Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP.
Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation.
Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [−0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [−0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures.
We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.
Key concepts of contemporary NDT practice include:
1. A holistic and interdisciplinary view of practice informed by current evidence.
2. Use of clinical reasoning strategies informed by ongoing analysis of interactions within and between domains of the ICF model, as well as contextual facilitators and barriers.
3. Outcomes based on increasing functional activity and participation in accordance with patient/family goals and preferences
4. Incorporation of patient-specific therapeutic handling within the context of functional tasks and the environment. It is based on movement analysis and consists of an active reciprocal interaction between the child and therapist.
Our literature review revealed multiple recent, peer-reviewed publications, which investigated NDT intervention efficacy incorporating the contemporary NDT Practice Model and definition.2-5 While not all publications were traditional RCTs, patient populations, interventions and dosing were well defined and consistent across groups. Appropriate outcomes measures were used across multiple domains and ICF levels. Analysis of this body of evidence provides support for the continued use of contemporary NDT interventions for children living with CP
For example, Sah,et al’s 2019 RCT compared contemporary NDT intervention to conventional physical therapy in 54 children with spastic diplegic CP.3 Outcomes measures included the Gross Motor Function Measure-88, the Postural Assessment Scale, the Pediatric Balance Scale, and the Trunk Impairment Scale. After a 6-week intervention, results supported contemporary NDT over conventional PT in improving trunk control, balance, and gross motor function. Tsorlakis et al4 and Evans-Rogers5 examined dosing of contemporary NDT intervention and reported improved gross motor function with increased NDT dose.
Research of contemporary NDT practice does not support the de-implementation of NDT as a clinical practice model. We recommend continued research using the contemporary NDT Practice Model and definition, with appropriate selection of subjects and outcomes measures.
References
1. Bierman J, Franjoine MR, Hazzard C, Howle J, Stamer M. Neuro-Developmental Treatment: A Guide to Clinical Practice. Thieime, 2016
2. Holland H, Blazek K, Haynes MP, Dallman A. Improving postural symmetry: The effectiveness of the CATCH (Combined Approach to Treatment for Children with Hemiplegia) protocol. J pediatr Rehabil Med. 2019;12:139-149 DOI: 10.3233/PRM-180550
3. Sah AK, Balaji GK, Agrahara S. Effects of Task-oriented Activities Based on Neurodevelopmental Therapy Principles on Trunk Control, Balance, and Gross Motor Function in Children with Spastic Diplegic Cerebral Palsy: A Single-blinded Randomized Clinical Trial. J Pediatr Neurosci. 2019;14(3):120-126. DOI:10.4103/jpn.JPN_35_19
4. Tsorlakis N, Evaggelinou C, Grouios G, Tsorbatzoudis C. Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy. Dev Med Child Neurol. 2004;46(11):740-745. DOI: 10.1017/s0012162204001276
5. Evans-Rogers DL, Sweeney JK, Holden-Huchton P, Mullens PA. Short-term, intensive neurodevelopmental treatment program experiences of parents and their children with disabilities. Pediatr Phys Ther. 2015;27(1):61-71. DOI:10.1097/PEP.0000000000000110.
A treatment is a tool for therapists’ toolbox, and a clinical approach is a way of viewing a condition to decide how and when to use which tool for each individual living with cerebral palsy, taking account of their particular presentation and context. This approach has much more in common with concep-tual frameworks like the International Classification of Functioning, Disability and Health suggested by the World Health Organization [3] than it does with an individual treatment. The advantage of which means it can be used by all disciplines and therefore facilitates collaborative thinking.
Cerebral palsy is a complex health condition and as such management requires significant clinical reasoning skills [4] that can be used across all levels and all classifications. As commented by Mayston, dis-implementation of Bobath risks losing vital clinical reasoning skills and clinical reason-ing training for therapists. Clinical reasoning is a fundamental part of every therapist’s practice. Clini-cal reasoning proficiency is required to select the most appropriate treatment, and to be effective, all of which rely on many practitioner attributes gained through both training and experience. Bo-bath therapists often expand their toolbox by integrating new information and treatments into their practice in the same way a plumber may add the latest drill, or a surgeon apply a new procedure. Using new information and adding new tools into a therapist’s toolbox does not prevent them from being a Bobath therapist, but it means they are being a reflective and proactive therapist - applying clinical reasoning skills and developing professional expertise. Keeping up to date is the duty of health professionals, although every professional population has a large range of abilities and experi-ence. A Bobath course is an introduction to a school of thought – to develop thinking therapists. Un-like treatments which have rules and criteria for guidance, a school of thought is open to interpreta-tion. Therefore, progress in practice is significantly dependent on the clinician and their environ-ment. This variation in practice extends to teaching, with differences observed across countries and outdated practice certainly exists. The Bobath Concept as a school of thought should be evaluated along with the effect of its courses on therapy practice, and this should be the direction of further studies.
