Readers’ thoughts on practising neuro physio, Bobath and EBP

Zack Siddells says: January 16, 2016 at 1:58 am

Thank you Sarah. This has been a fascinating series to read. I used to be involved in teaching neurological physiotherapy but in recent years have moved onto other things. I find it both disheartening and also most interesting that such “schools of thought” as the Bobath Method still has so much popularity amongst physios.

My disheartening is when I reflect on the enormous amount of clinical research that has happened over the last two decades; the enormous amount of evidence now for task based approaches and growing evidence for other approaches such as targeted strengthening to name but one; the more-or-less complete failure of trials investigating BB to show benefit. Yet a huge body of therapists just don’t get it and continue to flog a dead horse. And that old tired line of well “we have changed – we truly have and we now incorporate all that is new” while doing basically the same old stuff.

My interest is more in the sociology that we still seem to be a profession that is prone to cults rather than applied science. When I trained back when pterodactyls were still flying around we students watched as this massive fight between the PNF and Bobath adherents tried win over hearts and minds.

Not long after that in the 80’s Roberta Shepherd and Janet Carr injected true scientific scepticism into the profession and took a direct aim at the Bobath method in their crosshairs. They presented arguments based mainly on plausibility drawing from the movement sciences; clinical trials weren’t very common then and those that were done weren’t up to much. But that had an unintended effect. Far from assisting the majority of physiotherapists to move on it just created another skirmish and seemed to make the Bobath adherence dig in to their trenches deeper.

Carr and Shepherd were right to do this but I am not sure that how they went about it helped matters. Cults tend to flourish on acrimony. Now I wonder if this is what still drives the Bobath crowd to carry on this way rather than paying attention to the literature.

There can be a blurred line between recognising and paying respect to a leader in the profession who advances the development of the profession and a cult. And cults often get named after their leaders. Why are we still littered with names such as the McKenzie approach, the Bobath method, or the Maitland concept?

Why don’t we just attach a simple label the that describes the function of an approach? When the evidence supports it use it. As the evidence develops, refines, or refutes the approach it is much easier to deconstruct it, or chuck it away rather than having to attack the persona and dogma of the guru.

A lot of physiotherapy does do this but we haven’t shaken off the gurus and their cults.

JB8205 says: January 16, 2016 at 6:25 pm

I so enjoyed these blogs! I am so not a bobath fan but I do find I am often in the minority where I work. I work in acute neuroscience unit and usually use a much more functional/impairment/participation approach but recently had a young patient and I felt doing this would be a disadvantage to him…. Now reading these blogs and I am so questioning my practice! Yikes! I need to have the courage of my convictions and stand up for what I (and I know others!) think and need to stop worrying about what my colleagues in the rehab and stroke units think of my practice and I need to challenge their approach! Will re read these blogs and share! Thank you!

Sarah Tyson says: January 17, 2016 at 2:48 pm

Thanks for your thoughts Zack and JB
I agree Zack, life would be much easier and more effective if the cults and named approaches were done away with, but a lot of people have invested time, effort, finances and reputation on the named approaches and have gained status and often comfortable living from following and promoting the named approaches so there are many vested interests in keeping them going, which doesn’t make it right but does explain why it happens despite its illogicality.
The amount of acrimony around how to deliver effective physio has always been something of a mystery to me. This isn’t restricted to neuro physios, it is very prevalent in MSK and sports physio too. And I’ve observed the same sort of weeping and wailing, passive aggression (sometimes not so passive) and tantrums in other AHPs too, when their comfort zones are challenged. I think an important element is that many do not understand the difference between disagreeing and arguing. It is quite possible to do the former without the latter. It isn’t a personal attack or professional practice to hold a different view and express it (further thoughts in the post on EBP and professionalism), but many take it as such. I think it’s something about the maturity of the profession tbh.
JB, thanks you I’m glad you’re enjoying them. The feedback has been very heartening and it is amazing how many and how far they have reached. There might be something to this social media business after all!
You describe a common dilemma, and it is a difficult one. At the end of the day most people want an easy, harmonious life and to get on with their colleagues so it is easiest to go with the flow. In the original icsp discussions that were the pre-cursors to this blog some contributors did so anonymously, I suspect for similar reasons to the ones you raise. It is hard work swim against the tide, but if enough folk swim for long enough, others will join and the tide will turn. There has already been massive changes in the last few years; this blog and icsp discussions just would not have happened a few years ago. So keep going and stand by your convictions and the evidence!
I’m intrigued about why you felt your young patient might be disadvantaged by an EB approach.

