Evidence base for the clinical effectiveness of Bobath (Neurodevelopmental) therapy
Therapy for children with cerebral palsy aims to optimise their potential and function, prevent and minimise secondary deformity and weakness, and advise on daily management. Bobath (Neurodevelopmental) Therapy emphasises observation and analysis of the client’s current functional skill performance and the identification of clear therapy goals. The aims of treatment are to work for better active participation and practice of relevant functional skills and to influence muscle tone and improve postural alignment by specific handling techniques (Mayston, 2001b; Mayston, 2001a).
General research into therapy for children with cerebral palsy
There have been several reviews of research into therapy for children with cerebral palsy:
NDT/Bobath: (Ottenbacher et al., 1986; Royeen & DeGangi, 1992; Butler & Darrah, 2001)
Other therapy interventions: Hourcade & Parette 1984; Parette & Hourcade 1984; Tirosh & Rabino 1989; Campbell 1990; Turnbull 1993
Research methodology: Vermeer & Bax 1990; (Hur, 1995)
When reviews of research regarding the effectiveness of physiotherapy for children with CP are analysed, it is difficult to determine whether different types of physiotherapy are effective because of
- Poor quality of research
- Small study groups
- Poor quality measures
- Difficulty with matching between groups
- Difficulties with the creation of control groups
- Lack of detailed description of intervention
- Widely differing frequencies and intensities of therapy
- Other technical and ethical problems (Siebes et al., 2002)
The widely held expert opinion is that therapy is of benefit and appropriate early treatment will lessen the effects of Cerebral Palsy. Some evidence exists within the literature demonstrating the effectiveness of Bobath therapy as follows:
Research reviews regarding Bobath (NDT) Therapy
(Ottenbacher et al., 1986) conducted a meta analysis on the use of NDT in paediatric populations including 37 reviews, and found that clients receiving NDT or combination of NDT and other intervention performed better than 62% of subjects receiving other services.
(Royeen & DeGangi, 1992) conducted reviews on 19 published studies investigating the effects of NDT. There was some evidence to suggest an immediate gain in range of movement in children treated with NDT.
(Butler & Darrah, 2001) reviewed 21 studies with level II evidence. Comments from the authors of this study included that although there was no strong evidence to suggest that NDT was more effective than any other approach, neither was there any evidence to suggest that it was less effective. The evidence for the efficacy of NDT was as follows:
- 86 out of 101 outcome results did not confer an advantage to NDT, but there were some questions about the validity & sensitivity of the outcome measures which were used
- Small sample sizes may have reduced the power to detect an effect (total subjects in 21 studies = 416)
- Heterogeneity of CP may have obscured treatment effects
- A greater percentage of studies published after 1990 favoured NDT compared with those prior to 1990
- 4 studies: evidence of an immediate gain in range of movement
- 8 studies: evidence of some gains in quality of motor responses & aspects of gait
(Franki et al., 2012) investigated the evidence base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy with a systematic review using the international classification of functioning, disability and health as a framework. This included 37 studies on NDT, Conductive education, Vojta, Sensory integration, functional training and goal oriented therapy. Eleven studies of NDT were included (subjects =181).
- Body structure & function: Level IV evidence for effectiveness of NDT on posture (n=1), spasticity (n=1), range of motion (n=1) and mechanical efficiency (n=1)
- Activity level:
- Level II & III evidence for effectiveness of NDT on gross motor function (n=3).
- Two studies showed no significant effects on motor function
- Two studies focussing on treatment context & intensity of treatment showed significant effects on motor function in intervention groups, but no between group differences
- Participation level: Level III evidence on self care and care giver assistance (n=1)
Franki et al (2011) commented that previous reviews of studies of NDT used much older studies and that there was little overlap (Butler & Darrah 2001- one study; Brown and Burns, 2001 – two studies)
NDT Clinical trials and single subject design studies
Evidence for improvement
- gross motor function, self care skills and reduced caregiver assistance (Knox & Lloyd-Evans, 2002; DeGangi, 1994)
- improved walking demonstrated by improving stride length, range of movement, strength, reducing spasticity and other gait parameters (Desloovere et al., 2012)
- motor progress with more intense NDT and following intermittent blocks of therapy (Tsorlakis et al., 2004; Trahan & Malouin, 2002; Mayo, 1991)
- stride, step length, heel contact and velocity of walking (Adams et al., 2000; Embray et al., 1990; Laskas et al., 1985)
- reaching, hand opening and hand use (Jonnsdottir et al., 1997; Kluzik et al., 1990; Chakarian & Larson, 1993)
- improved postural control in premature infants (Girolami & Campbell, 1994)
- Improved daily living skills (videoed GAS goals) Bain & Chaparro 2012
- Intensive NDT as effective as Constraint Induced Movement therapy (CIMT) Acar et al 2012
No difference between Casting alone V casting and NDTor Intensive NDT & Casting V General OT and casting (Law et al., 1991) Law et al 1997
Less effective (Palmer et al., 1988) investigated 48 infants 12-19 months with mild to severe spastic diplegia. They were randomly assigned to NDT or learning games curriculum (control group). The control group improved more than NDT group. In this trial, NDT was aimed at improving righting and equilibrium balance reactions. The outcome measures used did not test righting & equilibrium reactions and were discriminative not evaluative. The reliability of tests was not demonstrated. There was some evidence that the NDT group may have been more neurologically involved.
Key features of the approach are as follows:
- Treatment programmes are goal focussed, and Bobath therapy follows a family centred approach with goals being set in collaboration with parents (Mayston, 2001b) Studies support a family-centred service and suggest it is valued by parents and professionals. Use of specific goals have been shown to enhance effectiveness of therapy, (Knox & Menzies, 2005; King et al., 2004; Bower et al., 1996).
- Treatment at a Bobath Centre is usually more intensive (daily sessions over 2 weeks) than typical local provision. Some comparisons of different intensities of therapy have been shown to correlate with increased improvement in motor skills: weekly more effective than monthly (Mayo, 1991); daily more effective than twice weekly or less (Tsorlakis et al., 2004; Bower & McLellan, 1992; Bower et al., 1996); and intermittent intensive blocks may be an effective strategy for producing long term gains (Trahan & Malouin, 2002; Gagliardi et al., 2008). A few studies have shown no difference (Ustad et al, 2009; Christiansen & Lange 2008; Weindling et al, 2007). A meta- analysis of studies from Jan 1996-June 2007 of intensive V non-intensive PT for children with CP showed intensive therapy tended to have a greater effect than non-intensive therapy on motor function and the effect was stronger for children 2 years of age, (Arpino et al, 2010).
- Parent/carer education to enable the parent to handle and manage their child’s difficulties appropriately and facilitate the parent infant relationship is a central aim (Mayston, 1992). Parent/Carer education maximises the child’s functional abilities for participation in daily life, facilitates family relationships, improves quality of life and evidence suggests family centred care is associated with enhanced developmental progress, decreased parental stress and improved parent satisfaction with services, (Knox & Menzies, 2005; Law et al., 2003) Law et al, 1998. Research has shown the Bobath Centres to be family-centred in their approach (Knox & Menzies, 2005).
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