Article

Bobath under fire

Issue: 06 January 2010

A debate about the Bobath concept is inflaming passions across Europe, Daloni
Carlisle talks to people on both sides of the dispute

As inflammatory statements go, this from a group of neurorehabilitation

physiotherapists might rank up there with the greats: ‘Evidence-based guidelines
rather than therapist preference should serve as a framework from which therapists
should derive the most effective treatment.’

It was made in a 2009 systematic review of evidence for the Bobath concept and
published in the academic journal Stroke1 (see panel: What’s the evidence?). It
concluded there was no evidence Bobath was better than any other treatment –
although there was no evidence any other treatment was superior to Bobath either.

Its final conclusion – Bobath should be put aside, hides within it an accusation that
has inflamed passions on both sides of the North Sea and contains echoes of a similar
row in the US: that Bobath therapists do not base their treatments on evidence and are
acting on personal preference.

There is now a growing body of research and opinion saying Bobath is out of date and
obsolete, not least because of emerging data from neurosciences2 and should be
abandoned in favour of an evidence-based approach. There is an equally convinced
group of Bobath tutors and practitioners who defend the concept vigorously and ask:
what else do we have that’s better?

In between are the agnostics who think there is room to keep Bobath and update it.
Talk to people involved in the debate and the strength of feeling is obvious on each
side. Words like ‘rift’, ‘complex’, ‘minefield’ and ‘sensitive’ rub up against
‘potentially far-reaching international consequences’ and ‘more than my job is worth
to talk about this publicly’.

The Netherelands moves on

Professor Gert Kwakkel, chair of neurorehabilitation at the VU University Medical
Center in Amsterdam, is one of the authors of the Stroke paper. He cites it as further
evidence to support the 2007 decision by physiotherapists in the Netherlands to
abandon Bobath in favour of a new evidence-based guideline approach.

Called ‘neurorehabilitation-stroke’, it is based on an improved understanding of the

mechanisms underlying adaptive motor relearning and mechanisms of functional
recovery after stroke and includes metrics for measuring change. Over the last two
years, 18 of the 22 Bobath teachers in the Netherlands have retrained using the new
approach, with the remaining four deciding to stand down. A similar approach to
Parkinson’s ‘neurorehabilitation-Parkinson’s’ is in the pipeline.

In Prof Kwakkel’s view, Bobath is obsolete. The understanding of how patients

recover from stroke has changed radically since 1948 and while Bobath has taken this
on board, it has been done so selectively, say Prof Kwakkel and other academics.

Prof Kwakkel is not alone in criticising Bobath therapists for this. In a 2006 letter in
Physiotherapy Research International, Margaret Mayston, senior lecturer at University
College London and a Bobath tutor and consultant, wrote: ‘The Bobath concept is
now so diverse that it can be difficult to know where it came from and what it is: there
are so many derivatives of it that it could be considered a disservice to Dr and Mrs
Bobath to continue to practise under the Bobath name.’3

But Prof Kwakkel’s key criticism is Bobath therapists are not measuring their impact
on patients. ‘Their problem is that they talk about quality of motor control and motor
performance, but they do not understand how to measure quality,’ he says. ‘But
observation is not an appropriate way to say this works. You need to make it
transparent for the world.’

This is echoed in the US where the debate rages over Bobath therapy in children.
Diane Damiano, a physiotherapist in the department of neurology at Washington
University and vice president of the American Academy for Cerebral Palsy and
Development Medicine, made the same point in a 2007 editorial in Development
Medicine and Child Neurology.

She wrote: ‘Many therapists purport that they use an “eclectic” approach, and pick
and choose techniques from multiple sources, as if there were a therapy method buffet
table. Medical science however, demands that we seek the best approach, and does
not support a practice where individuals can do whatever they want regardless of the
support for these personalised decisions.’4

Should UK embrace change?

Prof Kwakkel says therapists in Germany and Belgium are set to follow the
Netherlands’ example and the question must now arise: what about the UK? Should
we follow suit?

The answer from the British Bobath Tutors’ Association, which represents 17 Bobath
tutors who teach in the UK and internationally, is an emphatic no.

Referring to the Stroke paper, Paul Johnson, a BBTA member and lead
physiotherapist in the NHS, says: ‘We recognise this is a systematic review of the
current evidence, but it is limited. We do not see on the basis of that paper that there is
any reason to change practice in the UK.’

BBTA points out its courses are full and still in demand, despite the existence of a
range of alternatives. Paul Johnson says: ‘From an educational perspective, we
recognise there are many approaches used by therapists in the UK and we fully
recognise the Bobath concept forms part of them. The specific focus of the Bobath
concept is around the application of movement analysis skills as a basis for
developing clinical reasoning processes.’

