat it now?
• Improving right single leg stance and taking the first step with the left leg will more appropriately load the right lower limb in walking. I can get the 1^st part of this – improving right SLS will improve loading during weight transfer, but how does taking the 1^st step with the left leg improve loading of the right leg while walking? There is more to walking than just the 1^st step!

So to translate all this guff in to plain English – A middle aged mechanic with a spastic paraparesis following an incomplete C6/7 SCI (we don’t know how long-standing) wants to improve outdoor mobility, leisure, and back and knee pain. The nub of the assessment is diagnose the main problems as weakness in the legs and a ‘stiff’ pelvis so he can’t stand on his right leg very well. The treating Bobath therapist wants to make the pelvis move more; improve balance; and ‘train the core’ by ‘setting the scapulae’; line up the joints of the leg better (alignment); strengthen the leg(s) particularly the foot and calf and get him to stand on his right leg better and always start walking with the left leg.

If I was assessing this chap, I would also probably conclude that weakness (of all muscle groups below his injury level, I expect) was his main limiting impairment but I would also have objective information about which muscle groups were affected and how much. I’d also have objective measures of his sensation (RIvermead Sensory Assessment), range of movement, pain, reflex activity and balance activity (Brunel Balance Assessment, obviously) so I could tell how much influence these parameters were having. I wouldn’t be fretting about trunk, core, pelvis or hip alignment, activation and the like as these are just manifestations of the weakness. I would have used standardised measures of functional mobility (probably the Rivermead Mobility Index and Timed Get up and Go) and his walking activity (10 m WT; 6 Min WT and Walking Handicap Scale) and set some SMART goals with him.

Then we get to the treatment plan which consisted of three treatment sessions of 1 hour each. The sequence of treatment included

• linear acceleration and lateral pelvic tilt to increase extensor activity and selectively guide the postural transition into supine (any idea what on earth “linear acceleration into supine is?). It sounds like they are getting the patient to lie down (or facilitating/ doing it for him )- if that’s was ‘postural transition into supine’ is  . Really?? practicing lying down to improve single leg stance and walking???
• lower limb re-alignment and foot activation into crook lying with distal facilitation. Any thoughts on what foot activation into crook lying might be? Why are they in crook lying when the problem is thought to be SLS and walking)
• core training in supine
• Facilitation into side-lying to strengthen lower limb extensor/abductor mechanism (really?? You think that lying on your side increases the lower limb extensors and abductions?? And you think practicing things in side lying will improve single leg stance in standing and walking?
• core training in standing
• scapula setting in prone standing
• facilitation of a backward step; right single leg stance; walking

What a weird collection. It’s hard to work through the waffle and neurobabble jargon but it appears that this chap who wants to improve outdoor mobility and archery is mainly treated in lying (supine, side lying, crook lying; prone standing) with a little bit of standing and stepping. Possibly walking short distances indoors (while being facilitated). So much for patient-centred, goal-focussed treatment aiming to improve activity and participation. This treatment plan is unlikely to improve motor control, or motor learning, or strength (which is what tutors claim are the effects of Bobath) given that it does not include intensive practice of functional tasks/exercise which are specific, challenging and meaningful to the patient in a range of environments/ contexts. There is abundant evidence that these are the conditions needed to promote neuroplasticity, motor learning and strengthening.  

Now as a physio who uses the evidence-base, I would have gone for a daily exercise/functional practice programme focussing on lower limb strengthening; balance training; and functional mobility – walking distance/endurance (treadmill training if I had access to one); turning; kerbs; obstacles etc which were clearly related to SMART goals and involved the patient continuing to exercise and practise at home outside therapy sessions. If my assessment of RoM had shown limitations I’d add some stretching. Given his diagnosis (spastic paraparesis), I’d be having a good look at the reflex activity particularly of plantarflexors and be considering botox if the spasticity was focal and sufficient to be limiting his function/mobility. I would also discuss how to manage his pain (based on findings of assessment) with him; plus review his walking aids and other assistive devices. I’d have worked out what was limiting his archery as part of the assessment and including an exercise, training programme to address this too.

The final section is evaluation which includes quantitative, qualitative and reflective sections.

Quantitative evaluation: A list of quantitative measures are reported, presumably measured before and after treatment (whether this is after one session or all three, and whether these are one-off measurements or the mean of several attempts is unclear). There is a measure of dynamic standing balance (Fwd reach test); mobility and falls risk (TUG) and pain (VAS) which are good quality measures. They don’t relate to the patients’ goals; findings of the assessment or the treatment plan tho, so the rationale for their choice is unclear. The authors interpret the data to indicate improvement but the improvements in Fwd Reach and the TUG are within the measurement error/variability of measurement. The improvement in long-standing back pain (from 6/10 to 1/10) is marvellous however, but perhaps a bit too marvellous to be credible. But hey, let’s give credit to the attempt to make an objective evaluation of the effects of treatment. Here they are

• Functional Reach Test: pre 26 cm -> post 32 cm
• Timed Up & Go Test: pre 38.60 sec. -> post 38.00 sec.
• Visual Analogue Scale for back pain: pre 6/10 -> post 1/10
• Visual Analogue Scale for right knee pain: pre 9/10 -> post7/10

Qualitative evaluation:

• Post treatment intervention reduced flexion, adduction and internal rotation of the hips in standing. Funny this hasn’t been mentioned as being impaired, an important limitation or part of treatment before
• More fractionated locomotor pattern and greater trunk stability. Any idea what a fractionated locomotor (they mean walking) pattern is?
• Improved foot alignment with ankles as a reference point for the transfer from standing into sitting. Hmm, I’m just trying to working through this. Improved alignment with the ankles- Is this feet being flat on the floor? Transfer from standing into sitting – that will be sitting down then, but god knows where the reference point comes into it.
• More selective reach pattern in standing without displacement of the trunk. Again this does not link with the patient’s goals; assessment findings; hypothesis or treatment provided. So why is it here?

Reflection and considerations for treatment progression:

• Residual stiffness in the lumbar spine and hip alignment impact on lower limb alignment and strength in standing and for the sit-to-stand transfer and the need for compensatory strategies: more work is necessary in this direction. No, weakness is not caused by stiffness or position/alignment. It is caused the lack of excitation on the alpha motor neurones. Although I agree that further work to increase strength of the lower limbs is no doubt needed.
• Weakness of the core (including scapulae) and postural instability of the feet is a very important element in the clinical presentation. Now earlier they said that the main problems were pelvic stiffness and lower limb weakness. Has it changed? What is “postural instability of the feet” anyway? Bobath tutors are rather fond of talking nonsense about feet. Elsewhere they mention “poor interaction of the feet with the base of support”. I think that means something about putting your feet on the floor.
• Pain (back and right knee) reduces in therapy, but increases as the quality of movement deteriorates in necessary function during the day.
• Compensatory strategies decrease proportionally to the increase of postural stability.
• Well motivated, ability to motor learn, key strengths are good sensation [how do they know if it wasn’t assessed?], and the almost total absence of neural components (Funny, in the introduction, it said the patient had a spastic paraparesis. Isn’t spasticity a ‘neural component’?)

So that’s it. How Bobath therapists would assess and treat a middle-aged mechanic with an incomplete C6/7 spinal cord lesion who wants to improve his walking endurance and outdoor mobility and archery. Many of you, dear readers will have been involved in assessing the competence of undergraduates to assess and treat a patient – either as a student or assessor. Now tell me, if someone presented something that involved

• Incomplete reporting of the past medical and social history
• Incomplete assessment of impairments – no Ax of weakness; sensation; reflex activity; pain;
• No assessment of activity or participation – balance; functional mobility; functional walking; extended ADL; work capacity/neds
• No SMART goals
• A treatment plan which did not relate to the patients’ goals; findings of the assessment; working hypothesis or include anything with evidence of effectiveness
• Outcome measures which did not relate to the patients’ goals; findings of the assessment or working hypothesis

Would you pass them? No me neither. Oh dear.

The paper then presents a second case study. This time, a 40 year old woman who had malignant left middle cerebral artery stroke with brainstem compression some years previously. She is independent in most ADL (no details of which ADL and what assistance she needs with the others) and wants to improve outdoor mobility and upper limb function.

I have gone through it all in detail but it raises much the same issues so Case Study 1 so I have not reproduced it all here. Again, there is an incomplete history and assessment which just relates to very limited aspects of motor/movement impairments – nothing objective; nothing on weakness; range of movement; sensation; balance (other than saying it is ‘reduced’); reflex activity; co-ordination; function in terms of mobility or the upper limb. Given the patient’s diagnosis I’d expect some assessment/discussion of vestibular function; visual disturbance (especially diplopia); breath control/CV fitness; swallowing too. No assessment of activity/disability; participation; no SMART goals; nothing on multi-disciplinary input (I would suggest that the patient would benefit from referral to an OT and maybe orthoptist). Nothing about continuing therapy outside the treatment sessions. This really does put paid to the claims (in earlier papers) that Bobath is holistic; 24h-hour; patient-centred; goal-driven; have activity and participation as the ultimate goals of treatment and are multi-disciplinary.

As with Case Study 1, the therapist/authors feel that the patient’s problems are due to deficiencies with the trunk/core, hip alignment and single leg stance. Again they note weakness of the lower limbs. They put the limited upper limb function down to soft tissue stiffness of the forearm and wrist with  no mention of weakness (which I would guess is the underlying problem). The patient is also thought to have excessive visual dependence, but vision and visual dependence have been assessed.

These problems are treated (in a single assessment/treatment session) with:

• Soft tissue mobilisations to reduce structural tension of the forearm, wrist, and hand.
• Use of light touch to facilitate postural orientation (that’s holding on to balance better, isn’t it?)
• Facilitation of stand-to-sit to improve eccentric extensor control.
• Use of the posture of reclined sitting to re-align the hips, activate the core, and mobilise the right foot to improve foot to floor interaction. This raises so many questions. How can reclined sitting (which could be half lying, I guess, or maybe just slouching/ lounging) ‘activate the core’?? What does re-aligning the hip in reclined sitting mean? Is it straightening your leg out while lounging? Could “foot to floor interaction” mean putting your foot on the floor? Funny it hadn’t been noted to be a problem in the assessment. And as the patient can walk it probably isn’t a problem in real life either
• Facilitation of reach-to-stand through the right upper limb to load the right foot/heel and gain eccentric length of the right gastrocnemius and soleus. Weird- reach to stand uses concentric activity of the calf muscle (going from a plantarflexed to neutral position as the patient stands up) If you want eccentric length then you want then try stand to sit. Not that length of the calf had been noted to be a problem in the assessment, critical clues, diagnosis or hypotheses so why treat it now?
• Use of prone standing to activate the trunk extensors against gravity, to gain length in the right latissimus dorsi, and to activate scapula setting. This is also thought to improve visual dependence. If you want to “activate trunk muscles against gravity” it would be much more effective to just stand up (using upper limb support if needed) rather than use prone standing which is uncomfortable, undignified and pretty useless. But given the thoracic spine was considered to be hyperextended in the assessment section (but no problem with lat dorsi or scapular setting were noted) why would you want to be activating the trunk extensors or stretching lat dorsi anyway? As for the effect on visual dependence- how can leaning someone one over a plinth and fiddling with their shoulder blades make them use less dependent on their vision to balance?? Balance training in standing with their eyes closed (in a safe environment, obvs) is what would reduce visual dependence.
• Facilitation of a backward step with the right leg, with the upper limbs placed at 90 degrees to facilitate trunk and lower limb extension, gain length in the right calf, and to improve left single leg stance activity. Optimal loading of the right lower limb with heel contact to facilitate selective extension during right single leg stance. The Bobath tutors are very fond of a backward step – no idea why! I agree that walking backwards (and sideways) are useful parts of advanced mobility/gait adaptability training but why do it as a single step? There’s no evidence (nor common sense) to suggest that taking a backward step with your arms out at right angles will make the leg and trunk extensors stronger, or make it easier to stand on one leg.

