The EBTA response to a review article by Novak et al 2013

Gill Stern recent past President European Bobath Tutors’ Association on behalf of the EBTA Executive Committee

We are writing in response to the review paper by Iona Novak et al (DMCN 2013), a conclusion of which is to give the ‘red light, don’t do it’ to NDT-Bobath. Before accommodating this drastic step of outlawing a particular approach, we believe it is important to attempt to clarify exactly what the Bobath approach or concept is, and to correct some misunderstandings about it, using previously published material.

Dr Karel Bobath, a medical doctor, and his wife Berta, a physiotherapist, developed the Bobath approach 70 years ago in the United Kingdom at a time when it was thought that little could be done to alter the pathology or the participation of people with stroke or children with cerebral palsy. Neuro-Developmental Treatment (NDT) is a name coined by Mrs Bobath, and used by ‘Bobath’ practitioners in the USA and elsewhere (Mayston 2004).

Dr and Mrs Bobath were among the very first to recognise and write about plasticity within the nervous system as well as the relevance of sensory disturbances, sensorimotor learning, individualised goal setting, outcome measures, activity limitation, functional participation, home programmes and parental education long before these terms were officially coined. (Bobath B and Bobath K in Foreword to Finnie 1968, Bobath B 1970, Bobath & Bobath 1984)..

The Bobaths also wrote in 1958 about the importance of motor learning based on a child’s own activity “…therefore one of the greatest art of the treatment is to know where and for how long to take our hands away, or to release our hold, so that the child has a chance of his own control whenever possible, even if only for a moment at first. This has been reaffirmed in current models by authors in the field of Motor Learning such as Schmidt and Lee 2005 “…learning cannot be measured directly – instead it is inferred based on behavior.” *

In her editorial in Physiotherapy Research International 2008, Margaret Mayston a Senior Teaching Fellow at University College London, as well as a Senior Bobath Tutor who has worked with Dr and Mrs Bobath, states that ‘there is an urgent need for an integrated approach to neurorehabilitation that is not based on approaches, but rather is client based with a sound theoretical, and where possible, evidence base. This does not negate the practice and teaching of Bobath-based therapy, but requires a shift in focus to recognize Bobath as a contributor to client-based neurorehabilitation, not the leading actor who wishes to be centre stage at all times.’

Mayston,(2008) gives the current view of the Bobath Concept and a reasoned argument for continuing use of a Bobath-based approach; an approach which has given thousands of therapists worldwide a framework and a sound basis for analysis of the complexities of cerebral palsy, a heterogeneous group of conditions, as well as empirically observable results, often transferable to improved levels of activity and participation (Bain 2012, Knox 2002).

Bobath analysis as a tool, can be used with every type of neuro-disability. It involves ‘observation, analysis, interpretation, experimentation, outcome measurement’ (Figure 1, Mayston 2008). A unique aspect of Bobath is the close experimental relationship between assessment and treatment (Bobath B 1978, Bobath B 1990). In other words Bobath practitioners aim through ‘trial and error’ to find what makes a new skill or part of a skill, possible or easier to achieve. They do this using the client’s own active or active assisted movements. Uniquely developed specialised handling to reduce hypertonia is used where appropriate, but this is not ‘passive’, and to describe Bobath as ‘passive handling’ Table 1 (Novak et al) is inaccurate.

The Bobath approach is holistic, covering all areas of daily life and includes advice and carer training regarding handling, equipment and other modalities.(Bobath & Bobath 1984). This is reflected in Nancy Finnie’s well-known illustrated book ‘Handling the young child with cerebral palsy at home’, first published in 1968, the third edition published in 2009. Finnie was a physiotherapist and one of Mrs Bobath’s early protégés, who worked and taught with Dr and Mrs Bobath for many years. Nancy Finnie dedicated her early editions to Berta Bobath and acknowledged her years of invaluable experience to them both. Her practical and parent friendly book, remains a standard volume on paediatric therapists bookshelves.

Mayston writes “Bobath (1990) stated that ‘the emphasis in treatment is now on the active participation of the patient with the therapist…’. The current emphasis on active participation was an integral part of the Bobath Concept even back then.” The Bobaths themselves did not claim that the Bobath approach was the only one ‘on the market’. Mayston (2008) refers to Karel Bobath, who in his speech of response on receipt of the Harding Award in 1975, said that ‘there are other methods and ways of treatment and that these should be explored’ (Bobath 1975). Additionally Mayston quotes Berta Bobath who, in at least two publications (Bobath 1970; Bobath 1978), explained that other techniques described by other workers may also need to be used at certain stages of treatment.

