Cheers Bobath (and thanks)

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Cheers Bobath (and thanks)

22nd February, 2016

One of the advantages of long service leave is that it gives me time to write on posts such as these! I also owe a great deal to the Bobath Concept. It introduced me to client-centred care, detailed movement analysis, hands-on palpation, handling and facilitation skills, teamwork, motor control theories, movement neuroscience and so much more. As a result, I decided  to study neuroscience further in the UK and pursued research into balance and gait movement analysis. BB also introduced me to mental imagery, CIMT and task specific practice!

 

Now as a clinician I use any arsenal at my disposal.The more ideas I have the better for my patients. However I, like so many others (of my ilk) we would be far less effective if it wasn’t for BB. BB remains popular for many reasons, however we all seem to agree that it does fill a huge void in the education needs of neuro therapists. BB has an effective teaching style , using real patient demos, plenty of intense practice and constant problem solving. Deciding to pursue a career as a Bobath Tutor would therefore be a huge commitment and personal sacrifice as there is much to learn. For the rest of us, BB allows for an opportunity to learn skills in assessment using a combination of visual observation and manual handling. It explores the relationship between postural movements, balance and all body parts, and enables the patient to actively move. If you think it is passive, then perhaps you should be facilitated yourself!

 

Now, I find myself in a position that presents an enormous challenge. As coordinator of a Neurological Physiotherapy Masters program, I need to get a feel for where all of these concepts, approaches, skillsets and techniques fit into the future picture. What does a Neurological Physiotherapist of today need to know? What is the future of service delivery funding? When do we need to learn about and implement new technologies such as Robotics and FES? Do we wait for the evidence? When I worked in London in 2003-05 we used a BWS treadmill before any decent evidence was available. At our current teaching hospital we are using UL and gait robotics despite little to no evidence.

 

The next generation of Physiotherapists are expected to appraise evidence far more than ever before. And let’s not kid ourselves, the evidence for many key areas of neurological rehabilitation remains very weak – all of it. So where do we go from here?

 

At this stage the direction we have taken is to provide multiD and interD learning opportunities for our Neurological Physiotherapy students to update on the latest knowledge about the rehabilitation needs and key rehab developments for a number of adult population groups including Stroke. MS, Parkinsons, MND and electives on TBI, SCI and others. There is more on the horizon such as the many dementias and other movement disorders such as dystonia. We do not cover paediatrics unfortunately.  It is essential to explore the individual presentations and plights of our patients that may include, sensory, perceptual, biomechanical and psychological factors that challenge both clinical practice and research methodology.  In addition, we devote a topic to explore neuroscience and motor control theories and how this relates to the retraining of our patients. This way we expect our students to draw upon and critique both clinical and neuroscientific evidence to become better therapists, coaches and researchers. We do not promote nor reject any ‘approach’, but encourage careful scrutiny.

 

It’s true that research rules the roost in terms of university funding. Clinical trials, RCTs, systematic reviews and PhD students bring in the bacon for sure, however the reality is such that the strong research gets stronger. This is why simple and clearly defined techniques lead the way, such as treadmills, Task Practice, CIMT (although ‘shaping’ can be quite variable), FES, TMS, tDCS,  Robots, strengthening and aerobic fitness. These interventions spit out data for all kinds of colourful and often biased analysis. And don’t get me wrong, I really love this stuff (and research it myself), but it is such a small part of the overall rehabilitation picture. Unfortunately, it will take a long time to research the areas of physiotherapy that we often crave such as movement analysis, developing more specific and valid outcomes measurements for impairment and function, and perhaps more relevant issues of quality of life, self-efficacy and cost.