Again the treatment plan does not fully match up with important clues/hypotheses/aims. What happened to the need to improve impaired core control; right hip extensor/abductor mechanism; improve hip/femoral alignment and hip flexor soft tissue length bilaterally and the (unspecified) limitations in functional walking and standing balance? What happened to the patients’ goals to improve outdoor mobility and upper limb function?

SUMMARY

So there you have it. My review of Contemporary Bobath. It’s proved an interesting distraction during lock-down but the weather has improved and my garden is beckoning, so this is it from me. I hope you have enjoyed the reviews and found them thought provoking.

Dr VG and the international Bobath tutors set out to define and describe the theory and practice of Contemporary Bobath to use as a basis for their teaching and future research. This, they have achieved. The work is very thorough and methodologically robust. It is also rather long-winded, repetitive, and in places the jargon is ridiculous. It reveals that Bobath therapists base their assessment on a highly selected slice of impairment – the observation, and facilitation of a very limited number of movements. They don’t actually do anything about other impairments, activity/disability or participation in practice, despite assertions to the contrary. Nor do they consider ‘the whole person’; involve the multidisciplinary team; or continue therapy outside the treatment session. The theory papers that precede this application paper present a great deal of theory regarding neurological pathology; motor control and motor learning which has been standard stuff in neurological teaching for many years. But this is a presented in parallel to the application. The theory and evidence is not connected to the application of Bobath and, as this paper reveals, the application of Bobath is contrary to the evidence.

The Bobath tutors use the same sort of clinical reasoning processes as any other health care professional except they attach much greater importance to experience (the phronesis thing) than the evidence base. This appears to be as a way to justify working in a way that is contrary to the theory and evidence.

The hypotheses that the Bobath therapist generate to diagnose the patients’ problems and the basis of the treatment plan appears to come from a uniquely Bobath interpretation which focusses on the trunk, hip and feet (even for upper limb problems) and talks a lot about activation, control, alignment and afferent/sensory input. There is some sort of belief that moving people around (ie facilitating) and putting limbs in a particular position (ie alignment) creates sensory input and somehow this ‘activates’ muscles and ‘the core’ and make them stronger. This in turn, is somehow thought to improve motor control, motor learning and function/activity.

These case studies and the preceding ‘theory’ papers illustrate where Bobath has got it wrong and is contrary to well established evidence.

1. Firstly the belief that these bizarre movement impairments are the main problem.
   1. The primary problem is weakness. One also needs to know what other impairments the patient suffers and the activity limitations they experience using objective measurement tools and assessment techniques.
   2. The stuff about the trunk/core is engulfed in a masses of impenetrable neurobabble. It isn’t recognisably connected with applied anatomy or the literature on movement control/ biomechanics of everyday activities such as walking; balance; STS; upper limb movement. If one was cynical, one might think they just make this stuff up.
   3. Saying that one bases one’s expertise on experience over theory/evidence (the phronesis thing) is not justifiable in professional practice now-a-days, and counter to our code of professional practice.
2. The apparent belief that treating these problems to activate the core and control is all that is necessary. As far as I can tell, this is in mistaken belief that if one sorts out the movement impairments, these will carry over into the other impairments, activity and participation. This is incorrect. Any treatment effect is specific to the movements/ activities exercised/practised; improvements do not carryover from impairments to activity/participation, nor between impairments. That is why one has to practice exercise/ activities in a range of contexts and in everyday life outside therapy sessions to get transfer into everyday life.
3. The belief that facilitation provides sensory input which in some way ‘activates’ muscles and this promotes strengthening; motor control and motor learning. Like the description of Bobath movement analysis, the terminology used to explain Bobath interventions are littered with incomprehensible jargon and neurobable. It is very difficult to work out what is being done (that may be the intention). The primary problem in neurological motor problems is weakness. Neurological motor problems are effectively treated by exercise and task specific practice. At the risk of repeating myself, to be effective this needs to involve be repetitive/ intensive, involve challenge/overload, be specific to the tasks/function; be relevant and meaningful to the patient and involve practice in a range of contexts/ environment in order to get carry over into everyday life. This needs to be continued outside the therapy session with independent practice. These are the conditions which promote strengthening, neuroplasticity; motor control and motor learning. Bobath does not create these conditions, and that is why is does not work.

(Another) Delphi study to define Bobath

So the next paper in the series on Contemporary Bobath is a Delphi study involving international Bobath tutors to define the Bobath Framework. Here’s the reference and the link to the paper

Vaughan-Graham J, Cott C. Defining a Bobath clinical framework–A modified e-Delphi study. Physiotherapy Theory and Practice. 2016 Nov 16;32(8):612-27.

VG and Cott Delphi with tutors 2016

I’m getting something of a sense of deju vu now tbh. This is the 6^th paper from Bobath tutors about ‘what is Bobath?’ In 2007 Raine et al published a Delphi study with UK Bobath tutors, and then Raine, Meadows and Lynch-Ellerington published a book on the Bobath Concept in 2009. Also in 2009 Vaughan-Graham et al published an opinion piece (the 1^st of the papers on contemporary Bobath reviewed here https://sarahtphysioblog.wordpress.com/2020/02/28/a-review-of-contemporary-bobath/). In 2011 Levin and Panturin (2011) published another opinion piece about the key principles of Bobath. This was followed Dr VG’s systematic review of the studies defining Bobath in 2015 reviewed here https://sarahtphysioblog.wordpress.com/2020/03/24/contemporary-bobath-a-definition/), then Dr VGs interview study about tutors’ clinical reasoning (reviewed here – the phronesis https://sarahtphysioblog.wordpress.com/2020/04/13/278/). Ive added the references for these papers at the end, just fyi.

Given the amount of literature on the topic I was surprised to read in the introduction of this paper that “Little to no attention has been given to the development of a Bobath clinical framework, assumptions and principles the Bobath therapist holds ….” And also “To date no studies involving IBITA members worldwide have been undertaken to document the theoretical and clinical evolvement [they mean evolution. Evolvement is not a real word!] of the Bobath concept.” The authors and participants in the previous papers are Bobath tutors! Multiple papers on the same topic with the same people looks like more than enough attention to me! One would have expected a definitive answer to have been worked out by now. But apparently they need to have a go at it.

As with the other papers, the method is fine. A three round on-line Delphi process was used. For those of you who aren’t familiar, this is a process to establish consensus. A list of statements are produced by experts in the field (in this case the authors) usually based on previous research +/- clinical experience/expertise. In this paper these were drawn from the scoping review of papers defining/describing the Bobath Concept reviewed previously here https://sarahtphysioblog.wordpress.com/2020/03/24/contemporary-bobath-a-definition/. There were 21 statements.

The statements were circulated to 204 full members of the International Bobath Instructors Association (electronically) who indicate their level of agreement/ disagreement with the statements and with the opportunity to add any further comments. The responses are reviewed and the statements with least agreement dropped. In this case at least 80% of respondents needed to agree or strongly agree with the statement for it to be retained. The process is repeated, in this case twice more and the remaining statements are considered to represent the consensus on a topic. Eight-nine (43%) of tutors responded to the 1^st round, then 33% and 32% responded to rounds 2 and 3, which isn’t an overwhelming response rate. It indicates that the consensus was from those who responded, rather than all International Bobath tutors.

The results: During the consultation rounds statements about compensation, ab/normal movement and balance caused controversy amongst the tutors. The problem appeared to be that they could not decide how to define/describe normal movement or quality of movement; whether Bobath allowed compensations or not, and whether balance was “fundamental” to Bobath, or not. In the end, balance was dropped and a fudged description of the other issues were included.

The results and discussion detail the statements which reached consensus about the assumptions and principles underpinning Bobath. It is very difficult to see what is new here. The summary of Bobath at the beginning of the discussion is the same that from Raine et al 10 years previously and is repeated by Dr VG et al in their publications in 2009 and 2015: “The Bobath concept is now founded on a systems-based model of motor control; no longer subscribes to a hierarchical control model ….The experts were also in agreement that the Bobath concept is an individualized problem-solving treatment concept, can be applied to a broad range of clients, and is not exclusive of other interventions” This paper adds that in the Bobath Concept “the individuality of movement dysfunction is critical to the application of the Bobath concept”. I dont really know what this means. It is one of those wafflesome, sound-good empty phrases beloved of Bobath publications. I have invited Dr Vaughan-Graham, the IBITA and BBTA to reply to these reviews  but they either don’t reply or decline.

The only bits that I can find in this paper which are new compared to the previous papers defining and describing the Bobath Concept is that normal movement is out and the tutors now talk about ‘typical movement behaviour’ instead. However the thinking behind it seems to be the same, they have just changed the buzz word. Or to put it rather less succinctly “Today, it is recognized that there is no “normal” movement, but a range of typical motor behaviours (i.e. similar characteristics of age and gender-matched motor behaviour) (Levin and Panturin, 2011). In contrast, those persons who present with dissimilar movement characteristics, or atypical motor behaviour, are no longer referred to as having “abnormal” movement.

