Readers’ comments – How to do Bobath Part 5

jackie wright says: October 20, 2015 at 10:04 am

Thank you SarahT for clarifying and bullet point listing statements from Bobath Tutors on Facilitation. I have duly made my comments to each bullet point on my own iCSP thread http://www.csp.org.uk/icsp/topics/bobath-research-why-there-none#comment-132556?utm_comment=253829
In my last post to your blog I asked to be called Granny Jackie. I am now not sure whether I like the name! Would it be possible to change it again to either JackieW or JacquelineWright?
Best Wishes Jackie

Sarah Tyson says: October 20, 2015 at 5:22 pm

Hi Jackie
You can be called whatever you like! JackieW it is.
BB – stands for Bobath

Jose Lopez says: October 20, 2015 at 10:53 am

have you read these articles? http://www.ncbi.nlm.nih.gov/pubmed/12210789 and https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-2006-943591 … what’s your opinion? Thanks!!

Sarah Tyson says: October 21, 2015 at 9:37 pm

Hi Jose
Here are my thoughts

Both papers were produced by the Bobath Memorial Hospital in Japan and used near Infra-red spectroscopy (NIRS) to measure cerebral blood oxygenation (an increase in oxygenation levels is assumed to indicate increased brain activity) while walking. In the 1st study they recruited 6 young (mean age 57 years) sub-acute stroke survivors with a severe stroke, who were unable to walk in every-day life. They measured NIRS, step frequency (cadence) and swing time symmetry while patients walked on a bodyweight supported treadmill. They walked for 2 mins, divided in to 4x 30 seconds spent walking (with 30s rest in between). During two of the walking phases the participants’ gait was also facilitated at the pelvis and for the other two walks their weak foot or thigh was “held by the therapist to help swing in the swing phase and to ensure stable stand phase”. For an inexplicable reason, they called this mechanical assistance but it sounds very much like facilitation to me.

They found that the medial sensorimotor cortex, primary, supplementary and pre-supplementary motor areas are activated during hemiplegic gait in patients with severe stroke – as found in healthy patients but the activation was more asymmetrical than healthys. So no real surprise there. They also reported found that the activation levels were higher during the BWSTT+ pelvis facilitation than during BWSTT+Leg facilitation during the 30s that the participant was walking. What does it tell us? Not much. It shows the cortical activation while walking with BWSTT + facilitation for a very short period – much as one would expect. It doesn’t tell us anything about whether facilitation has any effect, or not To test this, one would have to compare with walking while facilitated with walking without facilitation or BWSTT for a feasible period (ie longer than 30s). There may be some limited value of testing whether gait pattern is altered by facilitation while the ‘hands are on’ but in order to make any meaningful claim of a treatment effect then one would also need to demonstrate an enduring change once the facilitation was removed. The paper by Hesse et al (described in the Blog post on facilitation) showed that gait pattern reverted to pre-facilitation levels within half an hour.

The 2nd paper is a congress abstract so it is very brief. The same team compared NIRS while walking in 6 children (aged 5-11) with 3 healthy children of a different age (9-11 years). This is not a meaningful comparator group; the control group needs to be age and sex matched to the CP group. The children walked for 30s under 3 conditions. Condition 2 was walking while swing phase was facilitated. We don’t know what the other two conditions were. They found no change in cortical activation in the healthy children (which one would expect- the technique didn’t work). In the children with CP, cortical activation was increased during the 1st task and reduced during the 2nd and 3rd. But we don’t know what the 1st and 3rd tasks were. What does this tell us? Nothing really.