Ruud van der Veen says: November 9, 2015 at 4:11 pm Edit

I have been following this discussion from the Netherlands. Bobath was abandoned in the Netherlands in 2007 in favor of an evidence-based approach, coincidentally the year I graduated as a physiotherapist. I’m one of the lucky few that was trained in Bobath, but never really got to use it. I think it’s good to take a step back and look at all we know now from recent research about post-stroke patterns of muscle activation, timing and sequencing, how they relate to functioning, how they develop in time and how we can (or mostly can’t) influence it with physiotherapy. Although the Bobath explanation like above sounds plausible, the evidence shows it’s flawed. That in itself should at least trigger people to question all assumptions that underlie their method and not try to incorporate new insights into the old paradigm, but question their paradigm as a whole.

Just because patients improve in function doesn’t mean there’s a causal relation with your therapy, nor that your approach is superior to other approaches. Assumptions that are made should constantly be put to the test to make progress. That’s evidence based medicine. If I was told to clap twice every time I approach an automatic sliding door and I do that for years, I could start to believe that it’s my clapping that opens doors. I could even get in a heated argument with people that try to convince me I shouldn’t clap, but what do they know right? They might have investigated the workings of the door, but they don’t have years of clapping experience. We’ve always done it this way….

Erik Prinsen says: November 10, 2015 at 1:54 pm Edit

One of the problems in these discussion is that people so easily say they disagree with statements being made and conclusions being presented. Let me start by saying that everyone is entitled to their own opinion. When I’m faced with an opposing opinion, I’ll be as stubborn as I can (which can be quite severe) and defend my own point of view. However, in this discussion it is not one opinion facing an opposing opinion. It is years of research leading to evidence-based facts against an opinion that is based on years of experience with BB therapy. This means that is not an equal playing field: evidence-based facts outweigh empirical evidence (also known as sense experience). It is a fact that muscle activation patterns hardly change after stroke and that they are only limitedly affected by BB therapy for a short duration of time. It is an opinion that BB therapy is able to change muscle activation pattern.

Recently, the difference between opinion and facts became all too clear to me again. I am a foodie and I love to cook for friends and family. Because I started to have an interest for some great British classics I decided to try a shepherd’s pie, which I never had before (maybe the biggest shock of this post). I found a great recipe, tried it and loved it. I made it for some friends and family and was praised for the dish: they all thought it was good. I was rather confident that I could make a mean shepherd’s pie. This confidence was a bit shattered when I ate a shepherd’s pie in a Gordon Ramsey restaurant. His shepherd’s pie tasted different than the one that I served my friends. Not long after I came home I had a group of friends over that wanted to try the shepherd’s pie I was talking about for quite some time. I could have made the same shepherd’s pie I made before. These friends probably never had a shepherd’s pie before, therefore they had no frame of reference to judge mine and my shepherd’s pie would probably be considered good. I also could try to improve my recipe as I needed to accept that fact that Gordon Ramsey’s shepherd’s pie was better (which is not much of a debate after all). By improving my recipe, my friends would probably love my shepherd’s pie even more.
Don’t hide behind the BB recipe you know, but try the new, better recipe that is out there. Don’t close your eyes, your patients deserve it.

