Responses:
We would like to commend the authors in their recent publication (Stroke 40: e89-e97), for recognising that in the United Kingdom BBTA provides evidenced based courses underpinned by current knowledge of motor control, motor learning, muscle and neural plasticity. In addition BBTA incorporate an understanding of functional human movement, which is also evidence based. Considerable advances in the understanding of neuroplasticity and the function of the nervous system have naturally led to changes in the theoretical basis of the Bobath Concept from its inception. A number of the original components however, including assessment, problem solving, clinical reasoning based on the study and analysis of human movement and facilitation skills, functional task analysis and therapeutic activities of daily living remain core components of practice within the Bobath Concept.
It is unclear what the authors new eclectic approach entitled ‘neurorehabilitation – stroke’ consists of, although they state that it is based upon evidence based guidelines it does not appear that it is related to any treatment interventions or improved understanding of mechanisms underlying adaptive motor learning and functional recovery. If this is different to the Bobath Concept then the only treatment rationale must be ‘function through compensation’, as is indicated by the main theme of the discussion within the article. It appears this ‘new approach’ is only for stroke. Arguably if it is evidenced based and uses a concept based on motor control and motor learning it is applicable to all patients with sensorimotor dysfunction, as is the Bobath Concept. It seems that this new approach in the Netherlands is an alternative to the Bobath Concept and the 22 Dutch IBITA tutors (adults and paediatric) have adopted a different perspective.
The systematic review highlights that research evidence to support clinical interventions based on ‘concepts of treatment’ in stroke rehabilitation is limited although, a lack of evidence of effect is not necessarily evidence of lack of effect (1). The authors draw attention to methodological shortcomings in the studies that they reviewed and call for further high-quality trials. This should include a detailed description of the intervention to enable replication, evidence synthesis and wider implementation (2). Evaluating complex interventions that contain several interacting components and a range of individual difficulties within the subject group receiving the intervention is complicated and a good theoretical and clinical understanding is required. The theoretical underpinnings of the contemporary Bobath Concept have more recently been defined (3,4,5,6). This will provide a framework on which more rigorous evaluation of the Bobath Concept can be based.
BBTA
References
1. Pomeroy VM, Tallis RC. 2003 Avoiding the menace of evidenced-tinged neuro-rehabilitation. Physiotherapy, 89, pp.595-601.
2. Craig P, Dieppe P, Macintyre S, Mitchie S, Nazareth I, Petticrew M 2008 Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ, 337, pp.979-83.
3. Raine S. 2006 Defining the Bobath Concept using the Delphi technique. Physiotherapy Res Int. 11, pp.4-13.
4. Raine S. 2007 The current theoretical assumptions of the Bobath Concept as determined by the members of BBTA. Physiotherapy Ther and Pract. 23, pp.137-152.
5. Graham JV, Eustace C, Brock K, Swain E, Irwin-Carruthers S. 2009 The Bobath concept in contemporary clinical practice. Top in Stroke Rehab. 16, pp.57-68.
6. Raine S, Meadows L, Lynch-Ellerington ME. 2009 Bobath Concept. Theory and Clinical Practice in Neurological Rehabilitation. Oxford: Wiley-Blackwell.
We would like to thank the authors for their comprehensive and well structured review of the evidence regarding the Bobath Concept in the rehabilitation of stroke. The review demonstrated that there is insufficient evidence to establish a best evidence synthesis in six of the seven domains examined, with limited evidence favouring the Bobath Concept in the domain of balance. The authors state in their conclusion that the review “confirms that overall the Bobath Concept is not superior to other approaches.” We do not believe that the evidence they have presented is sufficient to justify this statement. Although the authors identified 16 studies, 9 of these studies were investigating new or adjunctive interventions, (e.g. constraint induced therapy, robot assisted movement training, EMG feedback, treadmill training, rhythmic auditory cueing) with the Bobath Concept representing conventional therapy. These studies were not designed to test the efficacy of the Bobath Concept. Use of these studies in the analysis must be treated with caution. Many of the studies included were characterised by limitations in the research design, such as low participant numbers (six studies), insufficient data to confirm that groups were comparable at baseline (five studies) and/or lack of blinded assessors (five studies). For these reasons, we believe that the evidence to date is not of sufficient quality to validly conclude that the Bobath Concept is not superior to other forms of intervention; rather, we do not yet know whether the Bobath Concept is more effective than other interventions, for specific clinical populations. This systematic review should be considered in context with the Cochrane review on postural control and lower limb function that states there is insufficient evidence to recommend any one approach over another. The authors comment on the need for further high quality trials; we strongly agree with this conclusion.
The authors correctly identify the Bobath Concept as a problem solving approach. They note that the Bobath Concept is used in conjunction with evidence based therapies, where these are applicable. In the Netherlands, they have decided to replace the Bobath Concept with an eclectic approach. The Bobath Concept has a huge influence on rehabilitation around the world. Before we consider discarding it, the Bobath Concept should be adequately and appropriately tested. We acknowledge that teachers of the Bobath Concept have not pursued research in the past and are now actively seeking to initiate and participate in clinical trials. We strongly support research endeavours aimed at defining the clinical reasoning and practice of the Bobath Concept and developing high quality clinical trials investigating the effectiveness of the Bobath Concept.
Julie Vaughan-Graham and Kim Brock
Members of IBITA