jackie wright says: October 22, 2015 at 11:10 am

Hi Sarah and Jose.
The Ichiro Miyai et al paper on restoration of gait sounds very useful. It is interested that the activation levels were higher during BWSTT+ pelvis facilitation than during BWSTT+ leg facilitation.
Thank you Sarah for summarising the paper. I tried to download the whole article but found I was restricted because I have never had a paper published. I agree with you that “facilitation” is better wording than “mechanical assistance”.
Using my personal understanding of “compensatory trunk stability” I would hypothesise that the therapist’s hands on the pelvis were facilitating normal weight bearing through the stance leg and were also preventing asymmetrical compensatory trunk stability.
I do not find Hesse et all’s paper on gait pattern surprising. I too have found that “carry over” is often poor with many patients. I believe it is fear of falling that prevents patients from selecting a non compensatory gait.
Re Facilitation and learning new movements plasticity etc, I find that most of the practice learning etc occurs between physiotherapy sessions and not during the session. Thus “carry over” is much better when the patient is motivated to practice on his own.
Best wishes
Jackie

Sarah Tyson says: October 22, 2015 at 7:35 pm

Jackie
Sorry you can’t access the paper, I don’t think I can post it on the blog because of the copyright limitations. I wouldn’t read anything into the differences found in the paper tbh. The sample size is sooo small that many would consider an attempt at statistical comparison meaningless. I was always taught that no statistician worth his/ her salt would get out of bed for less than 10 subjects.
Another point occurred to me after I had posted yesterday ….. If, as the Bobath’s tutors claim, facilitation manipulates specific afferent/ sensory inputs, then one would expect activity in the sensory cortical areas. But that doesn’t appear to occur …….

jackie wright says: October 24, 2015 at 10:08 am

Sarah
Are you suggesting there should be more sensory cortical activity with hemiplegic patients than with normal healthy subjects not receiving physiotherapy handling?
If so I disagree. Does not the “Placing” handling/assessing technique as described by Berta Bobath (1990) facilitate normal postural reflex mechanisms? Are not these postural reflexes situated in the lower areas of the CNS such as the spinal cord, cerebellum and basal ganglia?
My observation with hemiplegic patients is that sensory awareness is not essential to the process of facilitating normal postural reflexes.
Best wishes Jackie

Sarah Tyson says: October 24, 2015 at 4:27 pm

Hi Jackie
I’m saying that if facilitation has its affect (if there is one) by manipulating sensory inputs and some how this improves neuroplasticity and motor learning (the stated underlying mechanism of the Bobath effect), then one would expect to see signs of the brain processing that sensory manipulation and integrating it into their motor activity. But activity in the sensory areas isn’t reported in the above paper. As I’ve said, provide very low level evidence (many would classify it as (pre)-pilot testing) in a very small non-representative sample so I wouldn’t read much in to the results one way or another. But the results such as they are aren’t supporting the idea that facilitation manipulates sensory inputs, and it is the only study (as far as I know) that has attempted to consider the effects of facilitation on neural activity.

jackie wright says: October 25, 2015 at 11:30 am

I agree with you Sarah one would expect to see some sort of activity in the sensory cortex where the physiological process entails neuroplasticity and learning. But the physiological processes I am talking about is about sensory stimulus and reflex response. By supplying the correct environment the patient is then subjected to the appropriate sensory stimuli which accordingly activates the appropriate motor response.
Yes I agree with you that stroke rehabilitation is mainly about neuroplasticity and learning. But could not this physiological activity be occurring between physiotherapy sessions than during a physiotherapy session?
By the way do you know who first coined the phrase “Sensory Manipulation”? I don’t think Berta Bobath used this phrase.
Best wishes Jackie

jackie wright says: October 25, 2015 at 10:39 am

I agree with you Sarah one would expect to see some sort of activity in the sensory cortex where the physiological process entails neuroplasticity and learning. But the physiological processes I am talking about is about sensory stimulus and reflex response. By supplying the correct environment the patient is then subjected to the appropriate sensory stimuli which accordingly activates the appropriate motor response.
Yes I agree with you that stroke rehabilitation is mainly about neuroplasticity and learning. But could not this physiological activity be occurring between physiotherapy sessions than during a physiotherapy session?
By the way do you know who first coined the phrase “Sensory Manipulation”? I don’t think Berta Bobath used this phrase.
Best wishes Jackie