There seems to have been an expansion of the things that Bobath encompasses and the words used to describe them – no actual expansion of the scope or meaning just using more words. For example

• “The Bobath concept is based on the understanding that sensation, action, perception, cognition, and emotion are interlinked and interactive” Well of course they are, what sort of eejit would think/suggest anything else?
• “Postural control is viewed as the organization of stability, mobility, and orientation of the multi-joint kinetic chain, which is reflective of the individual’s body schema in order to maintain, achieve, or restore a state of equilibrium during any posture or activity”. This is considered unique to Bobath but the understanding that postural control is the integration of stability, mobility and orientation is a generic (but less wafflesome) element of physiotherapy practice and comes from Shumway-Cook and Woolacott’s systems model of balance, nothing unique to Bobath expect the waffle. The idea that postural control is directly linked to ‘body schema’ is stretching an idea a long way though.
• “A goal is to improve movement strategies such that aspects of ease, rhythm, coordination, specificity, variability, repeatability, and speed are addressed” This is a long list of descriptors which are all encompassed in Grade 5 strength /automatic movement in the MRC Strength Scale. Again nothing unique to Bobath except the number of words
• “[Bobath] Intervention is a skilful, logical, analytical process, individual to the client, therapist, and environment [but then so are all physiotherapy intervention] to improve the quality of movement such that all body segments cooperate harmoniously with one another in the context of the task” I’m loving the idea of body segments cooperating harmoniously – I think they mean co-ordination.
• Task selection … is specifically chosen and manipulated with respect to velocity, direction, load, and magnitude in order to optimize the client’s postural control and selective voluntary movement” Interesting. So Bobath involves selecting tasks (not that tasks are ever actually practiced during Bobath treatment sessions) in order to improve postural control and voluntary selective movement rather than vice versa. So much for the goal of Bobath being to improve activity!
• “The Bobath concept considers that the ability of the individual to selectively adapt motor activity and alignment of body segments with respect to a supporting surface and gravity provides critical information on the ability of the individual to receive, integrate, and respond appropriately to relevant information and is fundamental to the acquisition and development of postural control” I’ve been trying to add a precis to summarise what this means in plain English, but it’s beyond me. If anyone else is up to the task please add the translation into plain English in the comments
• “The Bobath concept seeks to optimize functional independence by potentiating the reacquisition of as close as possible typical motor behaviour and minimizing atypical and compensatory motor behaviour and thus the development of secondary impairments, whilst recognizing the limitation of the CNS lesion, context-based to the individual” Again, I’ll try to precis, but my mind is still boggling at “potentiating the reacquisition of ..” I think they mean restore as normal movement as possible – but then normal movment is out, they don’t do that any more.

The aspects of Bobath that the tutors consider particularly important remain the same as the previous papers;

1) Movement analysis of task performance. How this analysis works is never explained. The authors do say that they draw on biomechanics (and other evidence) but in the paper on clinical reasoning (the Phronesis one) the authors highlighted that Bobath experts used experience over evidence/ theory as the basis of their analysis and there is precious little evidence being used in the videos of Bobath tutors in action. Interestingly, the whole phronesis thing does not feature in this paper at all, despite it being considered such an important aspect of Bobath expertise in the paper published just a few months before.

2) The interdependence of posture and movement. “task performance within a specific environment is viewed by the Bobath concept from the perspective of the integration of posture and movement”. Hmm, not sure what this means really. I think it’s something about being able to perform a task requires the patient to be able to keep their balance and move, and the movement produced are specific to the task and environment – well doh!

3) the role of sensory information in motor control (later in the paper the authors throw in perception as well). The authors explain that “Understanding the interaction between the client’s body segments, supporting surface, and gravity was identified as a fundamental principle by the experts providing critical information on the client’s perceptual abilities as well as their ability to generate appropriate postural control. Sorry, I’ve tried but I can’t work out what the hell the interaction between body segments, surface and gravity is. I mean we all learnt (in the 1st year of physio school) how to alter position to make exercises/movements easier or harder depending on whether gravity was eliminated or not. Is that it? I can’t see that this tells you much about the patients’ perceptual skills though. It is all about their strength/ weakness (remember the good old MRC strength scale, that’s all there is to it). Facilitation seems to be tied up with the sensory information. From what I can gather, facilitation is how Bobath tutors think they manipulate somatosensory information which they consider a good thing, but the authors/tutor never really explain why or how, or what effect is has. Just that they do it and consider it an asset. Interestingly, here the authors use facilitation and therapeutic handling interchangeably, although in other papers they have been at pains to point out that facilitation is much more than mere therapeutic handling.

Finally the authors highlight a few ways in which they consider Bobath differs from other types of neurological physiotherapy interventions. They say that Bobath’s focus on movement quality contrasts with approaches that focus on task specific training. They have a list of aspects that they claim to address during ‘task performance’. When they talk about task performance they don’t appear to be talking about practicing functional activities (ie tasks) which we know from the videos and photos of Bobath in action doesn’t actually happen. Rather it appears that ‘task performance’ is a new buzz word to replace quality of movement. So when they talk about tasks, they mean movements. The authors are very keen to emphasise that Bobath is interested in how tasks/movements are done rather than what the patient can do ie function/activity. Oh dear.

Furthermore, the aspects of task performance that they emphasise as part of Bobath -ease, rhythm, coordination, specificity, variability, repeatability, and speed (as an aside have you ever seen a Bobath tutor actively getting patient to practice these aspects of movement/ function. No, me neither) would all be addressed in the final stage of motor learning/ task training while progressing from ‘practice without repetition’ to ‘automatic activity’. Not for the 1^st time, there is nothing specific to Bobath there

The final issue that the authors feel is unique to Bobath and is not addressed in other interventions such as Constraint Induced Movement Therapy and Body-Weight Support Treadmill training (BWSTT) is they consider the ‘whole person’ and claim that the ‘other interventions’ “fail to recognize the role of the trunk, head, and posture in motor control, and more importantly the role of the person in functional recovery”. Which is such nonsense it barely merits comment. The idea that CIMT or BWSTT doesn’t involve any body parts other than the limbs is just silly, as is the notion that they are not related to the patients’ goals and does nothing except demonstrate how little the authors know about delivering these effective, theory driven interventions.

The authors finish by falling back on the clichés beloved of people who can’t justify their practice with theory or evidence by saying “on the ground all clinicians know ….” and focussing on “the art of neurorehabilitation” presumably because they don’t have the science.

 

Phronesis (it means experience) – the key to Bobath experts’ clinical reasoning

Hello All

Happy Easter, hope you are all coping in these locked down times and the Easter Bunny managed to find you. We have been having wonderful Spring weather in NorthWest England so my garden and new lambs have been getting all my attention, but today winter has returned so I’m back inside with another Bobath review. This one is about Phronesis. No, me neither. I had to look it up. Phronesis are a jazz trio based on London. They’re not bad if you like that sort of thing http://www.phronesismusic.com/.

Here’s the reference and link to the paper

Julie Vaughan‐Graham, Cheryl Cott. Phronesis: practical wisdom. The role of professional practice knowledge in the clinical reasoning of Bobath instructors Journal of Evaluation of Clinical Practice 2017 Oct;23(5):935-48.

here the link to the paper

Phronesis also means ‘traditional wisdom’ or ‘wisdom from action’ and is used interchangeably in this paper with other terms such as tactic or implicit knowledge and experience. I’m a plain English kind of gal so I’m going to stick to ‘experience’.

Before looking at the paper in the detail, I need to add a caveat: I’m not a stupid person and my reading level is pretty good, but I am struggling to follow this paper. Each to their own and all that, but Lordy there’s some pretentious waffle here. But dear reader, I have persevered and done my best to make head and tail of it. If anyone has a clearer understanding please add to the comments. As usual, I will try to work through the paper each point at a time.

So, the aim of the paper was to examine Bobath tutors’ clinical reasoning processes. In the introduction there is a long section describing and defining clinical reasoning, which is a lot more complicated than it needs to be. For those who aren’t familiar, clinical reasoning is a process by which clinicians integrate theoretical knowledge with experience in order to make decisions ie how clinicians decide what the patient’s problem(s) is and what to do about it.

The method section is rather long-winded but methodologically it is fine. Dr VG video’d each of the participants (22 Bobath tutors from 7 different countries) treating a patient and then interviewed the tutor about how they decided how to asses and treat the patient (ie their clinical reasoning).

From the interviews, the authors describe three primary themes: (i) a Bobath clinical framework, (ii) person‐centered, and (iii) a Bobath reasoning approach. Each of htese themes are said to  contribute to the tutors’ reasoning processes to assess and decide a treatment plan.

They explain that the 1^st theme (the “Bobath clinical framework”) was the same as that in another paper published in 2016. I’ll review that one too in the fullness of time but one does wonder why they are publishing it as a separate paper as well as here, but perhaps they go into more detail in the other paper. The authors explain that the Bobath Framework is the basis of the tutors’ understanding of the patients’ presentation and guides their assessment, interpretation and synthesis to make decisions. That’s all bog standard stuff, which is common to all clinicians. Nothing specific to Bobath there. The authors don’t explain what the framework or the underlying theory are, although there is some indication that it involves ‘neurophysiology’. Perhaps it is detailed in the other paper but they do specifically emphasis sensation saying that this is “used from the perspective of (a) the patient, (b) their body/movement, (c) the tutor and (d) the environment, interactively and iteratively to inform their clinical reasoning process”. I really have no idea what this means. Do you? If so, please add your plain English explanation in the comments section.

The authors also say that facilitation, which now-a-days includes handling skills (in days gone by handling skills and facilitation were synonymous) is a key aspect of Bobath but do not link this to sensation or the Bobath Framework, so I don’t really understand how it fits into this section of the paper. Then there is a long section where the authors give examples/ quotes of how the tutors are ‘using’ facilitation. This includes manipulating the environment and alignment of body segments, observation and instruction. They say that the tutors combine cognitive and handling skills with “a visuospatial‐kinesthetic perception of the person/patient”. No, I have no idea what that means either, but it sounds clever. If you do understand it and can explain it please add in the comments section.

So in summary, the Bobath Framework combines theory and experience and is the basis of Bobath experts’ understanding and decision-making. The bit that are unique to Bobath is the importance given to ‘sensation’ and facilitation. Now, that didn’t really need to take several hundred words did it?

The second theme was more succinct – Person‐centered: It is basically highlights that each patient is individual and that clinical reasoning/ decision-making is based on building a rapport with the patient and understanding the breadth and depth of their history and goals – same as any healthcare really. Where the tutors’ reasoning differs from the mainstream is in their beliefs about what is normal, why movement is abnormal and what to do about it. Much emphasis is given to the fact that this understanding is based on experience and not theory or evidence. I get the impression that the authors view this as an asset, rather than lack of awareness or understanding of the extensive evidence-base, or our professional code of conduct which expects evidence to be used.

The 3^rd theme is the “Bobath reasoning approach”: The authors have produced a diagram which shows how the five categories of ‘Bobath Reasoning’ work. The categories are individualized assessment and treatment; critical cues; movement diagnosis; activity/ task/posture selection; and reflective practice. If one made a diagram of any clinical reasoning process it would be much the same – assessment, diagnosis, treatment plan and reflection are universal.  I expect the ‘clues’ that a Bobath tutor consider critical would differ from a non-Bobath expert – someone who focussed on applying the evidence-base, rather than relying on experience, for example. It’s rather hard to see how this ‘Bobath Reasoning’ differs from the framework highlighted in theme 1 but after presenting the clinical reasoning diagram, the authors then present a long description with quotes from the tutors about what they do. This includes bizarre phrases such as “a nonverbal conversation between her hand and her patient’s”; “talking to the hand” [presumably because the face don’t wanna know]; “making a long arm” [ironically this is given as an example of explicit verbal cues] and “standing up against gravity” [can you do it any other way?] It is hard to see how these examples illustrate the reasoning process, but I presume this was the intention.

