Readers Comments – How to do Bobath Part 6

jackie wright says: November 8, 2015 at 1:09 pm

I am afraid Sarah, I just cannot agree with the conclusions you have expressed in the last 2 paragraphs.

“Our professional challenge as physiotherapists is to work out how to manipulate the tasks and environment (by using aids and equipment for example) to enable patients to do as much as they can, safely, comfortably and as easily as possible. And then to work out how they can learn to get better at doing that so they are able to do more, or do the same but more easily.”
Emphasis of treatment in the early days really does need to be on quality non compensatory function. By allowing a patient to use only the good arm to get from lying to sitting or doing any functional activity enables compensatory postural habits to become very easily established. Trunk posture thus becomes asymmetrical and one sided. Abnormal plastic adaptions thus begin to take place in the neurones muscles and fascia with inappropriate fascia and muscle shortening. Shortened muscles and fascia accordingly changes the nature of normal pressure and stretch stimuli onto the sensory neurone endings. It is much better to work on quality movement from the start of rehabilitation than to work on apparent impairments in the latter stages of rehabilitation. It is much more difficult to unlearn abnormal compensatory habits and lengthen shortened structures in the latter stages of rehabilitation.
“It is much better to get folk doing something and then train them to get better at it, than to stop folk doing something.”
Yes help patients to be active but Compensatory function needs to be strongly discouraged. By using Berta Bobath’s “Placing” handling technique patients can be helped to use their own automatic postural re-actions in functional activities such as rolling over in bed, moving from lying to sitting and from sitting to standing. By guiding patients to move in normal non compensatory patterns of movement, the appropriate proprioceptors are activated which accordingly activate the appropriate non compensatory automatic postural reactions. Yes I agree it is not enough to just facilitate postural reactions. Patients do need to learn to facilitate their own postural reactions. I however find that once patients experience normal posture and movement they are strongly motivated to practice for themselves in between physiotherapy sessions.

Roger Mepsted says: February 28, 2016 at 8:51 am Edit

Things Bobath tutors taught me that are untrue :-

  1. “Proximal Hamstrings”.
    We were told by the tutor that hamstring muscles could pull more at one end than the other. When questioned the tutor explained that although this was contrary to conventional theories of biomechanics it was a Bobath fact and she could feel it with her advanced handling skills. This is impossible.
  2. Core stability and proximal before distal
    Presumable based on the original model of infant development I was taught that core trunk stability was fundamental and that activity progressed in a proximal to distal pattern from this stable core. However, the research demonstrates that activity moves from base of support first (refs 1-3). The obsession with the core is misplaced, thus a stroke patient struggles to walk or sit because they lack control of their BoS (ankle/leg in gait, hip in sitting) not core trunk (which is relatively unaffected after stroke). Compensatory core activity is a symptom of this lack of BoS control.
  3. High tone muscles are an important impairment.
    I would spend hours each week manipulating high tone muscles and go to great lengths to suppress this demon. We now know that muscle weakness and lack of sensation are much more important than altered tone (refs 4-6).
  4. RCTs are not relevant to Bobath.
    I was taught that RCTs were invented for simplistic research like drug trials and that Bobath was so individualised, multifaceted and complex that research outcome measures cannot demonstrate its benefits.
    Firstly RCTs were invented to deal with agricultural field trials which, in my experience of both, are more complex and full of uncontrolled variables than neurorehab research.
    If Bobath worked it would produce changes in outcome that can be measured, to blame the lack of this on the RCT rather than Bobath is to start with the answer you want and then alter reality to fit. This is the defence used by homeopaths, who also honestly “know” what they do must work.

All the above led me to finally conclude that Bobath tutors lacked fundamental knowledge of biomechanics and were unaware or ignored research that was contrary to their teaching (they do however quote the very few RCTs that support Bobath on their website, so obviously some RCTs are less inappropriate than others)

If Bobath were invented today it would have to demonstrate its efficacy in RCTs, and it would fail this test and therefore would not be adopted. So why do we all follow it so religiously? Is it an easy all included package course to go on, rather than attend a series of courses on the techniques that are recommended in national guidelines? For some it does seem to be a quasi religious / faith process and these people do become very defensive if their habits of practice are challenged. For the sake of our patients we need to step back and objectively look at the evidence and in the light of this honestly assess our treatment habits. It is not being “holistic and balanced” to promote Bobath as an equal to alternative treatments that do have an objective evidence base. Why promote a treatment that, even after 60 years, is still not recommended in independent reviews and national guidelines?

