[ARTICLE] Bobath therapy is inferior to task-specific training and not superior to other interventions in improving lower limb activities after stroke: a systematic review – Full Text

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?[…]

Continue

[ARTICLE] Bobath and traditional approaches in post-stroke gait rehabilitation in adults – Full Text PDF

Summary

Study aim: The aim of this study was to compare the outcomes of a study of post-stroke gait reeducation using the Bobath neuro-developmental treatment (NDT-Bobath) method and the traditional approach.

Material and methods: The study included 30 adult patients after ischemic stroke, aged 32–82. Patients were randomly assigned to one of the treatment groups: the study group (treated with the NDT-Bobath method combined with the traditional approach, ten sessions), and a reference group (treated with the traditional method only, ten sessions). The measurements (spatio-temporal gait parameters based on 10 m walking test: gait velocity, normalized gait velocity, cadence, normalized cadence, stride length, and normalized stride length) were administered twice: on admission (before the therapy) and after the last therapy session.

Results: Statistically significant and favorable changes in the gait velocity, cadence and stride length regarding their normalized values were observed. Moderate and high correlations among changes of assessed spatio-temporal gait parameters were observed in both groups.

Conclusions: The NDT-Bobath method may be regarded as a more effective form of gait post-stroke rehabilitation in young adults compared to traditional rehabilitation.

Introduction

Despite stroke incidence and mortality rates slowly decreasing in selected countries (especially developed Western Europe countries) [6, 7], stroke is still regarded as one of the leading causes of death and long-term disability. Ischemic stroke cases constitute approximately 70–80% of all stroke cases [6, 7]. Post-stroke gait disorder reduces mobility of patients, their independence, participation in activities of daily living and community life. Gait disorders may be reflected in spatio-temporal gait parameters. Their assessment may be a useful basic or supplementary way to assess general efficiency of gait function restoration during a neurorehabilitation program.

The Bobath neuro-developmental treatment (NDTBobath) method for adults is still one of the most popular therapeutic methods in neurorehabilitation, including gait relearning [8, 21]. Current studies concerning its use in post-stroke gait relearning have methodological concerns related to study/treatment fidelity and measurement [16]. For this moment there is insufficient evidence (especially from randomized controlled trials – RCTs) to conclude that a particular physiotherapy method (including NDT-Bobath) is more effective in promoting recovery of gait than any other approach. Moreover, combined use of NDT-Bobath and components of any other approaches may diminish the aforementioned picture. The assumption that rehabilitation using a proper mix of components derived from different approaches may be more effective than no treatment control in attaining gait function following stroke may be true [18]. Research on various mixed/eclectic approaches constitute an important step toward patient-tailored therapy and the need for further support. Current evidence concerning combined use of the NDT-Bobath method and components of another therapeutic approach is weak. Evidence of favorable combined use of the NDT-Bobath method is as follows:

− successful use of mixed rehabilitative procedures, including NDT-Bobath, in an individual training package [17],

− therapy based on the NDT-Bobath concept supported by task practice is more effective than task practice alone [9],

− injection of botulinum toxin type A combined with NDT-Bobath therapy showed improvements in lower limb spasticity, gait and balance in post-stroke patients greater than use of botulinum toxin type A alone [11].

The aim of this study was compare the outcomes of a study of post-stroke gait rehabilitation using the NDTBobath method for adults combined with the traditional approach and the sole traditional approach.

Full Text PDF

[BLOG POST] How to do Bobath? Part 4. Motor learning and neuroplasticity – When EBP meets neurological physiotherapy …

PUBLISHED ON October 18, 2015

There has been a lot of discussion in the icsp threads (found here http://www.csp.org.uk/icsp/topics/rationale-evidence-bobath-neurological-physio and http://www.csp.org.uk/icsp/topics/novak-review-casts-doubt-efficacy-bobath-should-we-embrace-or-ignore-it ) from physios who use Bobath about: what Bobath is, or isn’t, what it aims to do, how and why. Fair to say, I think, that there is considerable uncertainty, despite the earlier posts about the definition of Bobath. So I have tried to collect together the relevant discussions and to chunk them into easily digestible pieces. I hope this makes sense and represents everyone reasonably. You can always go back to the original icsp thread to check it out. If I’ve messed up, I’m happy to be shown the error of my ways. Unfortunately I can’t directly attribute the discussion to the person posting (unless they have specifically said that I can) because that would fall foul of the terms and conditions of icsp and their copyright rules, so I have to summarise the contributions in my own words. I have tried to do this as openly and even-handedly as I can.

In this chunk some of the theoretical beliefs about how Bobath works are considered in the light of evidence. I’ve taken the Vaughan-Graham 2009 paper (Top Stroke Rehabil 2009;16(1):57–68) as a starting point. In the paper there are several statements specifying aspects of the Bobath Concept. I published that list before in the icsp thread a while ago. At the time it didn’t raise a lot of discussion. So I’ve grouped the statements into several sections and will consider how they compare with the evidence. Ive also added some relevant queries, stated beliefs and discussion from the icsp threads and drawn on the Bobath Concept book (pub 2009 – a most illuminating read). There is a sprinkling of references to back up my claims or I have recommended other reading (would hate to be accused of not justifying my claims!) These are by no means a comprehensive indication of the evidence, they are some examples.