References
1. te Velde A, Morgan C, Finch-Edmondson M, et al. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis.Pediatrics. 2022;149(6)e2021055061 2. Mayston, M. and Rosenbloom, L. (2014), Please proceed with caution. Dev Med Child Neurol, 56: 395-396. 3. https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health last accessed June 16, 2022.4. Jackman M, Sakzewski L, Morgan C, Boyd RN, Brennan SE, Langdon K, Toovey RAM, Greaves S, Thorley M, Novak I. Interventions to improve physical function for children and young people with cerebral palsy: last accessed June 16, 2022. international clinical practice guideline. Dev Med Child Neurol 2022 ; 64: 536-549.
Alfred L. Scherzer, MD, EdD, FAAP, Weill FAAP Medical College, USA
ABBREVIATIONS
CP-cerebral palsy
SR-systematic review
MA-meta-analysis
CG-clinical guideline
EBM -evidence-based evidence
AMSTAR- Assessing the Methodological Quality of Systematic Review
As a developmental pediatrician with extensive experience in the field of cerebral palsy (CP), I was troubled by the Velde et. al. article1 . It concluded with clinical guidelines based on faulty evidence review procedures and inappropriate guideline methods.
I sought the opinion of Charlene Butler, long active in the development and critical appraisal of the quality of SR and MA research evidence. She noted that research evidence about the conduct of research demonstrates that conclusions cannot be taken at face value, but must be critically appraised to establish their credibility 2. For example, a recent evaluation of the methodological quality of all SRs and MAs of interventions for CP published worldwide in the last 5 years using AMSTAR-2, the critical appraisal tool for systematic reviews3, found that 88% of those reviews revealed 1) critically low confidence ratings for their conclusions, and 2) neither restriction to randomized controlled trials, nor inclusion of MA, improved the confidence ratings. AMSTAR-2 defines “critically low rating” of a SR/MA to mean that it should not be relied on as an accurate and comprehensive summary of the evidence from the included primary studies. Butler’s appraisal of the quality of this SR/MA by Velde, et.al.,using AMSTAR-2, shows this paper is also deficient in multiple elements of robust review and synthesis procedures, and results in a critically low confidence rating.
In addition to poor quality procedures for synthesizing study evidence, Butler pointed out that the conclusions made were not an analysis of evidence but were clinical practice guidelines developed with an unvalidated tool called the Traffic Light ALERT System. It reduces treatment guidance using the analogy of obeying traffic. If coded green, “do it”; red, “don’t do it”; if yellow “maybe do it”.
What are pediatricians to do when they must act in the absence of certainty about efficacy from research studies? First, be guided by the broad tenet of evidence-based medicine (EBM), that evidence for decision-making includes the equal components of 1) research evidence, 2) patient’s preferences/actions, 3) clinical state and circumstances which are interpreted and mediated by 4) clinical expertise.4 Then, when an intervention decision has been reached, create evidence of efficacy of that intervention for that patient, while implementing the intervention. That involves developing and monitoring a care/study plan which will detail the intervention procedures, the desired outcomes, how and when outcomes will be measured, as well as recording of adherence. The plan will establish points in time to evaluate whether to continue with the intervention, modify it, or terminate it in order to pursue an alternative that may be more efficacious for this patient.
In sum, pediatricians need to be aware that, at present, neither this paper nor other current research provides definitive evidence in favor of any specific or exclusive physical therapy treatment for children with CP. Instead, decisions about therapy for these patients by all practitioners must be guided by the above broad principles of EBM.
Refrerences:
1. Velde A, Morgan C, Finch-Edmondson M, et al. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis. Pediatrics 2022;149(6):e2021055061
2. Kolaski K, Romeiser Logan L, Goss KD, Butler C. Quality appraisal of systematic reviews of interventions for children with cerebral palsy reveals critically low confidence. Devel Med Child Neurol 2021; 63 (11), 1316
3. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Brit Med J 2017; 358: j4008.
4. Wieten, S. Expertise in evidence-based medicine: a tale of three models. Philos
Ethics Humanit Med 2018; 13. https://doi.org/10.1186/s13010-018-0055-2
Rather than focusing on this study’s limitations and misrepresentation, ABNDTA will clarify its contemporary teaching approach in Australia since 2008.
ABNDTA embed Bobath/NDT training in the ICF and accompanying F-words in childhood disability frameworks [3] with thorough analysis of each ICF domain and their interaction and relationship. Therapists conduct in-depth task analysis of the components for successful functioning, including all domains that impact on the child's function including personal factors (sensory, motor, cognition), family factors and environmental context. Age and stage of the person reflects a lifespan approach. Current neuroscience curriculum is evidence based, including neuroplasticity and movement sciences – not neuro-maturational/ reflex-based theories of the last century.
Interventions are targeted and matched to the child's goals based on individual needs and context and evaluated using valid outcome measures. Training develops skills to understand which approach(s) to apply and when, to maximize outcomes – forming the basis of Bobath clinical reasoning practice. Clinical guidelines [4] are useful for novice clinicians as a starting point but cannot replace the clinical judgement and individualized application by a skilled therapist.
