Abstract
Question
In adults with stroke, does Bobath therapy improve lower limb activity performance, strength or co-ordination when compared with no intervention or another intervention?
Design
Systematic review of randomised trials with meta-analyses.
Participants
Adults after stroke.
Intervention
Bobath therapy compared with another intervention or no intervention.
Outcome measures
Lower limb activity performance (eg, sit to stand, walking, balance), lower limb strength and lower limb co-ordination. Trial quality was assessed using the PEDro scale.
Results
Twenty-two trials were included in the review and 17 in the meta-analyses. The methodological quality of the trials varied, with PEDro scale scores ranging from 2 to 8 out of 10. No trials compared Bobath therapy to no intervention. Meta-analyses estimated the effect of Bobath therapy on lower limb activities compared with other interventions, including: task-specific training (nine trials), combined interventions (four trials), proprioceptive neuromuscular facilitation (one trial) and strength training (two trials). The pooled data indicated that task-specific training has a moderately greater benefit on lower limb activities than Bobath therapy (SMD 0.48), although the true magnitude of the benefit may be substantially larger or smaller than this estimate (95% CI 0.01 to 0.95). Bobath therapy did not clearly improve lower limb activities more than a combined intervention (SMD −0.06, 95% CI −0.73 to 0.61) or strength training (SMD 0.35, 95% CI −0.37 to 1.08). In one study, Bobath therapy was more effective than proprioceptive neuromuscular facilitation for improving standing balance (SMD −1.40, 95% CI −1.92 to −0.88), but these interventions did not differ on any other outcomes. Bobath therapy did not improve strength or co-ordination more than other interventions.
Conclusions
Bobath therapy was inferior to task-specific training and not superior to other interventions, with the exception of proprioceptive neuromuscular facilitation. Prioritising Bobath therapy over other interventions is not supported by current evidence.
Introducton
The Bobaths developed a method of treating children with cerebral palsy and adults with stroke in the 1950s.1 Their method differed from other physiotherapy methods at the time, as it was based on the assumptions that: performance could be facilitated by the therapist; spasticity could be inhibited, thus permitting more normal movement; and these interventions could optimise recovery from the brain damage. As time passed, Bobath therapy, along with other new therapeutic methods such as proprioceptive neuromuscular facilitation (PNF), became more commonly used by neurological physiotherapists internationally.
Research into neuromotor control and movement science refutes the assumptions that underpin these methods. For example, research findings indicate that spasticity is not correlated with activity and participation measures after stroke.2,3 In contrast, loss of strength has been found to correlate highly with activity limitations, and strength training has been shown to improve strength and motor activity after stroke.3, 4, 5 Additionally, research findings indicate that motor skill acquisition is dependent on the individual performing active and repetitive practice of that skill, learning again to control movement in relevant environments.6 This contrasts with Bobath therapy, which assumes that movement control is dependent on therapists facilitating ‘normal’ movement patterns.7, 8, 9, 10
Despite its extensive clinical use, the efficacy of Bobath therapy has not been established. Efficacy of Bobath therapy would be most directly established by trials of Bobath therapy versus no intervention. A search of the PEDro database identifies no systematic reviews that compare Bobath therapy versus no intervention. To date, three systematic reviews have compared Bobath therapy with other interventions.11, 12, 13 These reviews did not include a pooled analysis of outcomes and were unable to provide any definitive conclusions. An additional systematic review compared Bobath therapy with other interventions, and pooled analyses of outcomes indicated that specific interventions, such as task-specific training, may be more effective than Bobath therapy.14 However, this review did not include a comprehensive search and analysis of trials comparing Bobath therapy with other interventions, as this was not the objective.
The primary aim of this systematic review was to evaluate the effect of Bobath therapy on lower limb activities after stroke. The secondary aim was to evaluate the effect of Bobath therapy on lower limb impairments, strength and co-ordination after stroke.
Therefore, the research question for this systematic review was:
In adults with stroke, does Bobath therapy improve lower limb activity performance, strength or co-ordination when compared with no intervention or other intervention?[…]
TBI Rehabilitation 