Discussion

As is traditional, the discussion starts with a summary of the main findings, which are (and I paraphrase a lot here) that Bobath tutors follows the same clinical reasoning processes as all health professionals. This is something of a relief, it would be a worry if they were off doing something else entirely! They refer to (unspecified) neurophysiological theory but emphasise the importance of experience over theory which appears to be the main basis of their reasoning. They use hypothetical-deductive reasoning despite their claim to act as experts. This reasoning process has been discussed in earlier blogs (“but my patient is a unique individual” https://sarahtphysioblog.wordpress.com/2015/10/27/individual-patients-assessment-expertise-and-the-bobath-concept/ ). Hypothetico-deductive reasoning is the notion that one’s assessment aims to produce a hypothesis about the cause of each patient’s problems and how to fix them. Then one tests out and refines (if necessary) 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, repeat themselves, do unnecessary, irrelevant stuff etc. That’s why they make obvious mistakes; because it isn’t obviously a mistake to them, and why they take ages. 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 treated before, understand the underlying mechanism/ cause and implement successful treatment without further ado. Experts only need to use hypothesis driven clinical reasoning if dealing with a particularly complex or unusual situation which one has not come across before. Even then, one should be able to work quickly and effectively through the ‘knowns’ to get to the ‘unknowns’. So it is rather curious that the Bobath tutors are basing their practice on this novice way of working, despite the importance given to experience (over theory/evidence) they appear not to be learning from it. Oh dear.

There are some elements of the tutors’ clinical reasoning process which are more specific to Bobath and these are the bits that make least sense – the visuospatial‐kinesthetic perception thing and the involvement of the tutor as “a tool in the reasoning process” for example. There is a section quoting Aristole and Schon about “perception is for action” which try as I might, I do not understand so I won’t comment further.

The authors claim that the role of experience is missing in work on clinical reasoning and the current evidence base. This is nonsense. Clinical reasoning has always involved the integration of theory/ evidence, experience and context. However, the literature on clinical reasoning does not share the priority that the Bobath tutors give to experience over theory/evidence. The authors of this paper appear to be making an argument that it is OK (in fact more than OK, positively desirable) to base clinical reasoning on experience rather than evidence. This flies in the face of professional practice which requires the evidence base to be used. Experience is used to work out how to apply the evidence in the given context (ie the patients’ presentation, goals, treatment setting etc). It is not an excuse to jettison the evidence if you don’t like it . We have discussed this in some detail in in previous blog posts (https://sarahtphysioblog.wordpress.com/2015/10/26/ebp-and-professionalism/ and

https://sarahtphysioblog.wordpress.com/2015/10/27/individual-patients-assessment-expertise-and-the-bobath-concept/ )

The CONCLUSION of the paper is that Bobath tutors use much the same clinical reasoning processes as everyone else (although they don’t put it as succinctly as that, obvs) but they “illuminate the role of phronesis, specifically visuospatial‐kinesthetic perception”. I am still none the wiser about what a visuospatial‐kinesthetic perception is, or who has it – patient or tutor? If you do understand it please explain in the comments section.

I am trying to contact Dr VG to invite her and the other Bobath tutors to comment (and hopefully explain). I have done this many times over the years with negligible response but I’ll keep going, the Bobath tutors have always had a right to reply to my reviews, blogs etc. They just choose not to. However when this paper was first published, it caused a bit of a stir and there was an exchange of Letters to the Editor between Roger Mepsted, me and the authors. Here, for completeness are those letters.

LETTER TO THE EDITOR 1 from Roger Mepsted

Dear Editor,

I read with interest the recent paper by Vaughan‐Graham and Cott, and I believe that it raises some important issues. The authors examine at length the “why” process of thought that Bobath therapists use as they apply their intervention to an individual. This they call clinical reasoning and rightly point out that it is a vital part of the whole treatment process. They complain that rehabilitation has become dominated by a scientific evidence–based approach and that the role of such clinical reasoning has been largely ignored. This they say has produced a widening chasm between research and practice. Whilst I agree that clinical reasoning is vital, I believe that there are some significant omissions in this study [1].

First, the authors state that “the effectiveness of the Bobath concept has been widely investigated” yet fail to mention that these numerous investigations overwhelmingly conclude that Bobath is less effective than the alternatives. This is why it is not recommended in national guidelines and is criticised in reviews [2–4]. These reviews recommend a range of specific interventions but do not recommend the following of any named concepts or approaches.

Second, they describe the clinical reasoning processes of Bobath instructors in depth; but to my mind, they are no different to those used by any experienced therapist. I see nothing that makes them uniquely Bobath, other than being largely confined to the Bobath methods and concepts. Bobath‐trained therapists do not have a monopoly on such clinical reasoning. This is the fundamental flaw in this paper; we all agree that advanced clinical reasoning is an essential skill and helps us select and adapt generalised interventions to each individual patient, but we need to combine clinical reasoning with treatments that have a good objective evidence base.

Therefore, I conclude that whilst this study of the thought pro- cesses of Bobath therapists may have some academic merit, it is incomplete if it ignores the objective evidence that better interventions exist. Where is the clinical reasoning in using a sub-optimal approach? I believe there is no rationale for a scientific evidence‐based approach to result in what the authors describe as the ever‐widening gap between research and practice. This divergence exists because the evidence based has moved and the Bobath concept has not.

Roger Mepsted BSc (Hons) PhD

Retired Neurophysiotherapist, Carlisle, UK

REFERENCES

1. Vaughan Graham J, Cott C. Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors. J Eval Clin Pract. 2017;23(5):935–948.
2. Royal College of Physicians. National clinical guideline for stroke. 5 ed 2016. Available at https://www.strokeaudit.org/Guideline/Full‐

Guideline.aspx . Accessed 9 January 2017.

3. Novak I, Mcintyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013;55:885‐910. Available at http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/full. Accessed 9 January 2017
4. Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence? Stroke. 2009;40(4):e89‐e97. doi: 10.1161/STROKEAHA.108.533828 Epub 2009 Jan 29

LETTER TO THE EDITOR 2 Author response to “Letter to Editor by Roger Mepsted”

Dear Editor,

The authors would like to thank Mr Mepsted for his interest in our study and for encouraging debate on this important subject.

The purpose of this study was not to examine the effectiveness of the Bobath concept vis-a-vis other approaches but to gain a greater understanding of the critical aspects of tacit knowledge that inform and extend cognitive reasoning strategies of expert neurorehabilitation therapists. Clinical reasoning, a critical aspect of clinical practice, determines if an intervention is relevant and reasonable for an individual.

Ours is the first study to document the clinical reasoning of Bobath instructors [1].

We did not seek to demonstrate, or claim, that only Bobath instructors utilize expert cognitive reasoning strategies. Rather, the Bobath instructors were used as a sampling frame to obtain a sample of expert neurorehabilitation therapists. Numerous scholars have called for a reconceptualization of professional practice knowledge, practical wisdom, recognizing that clinical reasoning extends beyond the underlying cognitive processes [2].

Our study illuminates the role of practical wisdom, phronesis, the domain‐specific sensory‐motor acuity developed through professional practice, identifying the integration of a visuo‐spatial kinaesthetic perception as a unique dimension of a Bobath instructor’s reasoning process, extending beyond already identified cognitive reasoning strategies, and thus makes a unique contribution to the clinical reasoning literature. Even though our study is not concerned with effectiveness, we feel obliged to respond to some of Mr Mepsted’s comments about the effectiveness of the Bobath approach. The evidence to which he refers is not as conclusive as he states. The evidence does not “overwhelmingly conclude Bobath is less effective than the alternatives,” rather the conclusion by most rehabilitation scholars is that there is insufficient evidence either for or against Bobath/NDT interventions [3].

As part of our ongoing program of research, we conducted a scoping review of the literature on the Bobath evidence base from 2007 to 2012 in adult neuro‐rehabilitation. We clearly identified significant methodological flaws of the existing studies that are cited as evidence that does not support the Bobath approach including comparison groups; study fidelity; duration of care; and, measurement [4].

With respect to intervention comparison, only 1 of 12 intervention studies we examined actually had the Bobath approach as the study intervention. The rest of the studies used the Bobath approach as the “control” intervention assuming it to be “standard care,” with little attempt to operationalize and specify the care provided. All of these studies lacked sufficient operationalization of the Bobath approach and description of therapists providing the interventions such that the studies were not reproducible raising issues of study fidelity, one of the major limitations in stroke rehabilitation research [4,5].

We have argued elsewhere [6] that the Bobath approach is not a treatment technique, per se, but a problem‐solving approach to clinical decision making providing an overall conceptual framework enabling the development of an individualized intervention plan addressing complex movement challenges. The Bobath approach has been compared to other approaches such as motor relearning, multisensorial rehabilitation, and task specific training. We would argue that these studies are problematic in that it is not clear the extent to which these approaches differ sufficiently from the Bobath approach to warrant comparative study [4].

Further, the uncritical adoption of the RCT to study the effectiveness of complex, multifactorial and individualized neurorehabilitation approaches is inappropriate and fails to provide clinically relevant evidence [6]. Other intervention studies have compared the Bobath approach to constraint‐induced movement therapy (CIMT), partial body‐weight support (PBWST), robotic therapy, neuromuscular electrical stimulation (NMES), passive movement (PM), and rhythmic auditory stimulation (RAS). All of these interventions are treatment techniques (not conceptual frameworks), which are only applicable to select client groups or would only be considered an adjunct therapy, not a comprehensive treatment approach. [4]. A critical perspective of the evidence should question whether the actual interventions delivered were relevant and appropriate for the study participants [7].

All Bobath clinicians, and many neuro‐rehabilitation therapists, concur that the delivery of a predetermined package of interventions to a group of patients determined by their medical diagnosis irrespective of the individual clinical presentation is the antithesis of actual clinical practice [4].

Lastly, we would like to draw attention to recent peer‐review publications [8-12] and texts [13,14] that clearly document the ongoing evolvement of the Bobath concept by identifying the underlying theoretical assumptions and key aspects of clinical practice of the contemporary Bobath concept. An in‐depth review of this literature will inform the interested reader that the current effectiveness literature that claims to examine the Bobath approach does not reflect current Bobath clinical practice. Careful consideration is required in determining the optimal study methods enabling appropriate investigation of the Bobath concept [15]. Thus, according to the literature the Bobath concept has moved on, however, rehabilitation science is stuck, spinning its wheels attempting to produce clinically relevant evidence using a study methodology that fails to appreciate the individualized nature of client care.

In summary, one has to ask whether the Bobath Concept has yet to be effectively investigated. Our work aims to enhance the literature by defining the Bobath approach to help address some of the methodological issues raised above. We find it ironic that the Bobath approach is criticized for lack of evidence in the light of the problematic studies to date and that when we attempt to address these short-comings we are also subject to criticism based on the same problematic body of evidence

Yours sincerely

Julie Vaughan‐Graham,

Department of Physical Therapy, University of Toronto,

160‐500 University Avenue, Toronto, ON M5G 1V7, Canada.