Nikki Penny says: February 2, 2016 at 1:05 am Edit

So Sarah, we have had a lot of interaction on twitter. I have taken time to listen, read, absorb your evidence and reasons around the age old question of Bobath.
This reply is very personal to my journey in the neuro world that is all I have to offer. I don’t write, publish or research. What I do do is treat, question, reflect and learn. My journey is one of two halves. The first I was involved with the concept to a high level, although I cannot profess to having wonderful handling skills. I left one month shy of qualifying as a Bobath tutor. The second half half of my career has been about exercise and strength training in the neuro patient. This journey has been an 11 year clinical exploration. So I don’t have a financial gain in the concept,I have no misplaced loyalty to the concept, I am happy to go against the grain if I think necessary. I have tried to examine why my passions run high about the question of ditching the Bobath concept.
You may be suprised that I enjoyed your blogs and found many of your points are clear and valid.
The part that struck a cord with me was in the last blog when you summarised our professional challange, quoting the Shunmway and Woolcotte model of task, environment and individual. This model underpins my assessment and treatment planning with every neuro patient.
And I couldn’t agree more with you that this is our challange. So othotics, fes, treadmill, saebo, boxtox, task specific exercise fulfil the task and environment components without question or agrument. But for me Bobath allowed me to understand the individual in that model.
The Bobath courses to me are movement courses that allowed me to begin to understand movement. They provided a forum where I could see an experienced clinican identify movement problems and begin to develop a treatment plan forward. It allowed me a safe environment to put hands on, not to become a heal you with my hands therapist ,but to feel more confident and instill more confidence in my patients when I moved and handled especially my very acute dependent patients.
The movement knowledge I gained in those years has given me a foundation that I can explore other models of treatment. Fes, I attended one of the first courses and Jon Grahame continues to challange my thinking in this area. Saebo with Glyn and Amy have forever changed my approach to the upper limb. Bob Wood and Gary Grey challanged my clinical anatomy and introduced me to the world of functional training which has been the one biggest influence that has changed my practice.and being the oldest person on the uk strength and conditioning courses taught me that neuro physios really do need to understand the term strength.
So we all have to start our journey somewhere and in this country theBB courses gave me this opportunity to become a thinking therapist. It fills a very much needed educational gap and they do it well. They are, what we all are, a small cog in a huge wheel.
I struggle to understand what you researchers are testing when it comes to Bobath. When asked am I a Bobath therapist? No I am a therapist that has been on numerous Bobath run courses, and has taken from the course, many elements that I thought would help me treat in the field of neurology. So I will fight for having that choice as I believe absolutely it has a place in assisting indiviuals learn about movement.
I leave you with that Sarah, I am sure you will blind me with science, make this clinican question her validity but at least I posted an honest thought!

Sarah Tyson says: February 6, 2016 at 7:23 pm

Sorry it was a wee bit slow to approve this post. I had a blip while updating the blog (I’m new to this modern media business) but thanks to the marvellous Sarah Plant, it’s back in action.
Thanks for sharing your thoughts. Im intrigued about why you stopped just short of becoming a Bobath tutor but would not wish to pry if it’s personal. Not sure how one can use BB as a basis “to explore” the EB techniques you mention above when the theory (such as it is) behind them are pretty much diametrically opposed. Could you expand and give some detail about what you do and the theory / rationale behind it? It would be great if you could expand how BB helps one understand a patient as an individual any more than everyday physio assessment skills – What do BB practitioners do that others do not?
I agree with you that part of the reason that people still go on BB courses is for a lack of alternatives in a format they are familiar with. In a previous post (EBP and CPD) folk came up with many, often cheaper, alternatives but they do require doing things differently and often folk would rather stay in their comfort zone. Several people have asked why I (and my ilk) don’t set up and run CPD courses for EBP. The short answer is that university based CPD courses do not make a profit (or even breakeven). There are exceptions with particular funding streams and topics but they don’t include physio CPD. The university’s priorities (and therefor what they pay me to do!) are all about grant income, papers published, PhD student numbers and research impact. CPD just doesn’t figure on their horizon, any more than doing research does on yours.
As to what we researchers are testing when researching research. A good question! As highlighted in previous posts, it is very challenging as the BB proponents don’t agree what it is and they keep changing their minds (as it “evolves”). So the approach taken is to take BB as face value and test out what they say they do and what effects they say it will have – as Sheila Lennon did in her much quoted work on Bobath (in collaboration with the British BB tutors). In larger RCTs, such as Paulette van Vliet’s and Brigitta Langhammer’s comparing BB to the motor relearning approach, or the many trials of novel interventions in with BB was the ‘usual practice’ control group, the Bobath that was practised was accepted as such and recorded and measured, without attempting to standardise what it was or how it was delivered.
I don’t doubt the sincerity of your, and others, belief that Bobath is ‘a good thing’ and is effective, but I am afraid that mere belief/ faith is insufficient however firmly held. Professional credibility and accountability requires proof (ie objective evidence) to back up clinical choices. The fact is that the evidence to support BB is just not there; the evidence shows it is ineffective, not just that there isn’t evidence one way or the other. Despite many attempts to “prove it works”. I’ve asked several times in the icsp discussions and this blog why one would continue to use an approach that doesn’t work, rather than objective measurement approaches and interventions that do. Still waiting for BB fans to explain and justify.