Opportunities for supported clinical practice in certification training facilitates knowledge translation through the direct and immediate use of knowledge-in-practice. The experience-based learning is shared by Physiotherapists, Occupational Therapists and Speech Pathologists - a model of transdisciplinary care. Targeted interventions relate to the whole child, rather than just upper limb or lower limb function. Communication is “everybody’s business” but is rarely featured in interventions or practice guidelines but, like play and occupation, are embedded in Bobath training. Knowledge of the range of interventions in clinical practice is not used eclectically to redefine the Bobath approach; rather, its clinical reasoning model ensures other specific timely interventions are implemented when appropriate.
Can de-implementation science be applied to a clinical reasoning model – challenging to do [5] and of potentially limited value, given that lack of post-graduate clinically based education is a barrier for therapist’s perceptions of competency in CP management
ABNDTA’s challenge is to define accurately what we do and promote research into the clinical reasoning model for clinical practice. Participation in research is welcome, including qualitative research so key stakeholders - children, families, and therapists navigating career pathways in developmental paediatrics- have a voice on what matters to them.
1. te Velde A, Morgan C, Finch-Edmondson M, et al. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis. Pediatrics. 2022;149(6):e2021055061. 2.Toovey R, Spittle AJ, Nicolaou A, McGinley JL, Harvey AR. Training two-wheel bike skills in children with cerebral palsy: a practice survey of therapists in Australia. Phys Occup Ther Pediatr. 2019;39(6):580–597; 3.Rosenbaum P & Gorter JW The ‘F-words’ in childhood disability: I swear this is how we should think! Child: Care Health Development.2012;38(4): 457-463. 4.Jackman M, Sakzewski,L, Morgan, C Boyd, RN et al (2021). Interventions to improve physical function for children and young people with cerebral palsy: international clinical practice guideline. Developmental Medicine and Child Neurology, 64 (5), 1-14. 5. Burton, C., Williams, L., Bucknall, T. et al. Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence. Syst Rev 8, 194 (2019).
It is clear that SRs can usefully provide a summary of the available evidence though they are not always robust forms of evidence [2] and are fraught with methodological challenges. A meta-analysis is similarly subject to limitations. A meta-analysis aims to look for consistency in treatment effects across a number of studies which are addressing the same question. This is a challenge for any study of Bobath or NDT. Not only are the two different, they contain many elements of intervention by a variety of disciplines, and will differ according to the age, GMFCS level of the child and their diagnosis [3]. It is therefore a challenge to directly compare the studies cited in the meta-analysis of te Velde et al [1].
The meta-analysis focused on several domains: NDT vs control; NDT vs activity based approaches; NDT vs Body Structure and Function; NDT vs environmental based; NDT low dose vs high dose, based on the findings from 34 studies, 16 of which were published before 2000. Subject groups were mixed and different subject groups were in the same comparison, dosage was not always equal, some studies focused on upper limb, some lower limb to name a few of the limitations. For example, the first study in the NDT vs activity-based approaches compared 112 hours of Constraint Induced Movement Therapy to 16 hours of NDT [1,4]. This meta-analysis hardly offers a current perspective on the state of Bobath and NDT practice and much of the discussion is based on misinterpretation of Bobath clinical practice. There is no one way to manage a child with CP- there are over 100 interventions- and Bobath clinical practice contains many of those listed in the SRs published by Novak et al [5].
The recommendation to deimplement Bobath and NDT appears to be short sighted. It would result in the loss of some excellent instructive courses about clinical reasoning for clinical management of infants, children and young people with CP. It would result in the loss of clinical expertise of Bobath trained clinicians who offer in-depth knowledge and the clinical reasoning and activity-based treatment skills to improve the lived experience of people with CP. Maybe a better conclusion would be to accept the results of the study very cautiously, recognizing the limitations of the methodology and the complexity of the clinical management of cerebral palsy, which requires an individual approach based on sound in-depth clinical reasoning. Future studies would be better to implement cohorts of children at comparable age, GMFCS levels and diagnosis receiving equal intervention dosage, and focus on the ingredients of current Bobath clinical practice.
References:
1. te Velde A, Morgan C, Finch-Edmondson M, et al. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis. Pediatrics. 2022;149(6):e2021055061. 2. Kolaski K, Romeiser Logan L, Goss KD, et al. Quality appraisal of systematic reviews of interventions for children with cerebral palsy reveals critically low confidence. Dev Med Child Neurol 2021; 63(11):1316-1326. 2. Mayston M. Bobath and NeuroDevelopmental Therapy: what is the future? Dev Med Child Neurol 2016; 58 (10):994. 4.Al-Oraibi S, Eliasson A-C. Implementation of constraint-induced movement therapy for young children with unilateral cerebral palsy in Jordan: a home-based model. Disabil Rehabil 2011;33(21–22):2006–2012. 5. Mayston M, Rosenbloom L. Please proceed with caution. Dev Med Child Neurol 2014; (56)4: 385-396.