To the Editor
Re NHS Evidence – Eyes on Evidence Issue 10 February 2010
‘Bobath – popular but may not be the best for stroke’
As Dr Tyson is aware structured rehabilitation programmes are effective in reducing morbidity and improving outcome following stroke (Stroke Unit Trialists' Collaboration 2007). She rightly points out that in the UK the Bobath Concept is the most popular treatment approach used in the rehabilitation of persons with neurological disability however she is mistaken in her assertion that the aim of Bobath therapy is to reduce spasticity and facilitate more normal movement. The Bobath Concept is based upon present-day knowledge of motor control, motor learning, neuromuscular plasticity and human functional movement [Raine 2006, Raine 2007, Graham et al 2009] and functional task practice, treadmill training and constraint – induced therapy are integrated within the clinical practice framework.
With respect to Kollen et al (2009) this review was limited to RCT level 2 evidence but the studies included were not all of the same level of quality. Other studies at a lower level of evidence such as comparative studies, case series and case presentations may have yielded evidence of a similar quality and therefore could have been included. In many of the studies included there were limitations in the research design, such as low participant numbers (n=6), insufficient data to confirm that groups were comparable at baseline (n=5) and/or lack of blinded assessors (n=5). These limitations, relating to methodological quality and to contextual factors investigated, restrict the ability to draw conclusions rather than suggest that there is evidence that interventions based on other approaches are more effective than the Bobath Concept. It is therefore as valid to use the Bobath Concept as other approaches. This is also the conclusion from three other systematic reviews (Paci 2003, Van Peppen et al 2004, Luke et al 2004) where there was once again insufficient evidence to confirm or refute the efficacy of the Bobath Concept compared to other approaches.
There is a need for high-quality research trials and clinicians and researchers need to work together to design and undertake clinically relevant research projects. Before we consider discarding the Bobath Concept it should be adequately and appropriately tested especially as there was evidence for the superiority of the Bobath Concept in the domain of balance control (Kollen et al 2009).
British Bobath Tutors Association
References
Graham JV, Eustace C, Brock K, Swain E, Irwin-Carruthers S. (2009) The Bobath concept in contemporary clinical practice. Topics in Stroke Rehabilitation 16:57-68.
Kollen BJ, Lennon S, Lyons B, Wheatley-Smith L, Scheper M, Buurke JH, Geurts AC and Kwakkel G (2009) The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence? Stroke 40:89-97.
Luke C, Karen J Dodd K ,Brock K (2004) Outcomes of the Bobath concept on upper limb recovery following stroke. Clinical Rehabilitation 18: 888-898.
Paci M (2003) Physiotherapy based on the Bobath Concept for adults with post-stroke hemiplegia: a review of effectiveness studies. Journal of Rehabilitation Medicine 35:2-7
Raine S. (2006) Defining the Bobath Concept using the Delphi technique. Physiotherapy Reserach International 11:4-13.
Raine S. (2007) The current theoretical assumptions of the Bobath Concept as determined by the members of BBTA. Physiotherapy Theory and Practice 23: 137-152.
Stroke Unit Trialists' Collaboration (2007) Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000197. DOI: 10.1002/14651858.CD000197.pub2.
Van Peppen RP, Kwakkel G, Wood-Dauphinee S, Hendriks HJ, Van der Wees PJ, Dekker J. (2004) The impact of physical therapy on functional outcomes after stroke: what's the evidence? Clinical Rehabilitation 18(8):833-62.