 

We have such a long way to go, yet clinicians and patients need some reassurance that we are providing best practice NOW! This is why I understand the temptation to push aside Bobath and others (especially manual techniques), where it seems (and may well be) impossible to research, despite the important contributions from my Flinders colleague Sheila Lennon and others (Lennon & Ashburn, 2000). I agree with Margaret Mayston and Lewis Rosenboom in that we should ‘Please proceed with caution’.(Mayston & Rosenbloom, 2014) I also agree that NDT/Bobath should have been excluded according to Novaks exclusion criteria in that controversial systematic review on CP.(Novak et al., 2013)

 

We are also investing time and money to explore the best ways to deliver clinically focussed CPD at university. In doing so, we should look at the strengths of the Bobath teaching style and use it (and acknowledge it despite fear of being labelled a heretic in some parts of Australia). We will explore a combined eclectic approach that reflects the real practice of so many therapists. I am hopeful, (but remain doubtful) that Universities across the globe can provide high level CPD. Young, enthusiastic and intelligent physiotherapists with an interest in neurology are often attracted to the challenges and clear career structure within universities, and are directed toward these clearly defined, funded research opportunities such as those that involve Transcranial Magnetic Stimulation, Robotics. gait labs or Body Weight Support Treadmill training. All great stuff, but these young guns with a PhD and only one or two years real clinical experience will be teaching the next crop of physiotherapists! This means that Bobath and other CPD providers play an important role in teaching and mentoring our young physios.

 

Further research into the role of sensation and movement will help determine where, when and for whom facilitation can play a role in skill acquisition and movement retraining. We can explore how certain handling techniques might allow for improving movement performance, and how it can be combined with additional protocols such as CIMT (this is happening with more severely impaired adults and children in the US), FES, functional strengthening programs and balance re-training. If we do cross fertilize like this, I realise the intervention can no longer be called ‘Bobath’ – an issue that may well be the key challenge for Bobath as it continues to evolve. I am a strong believer in ‘cross-fertilization’ and do not see it as ‘contamination’ like so many researchers. It might sound melodramatic, but there is a bigger issue here. If we over-simplify our practice, the future of neurological physiotherapy will be threatened. Health assistants, occupational therapists and exercise physiologist will be more than happy to stick our patients on robots, FES, treadmills or bikes based on available best evidence. This is already happening believe me! Evidence and information can always be misunderstood and misused.

 

The Bobaths were ahead of their time, which means that criticism comes with the territory. They attempted to explain their observations based on very the limited neuroscientific knowledge at the time, yet were more than happy for it to evolve with the passage of time. I agree with others that research evidence and Bobath are not incompatible, (Cott, Graham, & Brunton, 2011; Mayston, 2008) we just have a way to go. If you have been taught that Bobath is evil and outdated, perhaps you should ask yourself what motivates such extreme hatred, because the limited evidence against it just does not stack up. If you don’t know much about Bobath, I suggest you find out what all the fuss is about!

 

Cheers Bobath (and thanks)

 

James.

 

Dr James McLoughlin

BAppSc (Physio) MSc (Clinical Neuroscience), PhD  

Director JMNP Pty Ltd

Senior Lecturer, Flinders University

APA Neurological Physiotherapist

Accredited Vestibular Physiotherapist

 

Cott, C. A., Graham, J. V., & Brunton, K. (2011). When will the evidence catch up with clinical practice? Physiotherapy Canada. Physiotherapie Canada, 63(3), 387–390.

Lennon, S., & Ashburn, A. (2000). The Bobath concept in stroke rehabilitation: a focus group study of the experienced physiotherapists’ perspective. Disability and Rehabilitation, 22(15), 665–674.

Mayston, M. (2008). Bobath Concept: Bobath@ 50: mid-life crisis—What of the future? Physiotherapy Research International: The Journal for Researchers and Clinicians in Physical Therapy, 13(3), 131–136.

Mayston, M., & Rosenbloom, L. (2014). Please proceed with caution. Developmental Medicine and Child Neurology, 56(4), 395–396.

Novak, I., McIntyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., … Goldsmith, S. (2013). A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine and Child Neurology, 55(10), 885–910.