Email: julie.vaughan.graham@utoronto.ca

REFERENCES

1. Vaughan‐ Graham J, Cott C. Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors. J Eval Clin Pract. 2017;23(5):935–948.
2. Kinsella EA, Pitman A. Engaging Phronesis in Professional Practice and Education. In: Kinsella EA, Pitman A, eds. Phronesis as Professional Knowledge: Practical Wisdom in the Professions. Boston: Sense Publishers; 2012:1‐11.
3. Canadian Stroke Strategy. Canadian best practice recommendations for stroke care update 2010 [cited 2012 June 25]. Available from: http://

http://www.strokebestpractices.ca/wp‐content/uploads/2010/12/2010_BP_ENG.pdf; 2010

15. Vaughan‐Graham J, Cott C, Wright FV. The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part II: Intervention studies perspectives. Disabil Rehabil. 2015b;37(21):1909‐1928.
16. Page SJ, Schmid A, Harris JE. Optimizing terminology for stroke motor rehabilitation: recommendations from the American congress of rehabilitation medicine stroke movement interventions subcommittee. Arch Phys Med Rehabil. 2012;93(8):1395‐1399.
17. Cott C, Vaughan‐Graham J, Brunton K. When will the evidence catch up with clinical practice (Letter to the Editor). Physiother Can. 2011;63(3):387‐390.
18. Loughlin M, Bluhm R, Buetow S, et al. Reason and value: making reasoning fit for practice. J Eval Clin Pract. 2012;18(5):929‐937.
19. Raine S. Defining the Bobath concept using the Delphi technique. Physiother Res Int. 2006;11:4‐13.
20. VGraham J, Eustace C, Brock K, Swain E, Irwin‐Carruthers S. The Bobath concept in contemporary clinical practice. (grand rounds) (report). Top Stroke Rehabil. 2009;16(1):57‐68.
21. Levin MF, Panturin E. Sensorimotor integration for functional recovery and the Bobath approach. Motor Control. 2011;15(2):285‐301.
22. Vaughan‐Graham J, Cott C, Wright FV. The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review part I: conceptual perspectives. Disabil Rehabil. 2015;37(20):1793‐1807.
23. Vaughan‐Graham J, Cott C. Defining a Bobath clinical framework—a modified e‐Delphi study. Physiother Theory Pract. 2016;32(8):612‐627.
24. Gjelsvik B, Syre L. The Bobath Concept in Adult Neurology. 2nd ed. New York: Thieme; 2016.
25. Raine S, Meadows L, Lynch‐Ellerington M (Eds). Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation. 1st ed. Oxford, UK: Wiley‐Blackwell; 2009.
26. Vaughan‐Graham J, Wright FV. Re. Tang et al. early sitting, standing and walking in conjunction with contemporary Bobath approach for stroke patients with severe motor deficit (Letter to the Editor). Top Stroke Rehabil. 2015;22(1):6‐7

LETTER TO THE EDITOR 3 from Roger Mepsted and Sarah Tyson in response to Vaughan‐Graham and Cott “Author response to Letter to Editor by Roger Mepsted”. J Eval Clin Pract. 2016. doi: 10.1111/jep.12751.

We thank the authors for their response. It has made us reflect upon how physiotherapy has developed since we qualified. In that era, the only form of continued professional development was guru-led, e.g. the Bobath Concept. We dutifully attended their courses and bought their books. Their teachings were descriptive and we strove to master their methods. Things have obviously changed and we now no longer unquestioningly accept the word of the guru unless it is backed up with good quality evidence. This is unfortunate for the gurus and their concepts, as the emerging evidence rarely support them. This is certainly the case for the Bobath Concept, where the evidence for alternative interventions is now significantly stronger than for Bobath.

In their last letter and a previous paper (1) the authors defended Bobath against objective evidence on the following grounds.

1. RCTs are not appropriate for Bobath.

This view was supported by reference to the MRC Framework for the Development and Evaluation of Complex Interventions (2,3). Yet this explains how RCTs can and should evaluate complex interventions. There is nothing special about Bobath. It is no more, or less, complex than other treatments that involve multiple components and inter-personal interaction and there is no reason why RCT cannot be used. Reference to the complexity of the intervention misses the point, an RCT does not measure this, it only measures the significance of change in outcome. If treatment using the Bobath Concept produced better results than alternatives, the RCT would show this. If supporters of Bobath reject RCTs they need to describe an alternative, equally robust and objective assessment method. In this context, it is worth noting that the British Bobath Tutors Association (https://www.bbta.org.uk/) does quote RCTs that are produce results supporting the Bobath Concept. This obviously undermines their argument that an RCT cannot evaluate the Bobath Concept.

2. The treatment delivered in RCTs of Bobath does demonstrate modern or optimal Bobath.

By and large, the Bobath delivered in the RCT represents Bobath as practiced in the real world by Bobath trained therapists. If this is substandard, then the Bobath tutors who trained the therapists need to reflect upon the efficacy of their training. In an attempt to address this issue Lennon et al. (4) investigated the effectiveness of Bobath on gait when delivered in optimal conditions. Patients with greatest potential for improvement were selected and treated with unlimited input by either a Bobath tutor or expert Bobath therapists. However, the results showed that there was no change in the primary outcome concerning quality of gait. The expert Bobath treatment just did not work.

3. The evidence against Bobath is not overwhelming, it is insufficient

We disagree, there is much evidence about the efficacy of Bobath; it just does not support the use of Bobath. For example, a systematic review of Bobath for stroke rehabilitation in 2009 found only three RCTs with results favouring Bobath, yet 11 in favour of alternatives (5). The authors concluded that therapists should base their treatment methods on evidence-based guidelines rather than any named therapy approach, noting that the Bobath Concept is now regarded as obsolete in some European countries. In the same year, a NHS review of stroke rehabilitation concluded “it is increasingly difficult to justify the continued use of the Bobath Concept or its associated techniques” (6). More recently Novak et al. (7) reviewed the effectiveness of interventions for the treatment of cerebral palsy (CP). They concluded “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 [Bobath] within clinical care”.

Only one national guideline for stroke recommends use of the Bobath Concept (8), but even here it was given the lowest possible endorsement, saying it “may be considered” for gait rehabilitation. The same guidelines identify several other treatments with much stronger evidence that “should be performed” or are “reasonable to perform”. The recently revised UK’s RCP National Clinical Guidelines for Stroke (9) recommend many rehabilitation modalities yet make no mention of Bobath. Importantly, the authors stated that if a treatment is not mentioned, then it was not recommended and need not be funded. They also assert that therapists using such methods must objectively review their options in the light of the evidence supporting the recommended alternatives and patients receiving such interventions should be informed that it was outside mainstream practice.

4. The Bobath Concept is no worse than alternative approaches

Research comparing treatment “concepts” or “approaches” has, indeed, failed to distinguish between them, but the notion of basing professional practice on any concept or approach has been superseded by the use of more effective specific interventions (as noted above).

5. The Bobath Concept is a problem-solving approach and provides individualised client care.

This is an irrelevant detail. All professional health care involves holistic problem-solving and an individualised treatment plan. The Bobath Concept cannot claim these aspects of professional practice as their own. Indeed, their paper (10) clearly demonstrated that the reasoning processes of Bobath instructors are no different to those of other health professionals.

6. The Bobath Concept is evolving

Over the years, several of the key teachings of Bobath’s founders have been abandoned, whilst the ideas and evidence of others have been incorporated and are now claimed to be part of the Bobath Concept. This approach is justified by claims the concept has evolved. However, this notion has been challenged by the President of the American Academy of Cerebral Palsy and Developmental Medicine and the Past-President of the UK Association of Chartered Physiotherapists in Neurology (a former Bobath tutor) (11, 12), who feel that ‘modern Bobath’ no longer represents the key ideas, beliefs and techniques of its originators and the term ‘Bobath’ should no longer be used. Despite this, there a steady stream of textbooks, courses and some academic publications seeking to justify the Bobath Concept. All of these are produced by Bobath tutors who make their living (or at least part of it) by running Bobath training courses. This conflict of interest (which has not always been made clear) should be borne in mind when considering such publications.

Sincerely

Roger Mepsted. MCSP, BSc, PhD. Carlisle, UK.

Sarah Tyson, FCSP, Msc, PhD. Professor of Rehabilitation, University of Manchester, UK.

References

1. Cott C, Vaughan‐Graham J, Brunton K. When will the evidence catch up with clinical practice (Letter to the Editor). Physiother Can. 2011;63(3):387‐390.
2. Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. BMJ. 2000;321(7262):694-696. doi.org/10.1136/bmj.321.7262.694.
3. Medical Research Council. Developing and evaluating complex interventions: new guidance. 2006. https://www.mrc.ac.uk/documents/pdf/complex-interventions-guidance/. Accessed 31 May 2017.
4. Lennon A, Ashburn D. Baxter D. Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke. Disability and Rehabilitation. 2006;28:873-881.
5. Kollen BJ, Lennon S, Lyons B et al. The effectiveness of the Bobath concept in stroke rehabilitation. Stroke. 2009;40(4): 89-97. doi.org/10.1161/STROKEAHA.108.533828.
6. Tyson, S. 2009 Annual Evidence Update on Stroke rehabilitation – Mobility, NHS Evidence. 2009. http://arms.evidence.nhs.uk/resources/hub/37914/attachment.
7. Novak I, McIntyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev. Med. Child Neurol. 2013;55:885-910. http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pdf.
8. American Heart Association/American Stroke Association. Guidelines for adult stroke rehabilitation and recovery. A guideline for healthcare professionals. Stroke 2016;47:e98-169. doi.org/10.1161/STR.0000000000000098.
9. Royal College of Physicians. National Clinical Guideline for Stroke. Fifth edition. 2016. Section 1.8.. https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx. Accessed 31 May 2017.
10. Vaughan‐Graham J, Cott C. Phronesis: practical wisdom the role of professional practice knowledge in the clinical reasoning of Bobath instructors. J Eval Clin Pract. 2016;14. https://doi.org/10.1111/jep.12641
11. Damiano D. Pass the torch, please! Developmental Medicine & Child Neurology. 2007;49:723–723.
12. Mayston M. Letter to the editor. Raine: a response. Physiotherapy Research International. 2006;11:183-186.

Contemporary Bobath Part 3: Scoping review of Bobath studies

Hello All, hope you are keeping well and coping with these viral dramas. By way of distraction here is my review of the 3^rd paper in this series of papers on ‘Contemporary Bobath’ led by Dr Julie Vaughan Graham. Here is the reference the link to the paper.

Julie Vaughan-Graham, Cheryl Cott, and F. Virginia Wright The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part II: intervention studies perspectives. Disabil Rehabil, 2015; 37(21): 1909–1928DOI: 10.3109/09638288.2014.987880

file:///D:/miscillaneous/bobath/Blog/posted/VG%20Syst%20review%20Part%202%20bobath%20studies%202015%20.docx.pdf 

The aim was to do a scoping review of papers published 2007 – 2012 about the effectiveness of the Bobath Concept for adult neuro rehab. The quality of the methods used or the robustness of the findings of the selected papers weren’t addressed (as is the norm for a review), instead the focus was on the ‘theoretical framework’ used; population recruited to the study; fidelity with which the interventions were delivered; duration of the treatment provided; outcome measures used; with an ‘overview’ of the results in the selected papers. The authors explain each of these issues but don’t give any information about the criteria on which they were judged, or what made them decide whether something was good, bad or indifferent. I guess the response to this could be that’s it is a narrative review – but even narrative reviews need to set their context/ criteria a priori.