jackie wright says: February 20, 2016 at 8:01 am

I like your title Sarah for this Part 5 “The Facilitation Thing”. I do believe that “Facilitation” is the key word where there is most disagreement amongst all Neuro Physiotherapists. How can one facilitate normal postural reflex re-actions where spasticity is present?
Berta Bobath (1990) in her third edition of Adult Hemiplegia page 24 talks about Facilitating and assessing normal non compensatory movement. She calls this movement “Potential”. A patient has the ability to move normally in certain situations but instead chooses to select compensatory movement. But where the desired function is abnormal or very difficult to perform, Berta Bobath talks about spasticity and release of tonic reflex activity. On page 61 Berta Bobath (1990) states that “The patient has to learn to control actively the widespread total patterns of spasticity.”
But what is Spasticity? How can Neuro physiotherapists teach their patients to control it when we don’t even know its true nature?
My hypothetical theories “Compensatory Fascial Stability” and “Low Threshold to Sensory Input” I do believe go a long way to explaining these unanswered questions on the true nature of Spasticity. Sarah in previous correspondence you have challenged me to start my own research. This I do not feel I can do alone. I would dearly like someone to help me.
I apologise Sarah for using your blog to advertise my plea. But I really do believe that stroke patients today have the potential to make far better recoveries.

Sarah Tyson says: February 21, 2016 at 4:03 pm

Hi Jackie
Good to hear from you and pleased the blog is being used to promote discussion. Be my guest!
There seems to be some parallels with your ‘low threshold to sensory input’ and the BB tutors current explanation for what they do – manipulating sensory inputs which they say facilitates more normal movement. Not sure about whether/how the fascial contractions fit in. But the BB tutors have a website http://www.bbta.org.uk/ (and blog type thing that appears as the ‘news’ section). Perhaps they could help with your ideas
Sarah

jackie wright says: February 25, 2016 at 12:02 pm Edit

Thank you Sarah for your kind reply and suggestion that I use the BBTA blog.
You state that you are not sure about whether/how the fascial contractions fit into BB understanding on “Facilitation”. As you use the word “contractions” rather than “contractures”, I assume you are having difficulty with the idea that fascia has a contractile ability.
In spite of the work of Robert Schleip (2007) on fascia contract-ability, I too believe that the main feature of fascia is its connect-ability and not its contract-ability. I base my understanding of fascial connectedness on Thomas Myers (2001) “Myofascial Meridians”. I do believe these myofascial lines of strain go a long way to explain propriorceptive neuromuscular facilitation (PNF) and patterns of movement, developed by Kabat and Knott and expanded by Voss (Voss et al 1985). The patterns of movement are thus predetermined by fascial lines of strain rather than by higher centre neuronal firing.
Refs
Schleip R1, Klingler W, Lehmann-Horn F (2005) “Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics.” Med Hypotheses. 2005;65(2):273-7. http://www.ncbi.nlm.nih.gov/pubmed/15922099
Myers Thomas W (2001) Anatomy Trains Myofascial Meridians for Manual and Movement Therapists, Churchill Livingstone
Voss D, Ionata M, Myers B. (1985) “Propriorceptive neuromuscular facilitation patterns and techniques. 3rd ed. Philadelphia: Harper & Row.

Sarah Tyson says: March 2, 2016 at 5:48 pm Edit

Hi Jackie

My use of the term ‘contraction’ rather than ‘contractures’ was inadvertent. I’m afraid I hadn’t consciously made a distinction. It a long way back to my 1st year anatomy classes but from what I recall fascia is just collagenous connective tissue that can stretch and recoil but mainly resists strain but doesn’t contract. I don’t think there is anything within fascia that can contract, is there? If so, what? how?

I also can’t claim any great expertise in PNF, although I find the techniques useful sometimes. However I thought the movement patterns were based on muscle synergies. Possible the muscle fascia has some influence on those movements but I can’t imagine that they are of any significance compared to the influence of joint shape, ligaments and muscles/ tendon.

I’m afraid I haven’t come across the idea of myofascial meridians (whatever they are) and can’t see how fascia could influence movement. It is muscles that produce movement and nothing else, and the muscles are controlled by the nervous system. Are you saying that muscle activity is controlled by the fascial rather than the nervous system? Really? I’m afraid I’m not buying this idea at all .