 

Part 4. Neuroplasticity and motor learning

The Bobath tutors say: the Bobath concept utilizes present-day knowledge of motor control, the nature of movement dysfunction, neuromuscular plasticity, biomechanics, and motor learning….. The Bobath Concept is part of an active learning process. It assists the patient in problem solving and enables him or her to experience the patterns of movement and success in achieving the task. …… Treatment is focused toward remediation, exploring the individual’s potential to regain abilities through neuromuscular plastic adaptation.

 Neuroplasticity and motor learning are considered two of the main mechanisms by which BB has its effect (ie how it works). It is the mechanisms for all other types of neuro physio too, but we’ll leave that aside for now. In their book, the Bobath tutors have sections on motor learning and on neuroplasticity. They outline the principles of both and highlight some of the conditions needed to promote both, and carry-over into every-day life. These include:

• Working on meaningful goals/ tasks
• training in different real-life situations as appropriate and not only in the therapy department.
• enabling active participation which involves engaging the patient in a problem-solving process [ie the patient has to work out how to perform and to correct the activity themselves]
• using repetition effectively – varied tasks; varied environments; varied repetitions (random more than blocked practice); whole tasks (more than part task or practicing components);
• training intensively (the more the better)
• giving feedback occasional on the outcome (knowledge of results with wide ‘band-width, to use the jargon) more than continuous/ frequent feedback about the way the person is moving (narrow band-width knowledge of performance).

The BB book also includes mental practice, modelling (or demonstration) and guidance [AKA facilitation] as techniques that promote motor learning and neuroplasticity, which is extrapolating some early stage research a bit too far IMHO. However they do note that “excessive guidance [NB: guidance AKA facilitation] or physical devices offering continuous restraint and direct movement reduces the need for problem-solving and does not improve learning.”

All of which is sensible stuff and I agree with !! I can see the headlines now #TysonagreeswithBobathShock, they will be saying that I endorse BB next, Oh wait, they already do!  BUT but, but, but, there is nothing in the book, the courses or the papers they have published to actually connect BB with these principles.  No evidence that Bobath generates motor learning or neuroplasticity, although there is plenty of evidence that other interventions do: The EB ones like CIMT, exercise, electro-mechanical gait-training and treadmill training. It is just stated that they do, presumably we are accepted to take this at face value.  Although that may have been on in the past (for lack of an alternative), it is an insufficient basis for credibility now-a-days. Show us data to demonstrate that BB produces neuroplasticity and motor learning.

Although there is no evidence that BB involves the conditions that promote motor learning and neuroplasticity. There is evidence that it does not involve the right conditions to achieve it. Granted it is very low level but it does come from the horse’s mouth. Think of the Bobath courses you have been on; look at the examples of BB in action in the case studies (presumably the good ones) on the BBTA website (http://www.bbta.org.uk/poster-presentations-bobath-concept); look at the examples of BB in action in their book. How many examples involve meaningful goals/ tasks; training in different real-life situations; an actively engaged patient (them actually doing a meaningful/ functional task for themselves); varied practice conditions; high repetitions; varied practice conditions; knowledge of results; low frequency feedback?

Exactly! None or next to none. How often have you seen the conditions which prevent motor learning – excessive guidance, continuous restraint and directing of movement, abstract rather than functional movements, the patient being passive rather than active, low number of repetitions? Nearly all of them.

In the icsp discussions, contributors wondered whether low repetition/ intensity of practice was a factor in BB’s lack of evidence. She said “I would question the notion of “person centred approach” being used in the same sentence as the Bobaths’ approach.  All the Bobath courses I’ve attended were very much geared towards what the therapist was doing to or for the client, rather than what they [the patient] were generating for themselves within or beyond the treatment”….. The link between repetitive practice and neuroplasticity is well established in Neurophysiology research, and we know a significant amount of repetition is required.  Perhaps 1 reason why NDT/Bobath is not achieving proof of effectiveness or significant change in research trials is insufficient repetition?”

Another contributor agreed, adding that “If you want to learn to walk you need to practice walking; this is how infants learn to walk and how we all acquire new skills. However, in Sheila Lennon’s study ([D& R 2006:28;873-881] where the major aim was to enhance mobility by advanced Bobath techniques;  the patients actually walked for only 7-12% of their therapy time. This concurs with my own experience that Bobath trained therapists can be more interested in applying their complex handling techniques to patients than helping the patient do something useful themselves. The emphasis needs to be more on the patient practicing functional tasks than on ourselves exhibiting high level handling techniques; especially when the best evidence indicates they are are better alternatives”. 

The observation of a gap between what BB says and what they do is further illustrate din some work I did a while ago now, about the how neuro physio therapy is delivered in ‘real life’. Tyson, Connell, Lennon, Busse Clin Rehab 2009; 23;11;1051-1055  D&R 2009: 31:18;1494-150 D&R 2009;31:6;448-457. These showed that Bobath practitioners spent most of their time in therapy sessions ‘preparing’ patients using passive techniques such as mobilisations and facilitating selective movements. There were precious few repetitions, the patient was passive most of the time and the activities were abstract rather than functional.  None of which promote motor learning or neuroplasticity

Source: How to do Bobath? Part 4. Motor learning and neuroplasticity – When EBP meets neurological physiotherapy …