Seventeen studies were selected (11 RCTs, 1 prospective parallel group design, 5 N-of-1) and a systematic review. It is unconventional to include a systematic reviews in another review (unless one is specifically doing a review of reviews which, by and large I would avoid like the plague!) as unless one’s search strategy has gone wrong any papers in the review should also come up in one’s search so you end up ‘double counting’.

The first issue considered was the ‘theoretical frameworks’ – by which the authors meant the references used for the Bobath Concept in the selected papers, implying that they consider each was a different framework or version of Bobath. They state that some of these are out of date (but not which ones or why). Thus implying that the Bobath delivered was not ‘real’ Bobath and that any future studies should use the most recent publication describing the most up-to-date version of Bobath – which they just happens to have written. This may be an innocent coincidence or it could be pretty shameless self-citation, who knows. If nothing else, this does illustrate rather neatly how no-one really knows what Bobath is or how it should be done. It is also a rather nice marketing ploy- “Hey Guys, don’t worry if the old Bobath doesn’t work, take a course in the new Bobath, that’s much better”. It’s also a tad disingenuous because, as detailed in the previous two blogs, despite multiple publications, the Bobath doesn’t seem to have really changed much since 2007.

However Bobath has ‘evolved’ over the years, it have never come from an evidence-based stand-point. The publications about how Bobath is defined and practiced have always been a matter of a small group of Bobath tutors getting together and stating what they think Bobath is now. Raine et al (2007) did make some statements about what has been dropped (although, as detailed in the previous blog the Bobath tutors have carried on using the statements that were meant to be defunct). There has never been a clear description of the evidence/ theory that promoted the evolution, ie what new stuff has gone in and why, nor  why stuff has been dropped. So it is anyone’s guess what similarities and differences there were between the Bobath that was delivered in the selected studies and whether/how it differs from the latest version. Having studied the way Bobath has ‘evolved’ over the years in some detail, I can safely say that little has really changed in what is delivered. The buzz words have changed, and fashions have come and gone but when boiled down, it is all much of a muchness. I’ve written about what Bobath is (or isnt ,and how it has evolved (or not)) before so I wont repeat it here. But in conclusion, the argument that the Bobath delivered in the selected studies isn’t representative of Bobath because the references weren’t the authors’ latest version of Bobath isn’t a strong argument that the Bobath delivered in the studies was flawed and the results can be discounted.

Connected to this is the authors’ criticisms of the way Bb is operationalised in the different studies – ie what was done and how. They complain that it wasn’t clearly described or documented. This is a fair criticism that applies to nearly all research into complex interventions. It is extremely difficult to describe a multi-facetted intervention which is individualised to each patients’ needs and local context. Inevitably one ends up spending a lot of time saying “err, it all depends” when trying to explain what was done and how. So the authors have a reasonable argument for saying that the Bobath delivered was not clearly defined or described. Having said that, the irony of a Bobath tutor complaining that delivery of Bobath is not clearly explained did bring some sunshine into a rather chilly, dully spring! There are structured methods to explain the content of complex interventions such as the TIDIER framework and logic models, I don’t think that any of the selected studies used these and the authors don’t mention these. Perhaps they don’t know about them. It would be very good, and add much credibility if they were included in the publications to update the Bobath concept.

Another issue regarding delivery of the Bobath in the selected studies raised by the authors is the fidelity of the treatment delivered– that is the accuracy of, and adherence to the intervention. Was the intervention in the study delivered as expected and in the dose intended? I haven’t checked, but I don’t expect that the selected papers did report the fidelity (as historically few studies did this). There are ways of doing this – such as completing treatment logs, videoing treatment sessions and the like but usually only very big trials have the funding and staffing to do this. A reasonable criticism of the selected studies is that one cannot be really clear about what Bobath was delivered and how – but then no-one has ever managed to be clear about this. However, the authors’ consideration of the fidelity in the selected studies doesn’t consider how/ whether the content or dose of treatment was monitored but rather focusses on the training received by the therapists delivering the Bobath and whether they were ‘competent’ Bobath therapists. They do not define what constitutes a competent Bobath therapist, but they do imply that a reason for lack of effect found in the selected studies was that the Bobath wasn’t done very well. As the quality of the Bobath delivered depends on the quality of the training the participating staff received, and the authors are in the business of providing that training, the irony is stark! Most of the studies included therapists who had completed the basic Bobath course at least, so for good or bad, they do represent Bobath as it is delivered in real world practice. If that isn’t very good then the tutors only have themselves to blame. In a final ironic twist, the authors fail to note that some of the selected studies include Bobath tutors who were delivering the therapy, so the notion that the treatment wasn’t delivered effectively seems something of an own goal.

The next aspect of the way the interventions in the selected studies were delivered raised by the authors is individualisation of the treatment provided. The authors claim that the studies did not offer individualised treatment, which is nonsense. All physiotherapy treatments are individualised. It would be unethical to deliver the same treatment in the same way to every patient regardless of whether it suited them or not and I struggle to belief that any physio would do so. So this is not really a relevant point. The authors also complain that the Bobath treatment wasn’t provided for long enough in the selected studies, but as it was provided for the same length of time as the comparator intervention, this is another red herring

Then the authors consider the comparator interventions. In several of the selected studies the Bobath provided was the control treatment (ie usual practice/ standard care) – not that this makes any difference. They note that the interventions compared to Bobath were a range of other interventions and approaches and claim there is insufficient difference between the comparators and Bobath as the comparators are ‘allowed’ as adjuncts to Bobath. This isn’t a reason to negate the trials as although the tutors claim that many interventions can be included as part of Bobath, they never actually use them. It also returns us to the issue of ‘what is Bobath?’ In the systemic review of papers attempting to define Bobath reviewed in the previous blog, some of the tutor/authors specifically said that adjuncts are ‘allowed’ (but others disagreed). The adjuncts weren’t included as pert of the Bobath Concept in the conclusions of the review, so goodness who knows whether they are in or out?

The next issue the authors raise is the outcome measures used in selected studies, saying that they did not measure the right things. They say that as the ultimate aim of treatment is greater activities / less disability (wouldn’t argue with that) they criticise the selected papers for primarily measuring impairments. A fair point, I would expect the primary outcome to be a measure of activity, as it should be the ultimate goal of any treatment, but there is no problem with measuring impairments as secondary outcomes. In fact it would be welcomed in to assess a multi-facetted intervention. But in a contradictory twist, the authors complain that as quality of movement (an impairment) is the main purpose of Bobath, this should have been measured. This is much easier said than done as, despite much discussion, no definition of ‘quality of movement’  has been presented or adopted, even by the Bobath tutors. So it is not surprising that it wasn’t explicitly measured, as no one is really sure what it is, nor is there an accepted way to measure it. Having said that several of the selected studies have included movement analysis measures such as symmetry, step length, range of movements etc which is as close as one will get to quality of movement.

Then the authors claim to inform policy saying that randomised controlled trials aren’t suitable designs to evaluate Bobath due to “the diversity of practice settings and of clients’ needs and preferences” – which is balderdash. There is no reason why you can’t do RCTs in varied settings and with wide range of patients: that is what pragmatic trials are designed to address. The authors recommend that future RCTs should improve the way in which treatment fidelity is monitored – I agree and would add that details about how Bobath is implemented should be addressed too. They go on to say that small N or observational studies should be used in preference to RCTs and consider these a higher level of evidence than RCTs. This is suggested by proponents of ineffective treatments in all fields because it is much easier to get a false positive result in a poor quality design such as ‘small N’ and observational studies. The argument is just as silly here as it is from enthusiasts of ineffective treatments such as homeopathy, reflexology, craniosacral therapy or energy medicine. If they really do think this, the authors just don’t understand the basic principles of bias within research designs.

In conclusion, the authors opine that the selected evidence looking at the effectiveness of Bobath is flawed  because of their criticisms of the fidelity, outcome measures, therapists’ skill, the version of Bobath used and supposed lack of individualized interventions. As you can tell from the text above, these criticisms are not really very strong. Treatment fidelity and description of the intervention could no doubt be improved but these aren’t reasons to dismiss the results, they just mean that it isn’t very clear what was done or how – and, as has been demonstrated many times no-one really knows what Bobath is or how it is done! The other supposed criticisms raised are red herrings. They certainly don’t support the conclusion that the evidence is seriously flawed. My conclusion would be that the authors have selected a body of evidence that shows Bobath tends to be less effective than other intervention, is usually better than nothing but is certainly no better than anything else. The selected evidence isn’t perfect but it isn’t imperfect enough to be dismissed.

Stay well everyone

Contemporary Bobath – a definition

Hello again. Hope you enjoyed the last review of this series of papers regarding contemporary Bobath led by Dr Julie Vaughan-Graham. The next study is a scoping review in two parts which were published in 2015. Part 1 covers the conceptual basis of Contemporary Bobath and the 2^nd reviews the evidence on the effectiveness of Bobath. Here’s the reference and link to the 1^st one.

Julie Vaughan-Graham, Cheryl Cott and Virginia Wright. The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part I: conceptual perspectives Disability and Rehabilitation, 2015; 37(20): 1793–1807 DOI: 10.3109/09638288.2014.985802

SR of definitions of Bobath VG 2015

This was relatively a short and straight forward paper but, perhaps unsurprisingly there is a lot of overlap with the paper in the last blog which aimed to define contemporary Bobath as it is included here. I was quite tickled to see that a couple of my papers had been included too!

The paper’s objective was to describe and synthesise what is known about (adult) Bobath, identify knowledge gaps and develop recommendations for future research. It used standard scoping review searches (including grey literature) from 2007 to 2012 and thematic analysis techniques – all good straightforward stuff.

They found 14 publications aiming to define the theoretical foundations and identify key aspects of clinical practice of the contemporary Bobath concept, which included three theoretical papers, four surveys, a Delphi study (two papers), one qualitative study, three letters to the editor and one editorial. Nine of the selected papers were written by, or with Bobath tutors. Which seems an awful lot! Does it really take one group of professionals who teach this stuff day in and day out nine publications to work out and explain what they doing? Apparently so! Hopefully this review will let us know whether it needs so many because it very complicated; rapidly changing, or just flogging the same poor old horse. The selected papers include four surveys of clinicians about their understanding of Bobath, rather than the tutors and three editorial type papers (by tutors). I have just focussed on the papers by the tutors so, hopefully we can get to the nitty gritty of what they think Bobath is.