Refs

  1. Bozec & Bouisset (2004) Does postural chain mobility influence muscular control in sitting ramp pushed? Exp Brain Res 158 427-437. (available at :-http://www.researchgate.net/publication/8509104_Does_postural_chain_mobi…).
    2. Mercer & Sahrmann (1999) Postural synergies associated with a stepping task. Physical Therapy 79 1142-1152. (available at :-http://ptjournal.apta.org/content/79/12/1142.full).
    3. Misiaszek (2003) Early activation of arm and leg muscles following pulls to the waist during walking. Exp Brain Res. 151 318-329. (abstract available at :-http://link.springer.com/article/10.1007%2Fs00221-003-1501-x).
    4. Harris & Eng (2007) Paretic Upper-Limb Strength Best Explains Arm Activity in People With Stroke. Physical Therapy Volume 87 Number 1 88-97. (available at :-http://ptjournal.apta.org/content/87/1/88.full.pdf+html).
    5. Disa et al.(2004) Spasticity After Stroke: Its Occurrence and Association With Motor Impairments and Activity Limitations. Stroke 35, 134-139. (available at :-http://stroke.ahajournals.org/content/35/1/134.long).
    6. Ross SA, Engsberg JR. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil 2007; 88:1114-20. (available at :-http://www.fizjoterapeutom.pl/files/29/Ross%20SA%202007%20Re

jackie wright says: February 29, 2016 at 11:47 am Edit

Roger you identify 4 points which you believe are untrue and which were taught to you by Bobath Tutors. I comment on each point: –
1. “Proximal Hamstrings”
Could not the Bobath Tutor have been correct to detect extra muscular tension in the proximal part of the hamstring muscles? Is not protective muscle spasm localised to a specific area of a muscle? After key hole surgery to my right knee I was amazed to see so much tension in the distil end of the Vastus Lateralis Muscle.
2. “Core Stability and proximal before distal”.
You state Compensatory Core activity is a symptom of this lack of BOS control. I agree. But where I disagree with you is that muscle weakness is caused by brain injury and is an impairment. Could not the muscle weakness be simply caused by some form of inhibitory control at the alpha motor neurone?
3. “High Tone muscles are an important impairment”
To a point I agree with you Roger. All abnormal symptoms of a stroke such as muscle weakness and poor sensory awareness need to be addressed not just hypertonus. The skill in rehabilitation however comes with establishing the true underlying causes to movement dysfunction. Selecting Compensatory movement can often be the main contributory cause.
4. “RCTs are not relevant to Bobath”
Rather than compare Bobath Therapists with another group of Therapists, I do believe we need to be much more specific in what we compare. For instance in the Lennon et al (2006) trial would it not have been better to compare “Facilitation of Gait” rather than the overall gait outcome. Yes there was no difference in the overall outcome but was the gait any better whilst being handled by a Bobath Trained therapist?

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

ReplyRoger Mepsted says: February 29, 2016 at 2:19 pm Edit

Hello Jackie
Thank you for your comments, which i will now try to address.

Regarding proximal hamstrings.
I do not know if muscle spasm is localised, but I do know that all standard biomechanics texts state that tension in the muscle body produces an equal and opposite tension on the tendons at each end. My point is that if Bobath tutors have found something that refutes such a basic principle of biomechanics they need to back it up with better evidence than “it’s what I think I can feel”.
The tutor then told up that she could feel very weak proximal hamstring activity in the leg of one of my colleagues. This seemed odd to me as the woman concerned was in her twenties and had no injuries or deficits of mobility. My conclusion was firstly if proximal hamstrings existed they were of no consequence and that the Bobath tutor’s lacked a basic knowledge of biomechanics was compounded by an exaggerated faith in her own handling skills.

Regarding core stability & proximal before distal
I think we will disagree on the cause of muscle weakness, for me damage to the motor cortex seems like a good explanation, but I’m happy to also accepts there are also other factors involved. My point is that because Bobath tutors were ignorant of or choose to ignore the published evidence regarding BoS activity first, they have caused huge amounts of effort to be incorrectly concentrated on core stability and proximal control.

“RCTs are not relevant to Bobath”
RCTs compare treatment A to treatment B, the complexity or otherwise of each treatment package is irrelevant. We just want to know if there is a difference between A and B, if so there will be a difference in outcome measures, it really is that simple. I think it is also important to not think we are comparing Bobath therapist with other therapists, we are comparing treatments not therapists.
The Lennon paper was not an RCT, it was a before and after study, which showed that even under idealised conditions with unlimited therapy to cherry picked patients from advanced trained therapist that the Bobath approach has no effect on quality of gait. Are you suggesting that the quality of gait was only better when the therapist were handling the patients? These therapist themselves decided when to stop treatment and thus the patients had many more weeks of rehab than usual. Even then there was no carry over into quality of gait.
In this study improving gait was the main objective, yet patients only spent 10% of their therapy time actually walking! Based on my observations of Bobath therapists I suspect the remaining 90% of therapy time was occupied with their obsessions of normalising tone, core stability and proximal control. The results show how useful that was.