Mayston notes that Mrs Bobath’s other important statement, can be found in the Introduction to the third edition of the book ‘Adult Hemiplegia: Evaluation and Treatment’ (Bobath, 1990): ‘We all learn and change our ways of treatment according to our growing knowledge and experience. . . for better or for worse. Such changes are good and necessary and will continue. But the Concept from which they have evolved should remain intact . . .’ According to Jay Schleichkorn (1992), Mrs Bobath attributed the continuing positive impact of NDT (Bobath) to ‘ I think I learned all the time; I changed it according to what I learned….it wasn’t static’.

Due to the heterogeneous nature of cerebral palsy, Bobath ‘therapy’ involves using personalised combinations of specific analysis with clinical decision making and empathetic advice. So therapy sessions may vary from therapist to therapist, and each session may be different, depending on the needs, priorities, and responses of the client and their carer at that time. This can make comparisons of Bobath ‘therapy’ difficult and confusing as noted by both Novak et al and Mayston in their papers.

The effects of many localised interventions such as botulinum toxin, are not sufficient on their own, but are usually optimised by physiotherapy. The effective outcomes of such localised interventions, are also much easier to measure as they work at only one level of the ICF, than of an analysis tool such as Bobath, which may be applied over several domains of the ICF..  .

As Mayston (2008) also writes ‘it is also important to bear in mind that aspects of the Bobath approach could be useful, and a lack of evidence does not mean that empirical strategies that seem to work should be discarded. Rather, the challenge is to provide the evidence for their efficacy.’

As Bobath tutors and practitioners, we constantly strive to improve our standards of training and treatment, so that Bobath practitioners are a credit to the name of NDT-Bobath. Berta and Karel Bobath have provided a lasting legacy which we would be foolish to discount.

References

1. Bain K & Chapparo C (2012) The impact of neurodevelopmental treatment on the performance of daily living tasks by children with cerebral palsy. Dev Med Child Neurol54: Concurrent Free Papers (s5): 51.
2. Bobath B and Bobath K (1958) Principles of treatment. Bobath Manuscript
3. Bobath B  (1970) Adult Hemiplegia: Evaluation and Treatment. 1^st Heinemann
4. Bobath K and Bobath B (1984) in Scrutton. MacKeith Press
5. Bobath B Adult Hemiplegia (1990) Evaluation and Treatment. 3rd edition. Oxford: Butterworth Heinemann
6. Bower E (2009) Finnie’s Handling the Young Child with Cerebral Palsy at Home, Elsevier
7. Finnie N (1968) Handling the Young Cerebral palsied Child at Home Heinemann
8. Knox V (2002) Evaluation of the Functional Effects of a Course of Bobath Therapy in Children with CP: a Preliminary Study DMCN 2002 44: 447-460
9. Mayston M (2004) in Scrutton MacKeith Press
10. Mayston M (2008) Editorial: Bobath Concept: Bobath@50: mid-life crisis –What of the future? Physiotherapy Research International 13:131-136
11. Novak I et al (2013) A systematic Review of interventions for children with cerebral palsy: state of the evidence.Dev Med Child Neurol.Oct;55(10):885-910
12. Schleichkorn J (1992) The Bobaths a Biography of Berta and Karel Bobath Therapy Skill Builders
13. Schmidt R and Lee T (2005) Motor Control and Learning, a Behavioral Emphasis. Human Kinetics 5th Edn.

*Acknowledement: Evi Sideri Senior Bobath tutor and the Spanish Tutors Organisation, who linked and used the references in paragraph 4 for their presentation at the EBTA Congress in Madrid 2010.

Os três pilares da evidência científica segundo Sackett, 2000 são: O Paciente, a Experiência Clínica, A Pesquisa Científica.