In other words, Bobath teaches therapists to look at the individual in front of them,
analyse their needs and select the appropriate therapy. ‘We are trying to help people
to use the evidence,’ says Paul Johnson. ‘But there is a difficulty for people taking
pure forms of evidence and applying them to patients.’

Mary Lynch-Ellerington, BBTA member, adds that this ability to select the right
treatment for the right patient rather than follow a rigid protocol defined for a
diagnosis reflects UK physios’ autonomous status and strong continuing professional
education ethos.

‘This is something that does not exist in Europe where therapists are still required to
carry out a doctor’s prescription,’ she says. ‘I would hate, and that is the right word, to
go back to treatment of diagnosis and set protocols for every patient.’

The BBTA has taken on board the need for a better evidence base for Bobath, and in
the autumn of 2009 published a new work outlining the theory behind Bobath and its
clinical practice, which they hope will provide the theoretical basis for moving
forward.

Evidence for change

Others support more radical change and point to the range of guidelines and
systematic reviews already published. Sarah Tyson, reader in rehabilitation at the
University of Salford, cites a 2004 review of 128 randomised controlled trials and 28
controlled clinical trials in stroke rehabilitation, which found strong evidence for the
effectiveness of therapies focused on functional training of the upper limb, such as
constraint-induced movement therapy and treadmill training with or without body
weight support. There was no evidence in terms of functional outcome for a range of
other interventions, including traditional neurological treatment approaches.5

She says: ‘If we are looking purely at the evidence, then I would say yes, we should
have similar changes in practice implemented in the UK as seen in the Netherlands.’

Her reading of the growing body of evidence leads her to say: ‘The implications are
that exercise and intensive practice of functional tasks “work”, while traditional
approaches such as Bobath do not, and that other treatments which include exercise
and intensive practice interventions, such as treadmill training, work better than
Bobath. I would suggest it is hard to justify continuing to use Bobath nowadays, when
the evidence to support other treatments is so much stronger.’

Others are less convinced of the need for wholesale change, a stance that perhaps
recognises that the investment – emotional, cultural and financial – in Bobath is just
too large and that the UK lacks the insurance-based healthcare system that has in part
driven change in the Netherlands, where the government funded the retraining of
Bobath tutors.

Sheila Lennon, senior lecturer in rehabilitation sciences at the University of Ulster

and a co-author on the Stroke paper, says UK therapists should be wary of throwing
the baby out with the bath water, pointing out that although it showed no evidence
that Bobath was more effective than other treatments, it was no less effective either.

But change is needed, she adds, including more quality trials. ‘I personally feel we
need to implement evidence-based techniques and get away from a guru mentality and
use research in combination with clinical expertise and the wishes of patients and
carers.’ Like many, she is looking to ACPIN, the Association of Chartered
Physiotherapists Interested in Neurology, for a lead.

Mixed approach
Dr Margaret Mayston, president of ACPIN, agrees with Dr Lennon, that things are
changing here, but that the UK is not ready for a wholesale rejection of Bobath.
Rather than throw out Bobath, she advocates a mixed approach.

‘I don’t think we should do what the Dutch have done, which is modify Bobath so
much they cannot call it Bobath anymore. We should define what Bobath is, say what
is successful, explain it in terms of current scientific knowledge and then add other
things that work.’

The debate is set to run and run and should interest not just those in
neurorehabilitation, but also provoke interest more widely, highlighting as it does the
clash that can happen when research and clinical practice are at odds, when cherished
beliefs are challenged as in the extent to which physiotherapists have actually taken
on board what it means to base their practice on evidence. FL

REFERENCES

1. Kollen B et al. ‘The effectiveness of the Bobath concept in stroke

rehabilitation. What is the evidence?’. Stroke (2009), 40:e89
2. Oujamaa L et al. ‘Rehabilitation of arm function after stroke. Literature
review’, Annals of Physical and Rehabilitation Medicine (2009), 52:269
3. Mayston M ‘Editorial: Bobath concept: Bobath@50: mid-life crisis – what of
the future?’, Physiotherapy Research International (2006), 11:183
4. Damiano D ‘Pass the torch, please!’, Development Medicine & Child
Neurology (2007), 49:723
5. Van Peppen R PS et al. ‘The impact of physical therapy on functional
outcomes after stroke: what’s the evidence?’ Clinical Rehabilitation (2004),
18:833 http://cre.sagepub.com/cgi/content/abstract/18/8/833

What’s the evidence?