BBTA hide evidence.
One more point I have noticed is that the BBTA website contains a rebuttal of criticism of their approach, but does not tell us where the criticism is published. I presume it is a rebuttal of this blog and previous comments on iCSP. They then reprint the supportive comments of James McLoughlin from this blog, but again do not tell people where they can read the comments that are critical of them. Sarah Tyson in contrast is happy to openly debate all the evidence in an open manner, the BBTA only want to talk about what supports their position.
This desire to hide anything that is negative about them is also evident in the way they only quote the minority of research that support their approach. It is a sign of a defensive and closed attitude to best evidence and seems to put the interests of the BBTA before anything else. Is this really the best way forwards for our profession and patients?

jackie wright says: March 1, 2016 at 6:33 pm Edit

Thank you for your reply Roger. Yes I am suggesting gait could be better with the patients handled by Bobath Therapists.
That there was no “carry over” I also believe can be explained. For instance did the nurses handling patients for the remaining 23 hours of the day have the same Bobath handling skills? Were the patients encouraged/allowed to use compensatory tactics whilst being helped to roll over in bed, get from lying to sitting and from bed to chair. Were the patients discharged home using a compensatory gait?
In the distant past I used to work in a General Hospital for a short time. I used to discharge my stroke patients in a wheel chair. Fortunately I was lucky enough not to be challenged by senior physiotherapists or by medical staff. These very same patients that I saw as an Inpatient then came to see me as an outpatient. Perhaps it is wishful thinking, but I do recall the out comes as very good!
“Regarding proximal hamstrings”
Roger you refer to your knowledge of standard biomechanics texts that tension in the muscle body produces an equal and opposite tension on the tendons at each end. I question whether the tension can go in more than one direction. By examining cadavers Willem Fourie http://www.wayforward.co.za has observed collagenous tissue (fascia) to be distributed in all directions within a muscle belly. I also question the nature of protein molecular binding. I do feel Science has a long way to go.
Tom Balchin you challenge the cranial suture theory of movement as proposed by Cranial Osteopaths. I find it difficult to fully agree with your argument as I do believe we can palpate cranial plate movement. Rafferty and Herring (1999 ) investigations on young pigs and collagen distribution within different sutures does seem to suggest that different cranial sutures are designed for different movement strains. http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-4687(199911)242:2%3C167::AID-JMOR8%3E3.0.CO;2-1/abstract;jsessionid=C9552A12F5711E7F250E068D30975018.f04t01

ReplyRoger Mepsted says: March 2, 2016 at 1:24 pm Edit

Hello Jackie

Re; Sheila Lennon’s paper

I feel you are making too many excuses for these advanced trained Bobath therapists, they did their best and were confident it would improve the quality of gait. These cherry picked patients had far more therapy than usual, more than that is unrealistic and impractical. In the real world this as good a Bobath gets.

I think a better explanation for their failure to alter quality of gait is that they were using their out-dated model of core stability first and proximal activity before distal as so:-

“The therapists in this study hypothesised that improving selective control of the pelvis would improve weight transference over the hemiplegic leg, thus improving the movement patterns (both proximally at the hip and distally at the knee and foot) in both the stance and the swing phases of the gait cycle.”

This model does not now fit the research which, as I referenced above, indicates that activity works from base of support first (ankle in this case) to trunk. How many of us have spent hours using the Bobath model to work on proximal / core stability and hip control of patients who actually cannot walk because they lack control of their BoS.
I imagine it would be very difficult for the BBTA to abandon such a fundamental teaching and likewise I do not expect any therapist to just take my word for it. BUT I would urge anyone interested to read the papers concerned and form their own opinion. These BoS first papers (links above) and the paper by Lennon et al. could make a very good IST.

Why are the Bobath tutors so reluctant to justify their teachings in open an detailed debate?

The BB tutor who taught us proximal hamstrings would not explain the theory behind it or give us any objective evidence to support it. It seemed that the teachings of a Bobath tutor were there to be accepted and not discussed.

Likewise, when I tried to initiate a discussion of the Novak review (ref 1) onto the CSP website the Bobath -CP staff removed it on the grounds that they (British Association of Bobath Trained Therapists) owned that part of the site and its was there to promote Bobath rather than discuss it.

This was a deliberate attempt to hide evidence critical of Bobath from UK therapists. It sits very oddly with the statement that “The BBTA encourages an informed and respectful dialogue”. Luckily the CSP over ruled them.

In my experience (unless their hand is forced, as by the CSP above) Bobath tutors are very reluctant to discuss specific issues and prefer to talk in generalities on their own websites / blogs, where they will block any critical comments.

So it really is up to them to justify their theories of both proximal hamstrings and core stability first plus proximal before distal (in the light of the evidence that activity starts from the BoS). Just where is the objective evidence?

They could always prove me wrong and add Prof. Tyson’s reply to the criticisms of this blog to their website. But as the primary motive of the BBTA seems to be to promote their courses and themselves (rather than the best neurorehabilitation) I somehow think they will try to avoid that!

Ref
Novak et al. (2013) 55 885-910. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev. Med. Child Neurol. Available at :- http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pdf