É da integração desses tres pilares estruturantes que surge a reabilitação do paciente de uma forma eficiente. Observe, portanto, que o reconhecimento da evidencia científica é fundamental para o sucesso do tratamento. Assim, para o paciente com disfunções neurológicas, o valor dessa afirmativa é a garantia de que ele será realmente atendido em sua demanda relatada pelos pais e garantirá uma escuta por parte do terapeuta em relação à principal demanda.
O terapeuta com formação e atualização no Tratamento Neuroevolutivo – Conceito Bobath assegura uma excelente alternativa para o paciente com disfunção neuromotora. O paciente é avaliado de acordo com suas queixas principais e as hipóteses para o tratamento serão aventadas e implementadas. O sucesso do tratamento é fundamentalmente dependente da experiência clínica do terapeuta e de suas habilidades para avaliar e conduzir o tratamento segundo os modelos atuais da Classificação Internacional de Funcionalidade (CIF) e da neurociência contemporânea.
As pesquisas científicas permitem incorporar continuamente novos conhecimentos e fazer avançar a eficácia do tratamento, pela introdução de novas práticas, simulações, mobiliários, roupas, medicamentos, bem como pela utilização de modelos de mensuração da melhora do paciente.
Assim, a informação advinda do paciente, a experiência clínica do terapeuta e a pesquisa são essenciais e indissociáveis para o sucesso da terapia.
Algumas dessas pesquisas foram realizadas por profissionais com experiência clínica e com formação na Abordagem Neuroevolutiva (NDT). Esses trabalhos permitiram a realização de testes com formatos de comprovada eficiência para medir a melhora. Por exemplo, o teste TIMP, realizado por terapeutas formados na abordagem, Girolami, G e cols, 2000, valida a eficácia do Tratamento Neuroevolutivo no acompanhamento de bebes pré-termos que adquiriram controle postural do tronco em idade adequada.
Atualmente, já existem instrutores do Conceito Bobath que atuaram em suas clínicas por mais de trinta anos e após esse longo período de experiência baseado na prática realizaram mestrados e doutorados em universidades dos Estados Unidos e Europa. Os afazeres da prática clínica não os estimularam a disseminarem suas experiências com trabalhos científicos na clássica forma de publicações, apenas com comprovações de melhora em vídeos e estudos de caso. Entretanto, muitos trabalhos inovadores, relevantes advieram como resultado de toda essa prática. Esse trabalho não foi perdido e alguns, ao adentrarem nas universidades como docentes, os resultados de seus estudos e pesquisas foi considerado de extrema consistência. Foram profissionais que conseguiram formular perguntas exatas para realizar pesquisas academicamente formais e comprovar sólidas evidencias científicas advindas de sua grande vivência clínica. Temos, na atualidade, diversos artigos e livros publicados que dão a fundamentação teórica para a prática clínica baseada no Tratamento Neuroevolutivo. Apesar disso, existem ainda críticas e preconceitos para com os terapeutas do Conceito Bobath. Isso decorre talvez do fato de não conseguirem ainda perceber que os terapeutas, instrutores desse Conceito, já realizam o tratamento tendo como base os modelos de teorias da neurociência atual, como a Teoria do Controle Motor ou da Aprendizagem Motora que embasam as suas estratégias de tratamento.
Devido à fabulosa experiência clínica, devido ao literal manuseio dos pacientes, os terapeutas do Conceito Bobath têm facilidade de criar práticas de atividades funcionais altamente eficazes, utilizando esses já consistentes modelos teóricos. Eles têm a habilidade de manejar e manusear o paciente com disfunções neurológicas para que ele realize tarefas com uma boa base de suporte, bom alinhamento biomecânico e boa estabilidade postural o que proporciona ganhos para que ele possa desempenhar eficientemente suas atividades funcionais, pois são esses os pré-requisitos para a realização de uma função no caso de um paciente que tem deficiência em suas estruturas corporais e em seus sistemas orgânicos.
Helenice Soares de Lacerda
Fisioterapeuta, Especialista e Instrutora do Curso Básico do Tratamento Neuroevolutivo.

Referencias Bibliográficas .
1. Shumway-Cook, A.: Woollacott, M. – Motor Control Theory and Practical Applications. Baltimore, Williams & Wilkins, 1995.
2. Sackett,DL, Strauss,S.E, Ricuardson, W.S, Rosemberg,W. and Haynes,RB. (2000) Evidence Based Medicine, How to practice and teach EBM, Second Edction, Edimburg, Churchill Livingstone.
3. Herbert, R ,Jamtvedt,G ,Mead,J , Hagen,K.B , (2005) Practical Evidence – Based Physiotherapy, Elsevier Ltd.
4. Sue Raine, Linzi Meadows, Mary Lynch-Ellerington – Bobath Concept Theory and Clinical Practice in Neurological Rehabilitation A John Wiley & Sons, Ltd., Publication This edition fi rst published 2009 by Blackwell Publishing Ltd
5. Patricia C. Montgomery, Barbara H. Connolly, Clinical Aplication for Motor Control 2003, by Slack Inc.
6. Janet M, Howle – Neuro-Developmental Treatment Approach – Theoretical Foundations and Principles of Clinical Practice, collaboraton with NDTA Theory Committee, 2002.
7. Campbell, Suzann. – Pediatric Neurologic Physical Therapy, New York, NY, Churchill Livingstone, 1991
8. Kandell, Eric R.; Schwartz, James H; Jessel, Thomas M. – Princípios da Neurociência. Manole, 2003.
9. Lente, Roberto. Cem bilhões de neurônios – Conceitos Fundamentais de Neurociência. Ateneu, 2002.
10. Girolami, G and Campbell,S.K. (1994) Efficacy of a Neuro-Developmental Treatment (NDT) program to improve motor control of pre term Infants. Pediatric Physical Therapy, 6, 175-184
11. Campbell, S.K. , Kolobe, T.H.A. ,Osten, E.T., Lenke, M. and Girolamo,G.L. (1995) Construct Validity of the Test of Infant Motor Performance – TIMP,Physical Therapy, 75, 585-586