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Bobath physiotherapy. evidence based or habit based.

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The evidence for the use of Bobath methods is reviewed. The reasons for the continued popularity of this approach despite its poor objective evidence base are then discussed.

Published in: Health & Medicine

Bobath physiotherapy. evidence based or habit based.

  1. 1. Bobath Physiotherapy Evidence Based or Habit Based? Roger Mepsted. MCSP. PhD roger_mepsted@hotmail.com
  2. 2. Key points • UK Neurophysiotherapy is dominated by the Bobath (BB) approach. • Many very experienced UK therapists have spent a lot of time learning & using BB techniques and are convinced that it is effective • Yet BB is only recommended in one national guideline and no reviews of neuro rehabilitation.
  3. 3. Key points cont’d • There is now strong evidence that other techniques are more effective than BB. • Several basic teachings/practices of BB are now known to be incorrect. • It is not possible to “evolve” BB by adopting the ideas of others and calling it BB.
  4. 4. Key Points cont’d • How did this happen? • What of the future?
  5. 5. Bobath in the UK • Most methods used by UK therapists are BB based, even when therapist describe themselves as “eclectic” rather than wholly BB. (Tyson & Shelly 2007). • Fifty+ year tradition.
  6. 6. National Guidelines & Reviews. • Not recommended by the following national guidelines:- – England, NZ, Canada, Australia & Netherlands. • But these guidelines DO recommend many other rehab techniques.
  7. 7. AHA / ASA 2016 (the only guideline to recommend BB / NDT) • The effectiveness of NDT/Bobath has not been established but it “may be considered” as a treatment option for mobility. • This is their lowest classification of an acceptable treatment. Their two highest recommendation groups (“should be performed” and “reasonable to perform”) contained many treatments for which there is much better evidence. • NDT/Bobath was not listed as an option for arm/hand rehabilitation.
  8. 8. RCP 2016 Stroke Guidelines • As with most guidelines, does not mention Bobath at all. • But they say:- • If a treatment is not mentioned, then it was not recommended and need not be funded. • Therapists using unrecommended methods must objectively review their options in the light of the evidence supporting the recommended alternatives. • Patients receiving such interventions should be informed that it was outside mainstream practice.
  9. 9. The Effectiveness of the Bobath Concept in Stroke Rehabilitation. What is the Evidence? (Kollen et al. 2009) N +VE for BB +VE Other UL 7 0 3 LL 4 1 1 Balance 4 1 0 Dexterity 6 0 2 Mobility 5 1 3 ADLs 4 0 1 LoS 1 0 1 31 3 11
  10. 10. Conclusions • Therapist should base their treatment methods on evidence-based guidelines rather than any named approach. • Netherlands & Denmark Bobath no longer taught. • UK Bobath constantly evolving / compromise
  11. 11. NHS Annual Evidence Update on Stroke Rehabilitation, Mobility (Tyson, 2009) • “The strength of evidence that exercise and task- specific functional training are effective while Bobath is not indicates that a paradigm shift is needed within UK Stroke physiotherapy if evidence based practice is to be implemented; as has occurred in other countries in Europe.” • “It is increasingly difficult to justify the continued use of the Bobath Concept and its associated treatment techniques.”
  12. 12. Not just stroke. Novak et al.(2013) A systematic review of interventions for children with cerebral palsy: state of the evidence • “no circumstances were the aims of Bobath could not be more effectively achieved by other techniques” • “in the interests of doing the best for our patients we need to stop permissive endorsement of ineffective techniques and therefore cease all provision of Bobath within traditional care”
  13. 13. Things said in defence of BB • Patient centred problem solving approach. • No approach is superior to any other. • RCTs not appropriate. • The “knowledge of the profession”. • Constantly evolving / new books. • Quality of movement
  14. 14. “Patient centred problem solving approach” • But. • So is respiratory / orthopaedic physio, OT, nursing etc. They all involve holistic problem solving with an individualised treatment plan. BB has no monopoly on this “No approach has been shown to superior to any other” • But • 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 in national guidelines).