The upshot of the review is a definition of 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”. This is consistent with the Dr VG’s paper discussed in the last blog, and has nothing which distinguishes from any other aspect of neurological physiotherapy. We also highlighted that although the Bobath tutors say that they focus on activity and participation, the evidence of Bobath in action (see videos and photos in the last blog) indicate that they rarely, if ever actually do this.

The next section of this current paper is about the ‘key aspects of [Bobath] practice’. This neatly highlights how Bobath ‘talk the talk’ about focusing on function/activity but does not ‘walk the walk’. The key aspects of practice are all about impairments (eg postural control, alignment, selective movement, quality and efficiency of movement) rather than activity or participation. As discussed in the previous blog, I presume this is the mistaken belief that if one improves impairments there will be some automatic carry over into function. They don’t define any of these impairments (what is ‘selective movement? Of ‘quality of movement’?) and there is no evidence that they are related to function, or that Bobath treatment changes them. This focus on undefined, woolly impairments rather than activity and the belief that one gets carry over for impairment to function is one of the main areas where Bobath has got it wrong.

The section on key aspects of practice also highlights that the tutors believe sensory information has a fundamental role in motor control and that facilitation (which they say includes ‘environmental manipulation’ as well as ‘therapeutic handling’ nonw-a-days) is a skilled aspect of [Bobath] intervention.

New buzzwords are

• Movement deficits are limitations in the range of motor patterns normally available to healthy individuals. I don’t really know what this means. What is the ‘range of motor patterns’ on about? They may be harking back to notions of ‘pre-programmed’ patterns of movement that are somehow affected by the CNS lesion. Hmm, that’s not how motor control works, and contradicts the assertion below that hierarchical reflex theory has been dropped
• Movement analysis and treatment is based upon the integration of postural control and task performance, and the control of selective movement for the production of coordinated sequences of movement. I don’t really understand the point being made here. Of course postural control is integral or movement +/- task performance. What sort of eejit would ever suggest otherwise? You can’t do much if you can’t stay upright!! Is this just another important aspect of Bobath that is common to all other neuro physio? Maybe by saying Bb puts particular emphasis on this aspect of movement and function, they may be suggesting that if the postural control comes right, there will be an automatic transfer into improvements in function. As discussed, earlier in this blog and the previous one, that belief is mistaken

The authors also summarise what has been dropped from Bobath which is welcome (in the previous blog I criticised the authors for not making this clear). So the following are out

• reflex hierarchical theory
• basing recovery on the developmental sequence
• inhibition of reflex activity and spasticity
• preventing moving or function if compensations are being used.

However in the last blog we noted some contradictions. For example,  the definition of ‘tone’ (often considered a key aspect of Bobath, but not this paper) is the same as that for spasticity/hyperreflexia, so it looks like they have just replaced ‘spasticity’ with ‘tone’.

They also contradict themselves about the claim that compensatory movement is no longer prevented, Levin and Panturin (2011, one of the selected papers in this review) talk about “not permitting motor compensations’’ and problems “associated with suboptimal movement”, while Cott et al al (2011) emphasise that “optimal alignment” is essential.

There are several assertions in the papers selected for this review which are not addressed here, so we don’t know if they are in or out, . These include the previous:

• emphasis on normal movement (although Raine et al 2006 and 2007 say the Bb tutors have now swapped this for efficient movement);
• normalising tone (Raine et al 2006 and 2007)
• the importance of the trunk/core (from Cott et al al 2011) although I guess it might be part of the postural control/alignment thing- but it is never explained)
• enthusiasm for including “adjunctive therapies such as use of orthotics, treadmill, restraint, and muscle strengthening” (highlighted in Raine et al 2007)

The authors conclude by reiterating the definition of Bobath (which doesn’t differ from any other of neurological physiotherapy except for facilitation) and claim this is provides an updated framework of Bobath but tbh I can’t see anything of substance that differs from the paper discussed in the previous blog which was published six years previously except that it gives a list of things that have been dropped.

REFERENCES

• Raine S. The current theoretical assumptions of the Bobath concept as determined by the members of BBTA. Physiother Theory Pract 2007;23:137–52.
• Raine S. Defining the Bobath concept using the Delphi technique. Physiother Res Int 2006;11:4–13.
• Levin MF, Panturin E. Sensorimotor integration for functional recovery and the Bobath approach. Motor Control 2011;15:285–301.
• Cott C, Vaughan-Graham J, Brunton K. When will the evidence catch up with clinical practice. Physiol Can 2011;63: 387–90

A Review of Contemporary Bobath

Well hello! Its been a long time. I haven’t been active on this blog for several years as, tbh I thought that every that could be said about Bobath and the evidence-base had been said. But since then the Bobath tutors have published several papers which aim to update the Bobath Concept, many folk have asked me what I think. So here are my thoughts.

There are four papers which, I think come from the first author’s (Julie Vaughan-Graham, a Bobath tutor in Canada) PhD. The first which was published in 2009 aims to define and describe ‘contemporary’ Bobath; the 2^nd reviews the evidence for Bobath; the 3^rd is about clinical reasoning and Bobath, and the final one attempts to explain how Bobath is operationalised.

I will look at each in turn, and as you will need the paper with you to make head or tail of what I am saying I’ve posted them too. Also here are some to website pages and videos which show Bobath in action- tutors giving demonstrations, or photos from their websites, students on courses etc, so you can see how Bobath is being operationalised and whether the practice matches the rhetoric claimed in the papers.

https://www.bbta.org.uk/en/videos These are videos of the Bobath tutors during the courses giving demonstrations of how they do Bobath

https://www.bbta.org.uk/en/photos?archive=2019 NB there are photo galleries up to 2019 but nothing added since then. They are photos of the Bobath courses showing the tutors and students in action.

https://www.bbta.org.uk/en/case-studies?archive=2014 These are some of the case studies that students submit during Bobath courses (presumably the good ones).They are quite long and invariably rather difficult to follow because of the jargon and waffle but just look at the photos- what are they doing? NB there are only entries up to 2015.

https://www.bbta.org.uk/en/posters/20 Here’s a poster (also produced as part of the courses) on ‘scapular setting’. Just look at the positions they are getting the patient in – what function/ task is that addressing!?

Here are photos from the website from the Manchester Neurotherapy Centre website, which is a large private practice run by advanced Bobath tutors in North West England, of them in action. There may be a couple from the TherapyMatters website too, which is another provate practice run by another Bobath tutor, this time in Chester bobath in action photos

The following are youtube videos that these Bobath tutors have posted of themselves in action.

https://www.youtube.com/watch?v=YgRLagXE4jU

https://www.youtube.com/watch?v=9pTHM4cX-WM

https://www.youtube.com/watch?v=Ack4y1oNrSg

https://www.youtube.com/watch?v=9LNsmgh49Gs

Bear these in mind as you read the 1^st paper:

Julie Vaughan Graham, Catherine Eustace, Kim Brock, Elizabeth Swain & Sheena Irwin-Carruthers (2009) The Bobath Concept in Contemporary Clinical Practice, Topics in Stroke Rehabilitation, 16:1, 57-68, To link to this article: https://doi.org/10.1310/tsr1601-57

or here vaughan Graham Bobath in contempory practice 2015

The aim of the paper was to define the Bobath Concept as currently (ie in 2009) taught by International Bobath Instructors Training Association (IBITA) instructors, describe the underpinning theory, current clinical application and what differentiates Bobath from ‘other models of practice’.

We have been here before. There have been several publications which seek to update us about the most current version of Bobath. After Mrs Bobath’s text book, there was Pat Davies (a Bobath tutor from Switzerland) who wrote several books in the 80s and 90’s. In the 2000’s Sue Raine (a tutor from England) did an update as part of her masters and wrote a book (Bobath Concepts; theory and practice) with Linzie Meadows, Lynne Fletcher and Mary Lynch-Ellerington (also English Bobath tutors). Now we have this series of papers led by Dr Vaughan-Graham involving other tutors from the International Bobath Instructors Association. All of whom have attempted to explain how Bobath has ‘evolved’ and tell us what it is now, explain the underpinning theory and how Bobath is applied/operationalised. However, the publications all involve the tutors getting together and telling us what Bobath is at the present. Unlike other evidence based publications which aim to update the state of the art (Clinical Guidelines for example) they don’t explain what is new- what is in and what is out, and why. They just state what it is and presumably we should accept it without wondering why or how.

Time to have a closer look at what these tutors say about ‘contemporary’ Bobath. They define the Bobath concept as “as a problem-solving approach to the assessment and treatment of individuals with disturbances of function, movement, and postural control due to a lesion of the central nervous system. The concept provides a way of observing, analyzing, and interpreting task performance. The clinical implementation of the Bobath concept utilizes an individualized reasoning process rather than a series of standardized techniques”. Which is remarkably long-winded way to say that Bobath is a way of assessing and treating neurological conditions. All physiotherapy involves problem-solving, assessment and analysis, individualised treatment and is a process rather than just a technique. There is nothing in this definition which wouldn’t be applied to any other aspect of physiotherapy (neurological or otherwise, or most aspects of health care when it comes down to it).

The authors highlight several key issues to discuss.

Number 1 is the International Classification of Functioning, Disability and Health (ICF). I imagine that most of you are familiar with this but if not, it is an international collaboration which defines health, illness and disability in terms of pathology; impairments; activity/ disability, participation and environmental factors. It is a very useful framework on which to define and describe patients’ problems. The authors say that Bobath is congruent (an odd term to use) with the ICF and that Bobath clinicians have moved on from merely treating impairments, rather they now aim to overcome activity and participation restrictions. This isn’t new Bobath tutors have been claiming for some time that Bobath is all about function and not impairments – and rightly so. The aim of any treatment should be improve activity/function and addressing the patient’s goals rather than impairments . This is not only because patients don’t worry about impairments, their goals are nearly always activity-based and also because changes in impairments do not automatically translate in to changes in activity. So the Bobath tutors are on the right lines by saying that Bobath practitioners should focus on activity. BUT have you ever seen a Bobath tutor or students on Bobath courses doing anything functional? No me neither. Have a look at the videos and photos listed above, no practice of functional tasks going on there. I guess we should be pleased they are at least starting to say the right things, but they need to walk the walk as well as talk the talk.

Movement Dysfunction The next issue is movement analysis. The authors present a lot of evidence about motor control theory, postural control and the like (Bernstein, Mulder, Shumway-Cook etc). All standard stuff, I have been teaching to undergraduates for years – but none of it is specific to Bobath. Interestingly, neither is it connected to Bobath. It sort of sits alongside it, implying a connection but none are actually made – nothing about how the evidence/theory is interpreted or applied in Bobath.

One thing the authors do say is that the Bobath concept places particular emphasis on the “integration of postural control and task performance, the control of selective movement for the production of coordinated sequences of movement” and the “contribution of sensory inputs”, and that these factors are considered the key to recovery and function. Again this is rather unnecessarily wordy and hardly unique to Bobath say that postural control and sensory integration go hand in hand and that both are important for function- would anyone argue otherwise?

