Bobath therapy and lower limb activities after stroke

Does Bobath therapy improve lower limb activity performance, strength or coordination when compared with no intervention or other intervention? Q&A with Kate Scrivener and Roberta Shepherd.

Your recent systematic review sought to estimate the effects of Bobath therapy relative to other rehabilitation interventions on lower limb outcomes in people with stroke. What is Bobath therapy?

Bobath therapy is named after Dr Karel Bobath, who was a neurologist, and his wife Berta Bobath, both of whom were interested in movement and exercise.

They did interesting theoretical and clinical work starting in the 1950s, citing the early scientific work on the brain and movement that was carried out by neuroscientists of the late 19th century and early 20th century, such as CS Sherrington.

We challenge the use of their names to describe methods developed by physiotherapists decades later. Many of these more recent methods are not congruent to the original methods and ideas, not science-based or demonstrably effective.

What is the history behind Bobath therapy?

In the mid-20th century, the Bobaths developed a method for the physical rehabilitation of cerebral palsy in children, taking into consideration the scientific understanding of the times.

After a number of years, they also became interested in post-stroke rehabilitation. They developed two major techniques—inhibition of spasticity and facilitation of ‘normal’ movement.

At the time it was usual for people after stroke to be confined to bed, as were children with cerebral palsy.

The Bobaths were probably responsible for a radical change for the better for these patients, with an emphasis on getting the patients out of bed and moving.

However, by today’s understanding, the physiotherapy methods used originally by the Bobaths were overly dependent on the patient being moved about by the therapist.

In the 1950s and ’60s the Bobaths’ influence on European physiotherapy was considerable while at the time the dominant methods in the USA included proprioceptive neuromuscular facilitation (PNF) and other methods developed by Margaret Rood and others.

Since the deaths of Dr and Mrs Bobath and into the current decade, changes have been made to what is now, incorrectly, called Bobath therapy, as it bears little resemblance to the Bobaths’ original work.

Bobath therapy is now said to be a clinical reasoning approach, but at its cornerstone remains the belief that hands-on facilitation by the therapist is essential to the improvement of movement patterns.

Over the last few decades, our increasing scientific understanding of neuroscience and human movement—motor control mechanisms, motor learning, biomechanics—has resulted in the development of methods of training in which the emphasis is on the patient learning to move more effectively under different environmental conditions, concentrating on task- and context-specificity.

A major feature of physiotherapy, as in all areas of health, is that clinical rehabilitation methods must change over time as scientific understanding develops and in response to evidence from clinical studies on the effects of exercise and training methods.

This is reflected in neurological physiotherapy in university and postgraduate courses as they implement an evidence-based approach.

Why did you conduct this systematic review?

As an author group we were interested in the history of Bobath and they way it has transformed over time. We followed the research in this area and noted that there have been few reviews of Bobath therapy previously.

But more than that, these reviews have not included many trials and have not completed meta-analyses.

We believed a comprehensive review was needed to answer whether Bobath therapy is effective compared to no/another intervention. Interestingly we didn’t identify any trials that compared Bobath therapy to no intervention.

In the trials you identifed, what other interventions was Bobath therapy compared with?

We grouped the comparison interventions into broad categories.

Of the 17 trials that we could include in the meta-analysis, Bobath therapy was compared to task-specific training (nine trials), a combined intervention (four trials), PNF (one trial) and strength training (two trials). In the trials that could not be meta-analysed, Bobath was also compared to robotics.

How did Bobath stack up against the other interventions?

Bobath therapy was shown to be inferior to task-specific training, with task-specific training of moderately greater benefit compared to Bobath therapy for improving lower limb activities (SMD 0.48) and specifically for improving walking (SMD 0.64). Bobath therapy was not superior to other interventions.

So were there any instances where Bobath therapy outperformed another intervention?

Bobath therapy was shown to be more effective than PNF, based on a single trial with 72 participants and low methodological quality (PEDro score 4).

PNF is another historical intervention that has also been challenged by the emergence of modern neuroscience.

This favourable result for Bobath is in contrast to where Bobath was shown to be less effective than task-specific training.

This result was based on pooling of data from a large group of participants (487 participants in nine trials), including trials of better methodological quality (mean PEDro score 6.6) for lower limb activity measures.

What did you conclude?

Overall, choosing Bobath therapy over other interventions is not supported by current evidence. Task-specific training was shown to be more effective than Bobath for improving lower limb outcomes, and more specifically walking.

Dr Kate Scrivener, APAM, is a clinician, researcher and educator in neurological physiotherapy. She is a Senior Lecturer in Physiotherapy at Macquarie University and the Leader of Neurological Physiotherapy at Concentric Rehabilitation Centre.

We challenge the physiotherapy profession to move forward into the future of neurorehabilitation.

Our vision for this is a clinical-reasoning approach using the ICF framework and an understanding of modern movement science.

We are fortunate in neurological physiotherapy to have interventions that have solid scientific evidence behind them.

The challenge for physiotherapists is to select the appropriate evidence-based interventions for each individual with a neurological condition affecting movement function.

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