  15. 15. RCTs not appropriate to physio • BB is too complex and highly tuned to each patient. • RCTs too simplistic to measure complex interventions. • BUT • BBTA quote RCTs (some) on their website. • RCTs do not measure the complexity of an intervention, they only measures the significance of change in outcomes. Lack of RCTs is the problem. • Why do RCT with BB show the alternative are better? If BB produced the best outcome they would show that. It is all BB research. • NICE & NHS demand best evidence.
  16. 16. The Knowledge of the Profession • People would not do it if it did not work. • Do not denigrate decades of experience and knowledge. • BUT • How do we know what would happen if we did a different Rx to Mrs Brown? • Homeopaths and their patients know it works. • Hence need for RCTs.
  17. 17. Constantly Evolving • Mayston (2006) (Chair ACPIN) • • “The Bobath Concept is now so diverse that it can be difficult to know where it came from and what it is” • BB dilemma, stick to the original teachings or evolve. • “I do not support the idea that the Bobath Concept can be developed and changed and go under the name of Bobath.”
  18. 18. Constantly Evolving • Damiano (2007) Pass the torch please! • “..therapy principles and programs developed by other innovative clinical researchers or scientists are now considered an integral part of NDT or Bobath. Why does this method have the right to pull in everything that comes into its path like a supernova that becomes a black hole?” • “This may serve the therapists who have invested their careers in this method, but it does not serve the broader scientific community, the new generation of therapists, or the parents.”
  19. 19. New Books • The Bobath Concept in Adult Neurology. Gjelsvik B. (2007). • The Bobath Concept: Theory and clinical practice in neurological rehabilitation. Raine, Meadows, Lynch- Ellerington. (2009).
  20. 20. Amanda Connell (2010) reviews The Bobath Concept in Adult Neurology. • "reads as a philosophical treatise as opposed to an evidence based approach” • "the use of research to support the discussion is limited and biased" • "reflecting the authors views that, in places, contradicts research findings” • "prescriptive in its approach with limited exploration of clinical reasoning"
  21. 21. Review • Mayston (2010) (president of ACPIN, 2010) • “ I am not really sure that it is clear from the book what the Bobath approach actually is” • “often the prose turns into jargon” • “leaving the reader with the impression that Bobath is all about having the therapists hands on the patient” • "this book will do little to quell the critics; in fact it will no doubt give them more fuel for the fire".
  22. 22. Quality of movement • Lennon (2006). Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke. • Only 9 (but cherry picked) stroke patients. • Walk >10m + c 1. • Advanced ++ BB trained Physios. • Mean treatment daily or 2-3 /week for 17.5 weeks. • Stop only when physio wanted. • Motor analysis lab.
  23. 23. • Small trial but patients very carefully picked for max. rehab potential • Optimise chances of showing benefit. • Main aim is to retrain gait.
  24. 24. Effect of BB therapy on Gait Quality -10 0 10 20 30 40 50 60 70 Pelvic Tilt Hip ext. Hip flex. Knee flex. Dorsiflexion Plantarflexion PeakDegrees Pre Post
  25. 25. Effect of BB therapy on Gait Quality -10 0 10 20 30 40 50 60 70 Pelvic Tilt Hip ext. Hip flex. Knee flex. Dorsiflexion Plantarflexion PeakDegrees Pre Post Normal
  26. 26. Conclusion • Even under idealised conditions Bobath does not effect the quality of gait. • Even when gait was the main objective these patients averaged less than 10% of therapy time actually walking.
  27. 27. Some things that BB tutors teach / taught • Tone is the main problem not strength. • “proximal hamstrings”. Hamstrings can pull more at one end than the other. • Core stability, proximal before distal.
  28. 28. Core stability • Big emphasis in BB, Based on their neurodevelopmental model? • BUT • Certainly for stroke not appropriate as core stability is the least effected. • Trunk before arm in sitting, yet….