Spasticity/ Tone Next up is a section on movement dysfunction in which the authors present theory (referenced appropriately) about the causes of movement dysfunction in stroke- upper motor neurone syndrome, etc. Again standard undergraduate stuff.  They do mention weakness (briefly) but nothing about whether Bobath aims to treat it or not. They define spasticity (using Lance’s hyperreflexia definition) and say that it is recognised that spasticity is not the main cause of movement dysfunction now-a-days (good- a little bit of progress towards the evidence-base). Then they talk about ‘tone‘ (but don’t define it) saying that “Bobath therapists treat both the neural and non-neural components of tone”. Now, in the rest of the world outside the Bobath bubble, these components are recognised as contributing to spasticity and contracture (tone doesn’t really have much credibility as a concept outside Bobath World) so it seems that they have just replaced the Bobath focus on spasticity with another word – tone. Oh dear. They also fail to note that weakness is the main cause of motor dysfunction and therefore should be the main focus if one is treating the impairments that limit function. Bobath’s apparent on-going focus on spasticity/tone as a treatment priority and failing to treat weakness is against the evidence base and one of the areas where they go wrong.

Compensations Another big issue in Bobath is ‘compensations’, which the authors consider in several places in the paper. I have put them altogether here. They say that the reason that it is important to treat tone is it will “improve muscle activation patterns and minimise unnecessary compensations”. Tbh I’m not really sure what “muscle activation patterns” are. The authors don’t offer a definition but these patterns are often described as being task-specific. My best guess is that they just mean the muscles that are producing a movement (which are task specific, obvs) although what they mean by specifying ‘activation’ is anybody’s guess.

The authors don’t define compensations but I reckon they are talking about the different/ altered/ abnormal movement patterns that patients use to achieve a task or movement compared to the way they would have moved before their stroke (so called ‘normal movement’). The authors say that compensations are undesirable when they prevent the “reacquisition of other strategies available to the person”. Again, I’m tad lost in the waffle but I think it means the authors believe that if that person is using ‘compensations’ to move then it stops them relearning how to move in the way the Bobath people think the patient should move – which used to be called normal movement but the authors seem to be avoiding this term now-a-days.

Later in the paper they talk about ‘appropriate’ and ‘inappropriate’ compensations. Appropriate ones are those that are necessary to perform a task but disappear once the movement has stopped. Inappropriate compensations are those that “persist beyond the completion of a task”. They say that these inappropriate compensations “limit other functions, or mask potential for further recovery”. They also state that in Bobath patients are NOT prevented from functioning in order to avoid compensations, and it is a “misinterpretation of the Bobath Concept” that perfect alignment [of body segments] is needed before “engaging in task performance” (does that mean doing things?) I soooo hate the term “misinterpretation of the Bobath Concept” which the Bb tutors use when they mean they have changed their minds and are trying to drop something that they realise is nonsense, but won’t/can’t admit they were wrong. So they make out that it is our fault for getting the wrong end of the stick. I mean they did the teaching, if we all ‘misinterpreted’, who’s fault is that? There have been many misinterpretations over the years- sticks/ tripods/ AFOs are bad; exercise and strengthening is banned; inhibiting released reflexes; spasticity is the problem; normal movement is the aim etc etc etc. Their credibility would be greatly enhanced if they recognised and accepted where they were wrong and then moved on.

Either way, they are playing down the former focus on ‘normal movement’ and preventing functional tasks if compensations are used – a bit. As is so often the way with Bobath, the authors give with one hand and take away with another, contradicting themselves on the way. Having said that Bobath practitioners would not prevent function to avoid compensations, a bit further on in the paper they say that patients shouldn’t do something that will “impact on the potential for future performance”. Given that they believe compensations prevent the patient relearning ‘alternative strategies’ and cause secondary complications, they DO mean avoiding tasks that involve the patient using compensations to move.

This issue of compensations is important and it is one of the things that makes Bobath different from other aspects of PT, and where they are wrong. Although there is a certain logic to the belief that practicing using compensations prevents patients from learning more normal movement patterns, it isn’t supported by evidence. In fact compensations are the most effective way a patient can achieve a task with the motor function they have at the time; compensation is good- it enables the patient to function; as the patient becomes stronger and more skilled the compensations change with it. I find it helpful to think of compensations as overflow and radiation (remember that from undergraduate physio training!) of muscle activity. As the patient isn’t able to produce the same muscle forces and movements to perform a task as they would have before their stroke, they now recruit whatever muscle action they are able to produce to make the movements (or as close as they can get). It’s a normal mechanism working from a very low starting point. As they get stronger and more skilled, less overflow and radiation into other muscle groups is needed as the movement and muscle activity becomes more normal (not that it gets to ‘normal so perhaps less abnormal is more correct).

Having said that I am not suggesting that patients should do anything, any old how- safety is paramount (obvs) and then achievement of function- often using aids and equipment to achieve both. The skill of the therapist is to adapt of the task (what you are getting the person to do and how they are doing it) and the environment (including providing aids, equipment etc) to enable the patient to practice safely and effectively, and then to keep the challenge up by progressing as much and as soon as possible towards more normal movement patterns.

The authors’ next topic is neuroplasticity and motor learning – again standard undergraduate, none of it specific to Bobath, nor connected to it in the text. They say that Bobath uses “task-specific muscle activation patterns and sensory input to enable successful completion of the task”. They don’t explain how these aspects of movement are ‘used’ within Bobath. Let’s face it, it is pretty hard to avoid using muscle activity and sensory input to complete a task or a movement. They also claim that Bobath should include practicing tasks in different situations. Good idea- as it is key to successful motor learning and carry over in to everyday activity. So like the emphasis on activity, they are saying the right thing. But are they doing it? Have you ever seen a Bobath tutor working on  a functional task? Or getting the patient to actively practice a functional task? Or work in any environment other than a Bobath plinth? No, me neither. More talking the talk.

They also say that “Improvement of task performance is not only limited to practicing the task”. Like tone and compensation, this is important and is an area where Bobath differs from the rest of physiotherapy – and they are wrong. It is the belief that by treating the ‘underlying impairments’ (which seem to be always be postural control and ‘motor activation patterns’) you get automatic transfer from the impairments in to activity. This is just wrong! You are/do what you practice (whether you are healthy or disabled, it is a new skill or you are improving an existing one). At the very start of learning one might break the task down in to component parts (which is called part task practice) while you get your head around it (cognitive stage of learning) but it is essential to put these together into a whole task practice as soon as possible. The idea that by facilitating and mobilising body parts one changes the way a task is performed is one of Bobath’s main failing.

Facilitation. Then there is a section on facilitation, possibly the only thing that is specific to Bobath. They define facilitation as “the use of afferent information approximating that usually experienced during performance of the motor task to effect improvements in motor performance”. Later in this section they claim the facilitation has all sorts of effects- improves muscle activation, overcomes inertia, maximizes inter-joint coordination, minimizes abnormal muscle coupling and/or excessive co-activation; enhances stabilization and decreases compensations which in turn improves performance. They say this is all part of a motor learning process. They claim that this occurs because performing movements in a familiar way “uses neural substrates that do not demand excessive cortical attention” and they “access existing, undamaged neuronal circuits rather than having to learn a new Skill”. They also claim to be activating and modifying central pattern generators for good measure. They quote a couple of studies which examined the effects of facilitation.

There is, of course no evidence to back up these claims. The studies they mentioned do show some changes in movement pattern during facilitation but fail to mention that the movement patterns returned to baseline when the facilitation stopped – ie no carry over effect, which, by definition means no motor learning! This isn’t really surprising as neuroplasticity and motor learning are promoted by intensive, challenging, individualised, task-specific practice undertaken by the patient in varied situations. Facilitation doesn’t provide that. The Bobath tutors claim the patient is active during facilitation, but if you look at the photos and videos of Bobath in action you will see that the patient is generally passive (usually sitting) while the therapist does something to them. It isn’t intensive, the number of reps of anything is very low. Thousands of repetitions are needed to (re)learn skills. It isn’t functional or task-specific – try to work out what function is being worked without any clues from the commentary or text! It isn’t challenging – the patient is nearly always passive as they are being moved about. It isn’t done in a variety of situations – again have a look at the videos and photos, nearly all are on or by a Bobath plinth. So all in all facilitation is just about the antithesis of motor learning.

Furthermore there is no evidence that facilitation makes the patient feel the same as they did before their stroke, and I would think it highly unlikely if the patient has any sensory deficits. The whole idea of motor relearning is that the patient learns how to produce movements and how that feels with the body /activity they now have (this is the cognitive stage of learning) and then works to improve those movements (by getting stronger, and becoming more skilled as they move to the automatic stages of learning). Physically guiding the patient through the moment can be a useful short-term technique during the cognitive stages of learning while the patient is working out how movements feel NOW with their impaired body and therefore how to produce the movements again. They are not feeling the same as they were before (nor are they going to). They are not moving in the same as way as they were before (even when facilitated), nor are they going to. So guiding movements during part and whole task practice can be useful initially but it is a temporary stage, which should be overtaken by the patient working for themselves as soon as possible, it is not a treatment in itself. As for – muscle activation, inter-joint coordination, abnormal muscle coupling, co-activation neural substrates, cortical activation, central pattern generators and the like – there is absolutely no evidence that facilitation has any effect on these variables. It is at best a hypothesis, and a fairly far-fetched one at that.

So in summary, the original aim of the paper was to

1) define ‘contemporary’ Bobath – which it has done. It’s rather waffle-some and full of undefined jargon, much of it is indistinguishable from all other aspects of PT. They have just stated the tutors current thinking – no clear statement about what is new and what has been discarded, nor why.

2) to describe the underpinning theory. They have presented well known and widely applied theory but haven’t explained how it relates to Bobath

3) describe the current clinical application. Well they have said lots of things about what Bobath is, and a few things about what it is not. There is much waffle here so it not clear how one actually does Bobath. However it appears there are some aspects which are unique – the focus on tone/spasticity, postural control, ‘muscle activation patterns’ and compensations as the main cause of movement dysfunction; facilitation as the means of addressing them; the belief that changing ‘underlying impairments’ will change function – all of which are counter to the evidence about what is most effective to enable people with neuro conditions recover function. This is where Bobath has got it wrong. They also claim that Bobath includes several aspects of practice which are evidence-based and effective – that is, Bobath focusses on activity rather than impairments; that the patient is active during treatment; and treatment is to interdisciplinary. However the evidence from photos and videos of practitioners in action contradicts that.

4) explain what differentiates Bobath from ‘other models of practice’. This hasn’t explicitly addressed in the paper but I’ve drawn it out in this review. The bits that are unique to Bobath are the bits that are not supported by evidence and are ineffective. The authors do say that Bobath differs from CIMT or motor relearning as it can be used for a wider range of patients. I haven’t come across the notion (or any evidence) that motor relearning isn’t suitable for many patients, so I don’t think the argument that motor relearning isn’t suitable for many patients is any stronger than the argument that Bobath is. I agree that when first developed CIMT was limited to people with some activity in their upper limb but it has developed further to include most patients now-a-days.

What do you think?