Donncha Lane PT (@DonnchaLanePT) says: February 8, 2016 at 4:04 pm

Thank you Sarah and Nikki. Nikki, thank you for an honest and open post, I echo all of what you say and I suspect many others do too (based on conversations with colleagues at recent courses and conferences etc). In my opinion a truly open and professional discussion of the varied perspectives requires the optimal forum and a degree of skilled facilitation. Therein lies the problem. Kind regards.

Neil Webster says: November 9, 2015 at 8:46 pm

Hi Sarah and Glyn.

As Glyn has asked so kindly I thought I would leave some feedback since joining the ‘dark side’ and qualifying 2.5 years ago. I have been following your blogs Sarah on both the iCSP and here so hopefully my comments reflect someone who is new to their physio career and trying to work within the best EBP to help patients improve.
I personally work in an independent paediatric setting which uses a number of the ‘dark’ techniques and equipment such as treadmill, therasuit, spider and functional electrical stimulation along side all of the new Saebo products which we use daily.

My response is aimed at perhaps not just this blog but all of the information that I have read from you recently. With still a lot of therapists using passive stretches alone I have found it a breath of fresh air to see more and more therapists realising the true potential of muscle strengthening and how it can improve patients with and without spasticity. I am privileged enough to be in a working environment where we use lots of pioneering equipment that helps to improve the children we work with and really reinforce the whole quality vs quantity debate from other blogs. Looking more into the motor relearning research and the amount of practice needed to learn, consolidate and actually be functional in a skill it would be completely unrealistic to expect a child or adult to learn a skill that required a completely ‘hands on approach’. This I completely agree is where equipment like the treadmill comes in so handy to assure that there are options outside of therapy for patients to be progressing.

We use FES every day in clinic with positive effects on strength therefore function and follow progressive resisted muscle strengthening programs which are regularly monitored. I personally have seen such a change in all of the children that I have worked with (the ones with less neurogenic weakness obviously progressing quicker) and am baffled as to why some therapists still do not think that FES is an efficient and safe way to treat CP. We always check the standard contraindications with families and check with consultants if not sure. It is a cheap and easy way to help progress muscle strength (again recent research supports this) where the children do not even need to be performing a task to gain benefit from! What could be better than secret physio!

Thinking more from a recent students point of view I do feel as if lots of the treatment ideas given from lecturers, especially those not still treating can be dated and always restricted by finance as they expect most new therapists to go into services unable to fund such advancements. I class myself as very lucky to have attended Walkaide courses, Saebo days and the Neurological Expo in London (amongst others) to understand that the medical advances are staggering. Why oh why are we still seeing restricted programs given out to children with no muscle strengthening components?

Muscle strengthening works, its evidence based and most of all it makes perfect sense! You strengthen a muscle and it will have more contractile force, if that contractile force like you said Sarah exceeds the demand of gravity or resistance then there is more opportunity for function. More opportunity for function means more independence. This allows for an increased quality of life and a brighter future for the children struggling with movement and weakness. This is not even taking into consider the possible benefits from neuroplasticity or neurogenesis which again need opportunity (to which you need strength and practice).

All of your blogs Sarah have made perfect sense and I feel, although I still have much to learn, that I can treat and help the patients on my caseload to have a better future. This is an approach that has not been lead by my heart, instead my head. I am open to learning at any point in my career and would start passive stretches again tomorrow if this is what I saw clinically helped or was indicated in the research (including NICE guidelines). This applies too for Bobath, I just feel from my understanding and experience of both approaches muscle strengthening works much more. This was felt also from other colleagues when recently attending the introductory Bobath course. I felt the approach was very closed and not willing to take any direct questioning on how it improves its patients. The course was very costly and I was left with limited treatment ideas or really any real handling skills that I would use daily in clinic. Again I hope this is helpful and on the topics that have been raised as this will be my first post on the blogs!

I am open to comments and feedback from anyone interested in anything raised in this comment!