  29. 29. • In standing tasks it is the distal muscles that are activated first. (Le Bozec & Bouisset 2004; Misiaszek 2003; Mercer & Sahrmann 1999). • This makes sense as they are the base of support. • Cannot get further away from the trunk. So why spend so much time on core stability? • Carr & Shepherd (2008). “ the BB tutors have a poor understanding of biomechanics and neuro-anatomy”.
  30. 30. Summary • Some very important Neurophysios are highly critical of Bobath. • Very popular “approach”, but not supported by guidelines or reviews. • Where is the independent/objective support for BB? • The BB dilemma. (evolve or remain) • Senior staff are most likely to have had no alternative training and will influence junior staff. • Sometimes strong peer pressure to attend Bobath courses.
  31. 31. Why do physios follow BB • The Guru effect. • Want to learn complex techniques. • Want to be hands on. • Traditionally little understanding or training in research. • We happily learn the technique but don’t ask for the evidence that it works.
  32. 32. The Future • The Netherlands model? • Let tutors evolve BB and be the main source of training. • BB should just stick to traditional BB. • We need to be brave in our review of what we do. (Passive manual stretching:- Cochrane, NICE) • We need some better options, eg. Courses on the things that ARE recommended in guidelines.
  33. 33. Final thought • ”It's important to remember we were all physiotherapists first before we studied Bobath and it should be used or discarded in line with the evidence base like any other treatment modality.” Chris, iCSP 2015. • See iCSP 2015a & 2015b discussions. • See Sarah Tyson’s Bobath blog. There is a very good section with links to therapy options with a good evidence base.
  34. 34. References AHA / ASA (2016) Guidelines for Adult Stroke Rehabilitation and Recovery. A Guideline for Healthcare Professionals, 2016. Available at :- http://stroke.ahajournals.org/content/early/2016/05/04/STR.0000000000000098.full. pdf+html. Bozec & Bouisset (2004) Does postural chain mobility influence muscular control in sitting ramp pushed? Exp Brain Res 158 427-437. Damiano (2007) Pass the torch, please! Developmental Medicine & Child Neurology 49 723–723. Carr & Shepherd (2008) Science-Based Neurological Rehabilitation. St James’ Hospital, Dublin. Connell (2010) Review of the Bobath Concept in Adult Neurology. Physiotherapy 97 p360.
  35. 35. iCSP (2015a) Novak casts doubt on efficacy of Bobath. Should we embrace or ignore it? Available at:- http://www.csp.org.uk/icsp/topics/novak-review-casts-doubt- efficacy-bobath-should-we-embrace-or-ignore-it iCSP (2015b) The rationale and evidence for Bobath and neurological physio. Available at:- http://www.csp.org.uk/icsp/topics/rationale-evidence-bobath-neurological-physio Kollen et al. (2009) The Effectiveness of the Bobath Concept in Stroke Rehabilitation. What is the Evidence? Stroke 40 (4) e89-97. Available at- http://stroke.ahajournals.org/content/strokeaha/early/2009/01/29/STROKEAHA.108.5 33828.full.pdf Lennon et al. (2006) Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke. Disability and Rehabilitation 28 873-881. Mayston (2006) Letter to the editor RAINE: A RESPONSE. Physiotherapy Research International 11 183-186. Mayston (2010) Review of The Bobath Concept: Theory and clinical practice in neurological rehabilitation. Synapse Spring 2010. Mercer & Sahrmann (1999) Postural synergies associated with a stepping task. Physical Therapy 79 1142-1152. Misiaszek (2003) Early activation of arm and leg muscles following pulls to the waist during walking. Exp Brain Res. 151 318-329.
  36. 36. Novak et al. (2013) A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine & Child Neurology 2013, 55: 885–910. Available at :- http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/pdf RCP (2016) National Clinical Guideline for Stroke, fifth edition. 1.8 Treatments not mentioned in this guideline. Available at:- https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016- National-Clinical-Guideline-for-Stroke-5t-(1).aspx Tyson, Selley (2007) The effect of perceived adherence to the Bobath concept on physiotherapists' choice of intervention used to treat postural control after stroke Disabil Rehabil. 29(5):395-401. Tyson (2009) 2009 Annual Evidence Update on Stroke rehabilitation – Mobility, NHS Evidence. Available at :-http://usir.salford.ac.uk/2740/ Tyson (2016) When EBP meets neurological physiotherapy… Available at :- https://sarahtphysioblog.wordpress.com/author/sarahtysonblog/

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