In 2009, a group of Netherlands and UK physiotherapists and researchers published a

systematic review of randomised, controlled trials to evaluate the available evidence
for the effectiveness of the Bobath concept in stroke rehabilitation. Their argument
was although it is the most popular treatment used in stroke rehabilitation, the Bobath
concept has never been proven to be superior to alternative approaches.

Researchers carried out a systematic literature search in March 2008 and studies in
which the effects of the Bobath concept were investigated were classified into the
following domains: sensorimotor control of upper and lower limb; sitting and
standing; balance control and dexterity; mobility; activities of daily living; health-
related quality of life and cost effectiveness.

The next step was to measure the strength of the evidence in the literature retrieved.
Independent researchers rated it using the Physiotherapy Evidence Database scale and
derived a best evidence synthesis that was used to determine the strength of evidence
for the effectiveness of the Bobath concept and for its superiority over other
approaches. This approach whittled down an initial list of 2,263 studies to a final 16
involving 813 patients suitable for inclusion in the review.

The researchers found no evidence for the superiority of Bobath on sensorimotor

control of upper and lower limb; dexterity; mobility; activities of daily living; health-
related quality of life and cost effectiveness. Only limited evidence was found for
balance control in favour of Bobath.

They concluded the Bobath concept was not superior to other approaches, but equally
there was no evidence available yet for the superiority of any approach. However, the
review identified many methodological shortcomings in the studies and called for
further high quality trials.

Bobath: a brief history

The Bobath concept emerged in the post-World War II period in the UK as awareness
of the need for rehabilitation generally was increasing. It was first published in 1948
and now, more than 50 years later, it is the most popular approach for treating
neurologically impaired patients in the western world.

It was developed by husband and wife Dr Karel Bobath and Berta Bobath, a doctor
and physiotherapist, respectively, who shared an interest in understanding the
problems of adults and children with neurological conditions. The main aim of
treatment is to encourage and increase the patient’s ability to move and function in as
normal a way as possible by encouraging more normal postures. Therapists assess the
patient, observe their movements and develop a treatment plan. It is a hands-on
approach, with the therapist directing the patient’s movements.

Bobath therapy has changed over time, incorporating new scientific knowledge. Karel
and Berta published their concept for the last time in 1990, a year before they died.

Useful resources
• The Royal College of Physicians’ National Clinical Guidelines for Stroke was
updated in 2008 and includes a section on rehabilitation. It does not contain
the latest (2009) reviews of the effectiveness of Bobath
www.rcplondon.ac.uk/pubs/brochure.aspx?e=250
• The evidence-based stroke rehabilitation guidelines and flow chart developed
by the Royal Dutch Society for Physical Therapy are available to download in
English here www.kngfrichtlijnen.nl/654/KNGF-Guidelines-in-English.htm
• Meadows L et al (ed), Bobath concept: theory and clinical practice in
neurological rehabilitation. Wiley Blackwell, October 2009
• Hesse S ‘Treadmill training with partial body weight support after stroke: A
review’, NeuroRehabilitation (2008), 23(1):55

Response
BBTA's response to Frontline

To the Editor,
“Bobath under fire”
Structured rehabilitation programmes are known to be effective in reducing morbidity
and improving outcome following stroke (Stroke Unit Trialists' Collaboration 2007)
and increased intensity of therapy positively influences outcome (Kwakkel et al 1997)
however the optimal content of the ‘rehabilitation package’ remains uncertain.
Four systematic reviews (Paci 2003, Van Peppen et al 2004, Luke et al 2004, Kollen
et al 2009) have attempted to address this issue and, due to a number of
methodological issues, the results of best evidence synthesis of all available evidence
has been inconclusive. The recent publication of a new text outlining the theory and
clinical practice of the Bobath Concept (Raine et al 2009) has addressed the
considerable gap in available reference publications. It is clear within this text that
many aspects of therapy referred to by contributors to the Frontline article such as
functional task practice, treadmill training and constraint – induced therapy are
integrated within clinical practice using the Bobath Concept. The importance of
measuring outcome in terms of functional recovery is fundamental to the clinical
practice of the Bobath Concept and is also clearly described within this text. As
acknowledged by Kollen et al (2009) BBTA deliver evidence based courses to
physiotherapists and occupational therapists. These courses offer an opportunity to
develop skills of movement analysis and treatment; the principles of which can be
applied to the assessment and treatment of adults with a broad spectrum of
neurological disorders rather than focusing on a single diagnosis.
BBTA and our international colleagues look forward to being involved in and seeing
the results of high quality targeted research to investigate the efficacy of
interventions. It is our professional responsibility to ensure we deliver high quality
education packages to those attending our courses and effective therapy to our
patients.
Catherine Cornall
Chairperson BBTA