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To: Journal of PRACTICAL NEUROLOGY Letters

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Papers: P M van Vliet, N B Lincoln, and A Foxall Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial J Neurol Neurosurg Psychiatry 2005; 76: 503-508 [Abstract] [Full text] [PDF]

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Authors' reply

Paulette M van Vliet, Nadina B. Lincoln, Andrew Foxall   (16 May 2005)

Response to van Vliet et al.

Roberta B Shepherd, Janet H Carr   (19 April 2005)

Authors' reply 16 May 2005
Paulette M van Vliet, Research Fellow University of Birmingham, Nadina B. Lincoln, Andrew Foxall Send letter to journal: Re: Authors' reply paulette.vanvliet{at}ntlworld.com Paulette M van Vliet, et al.	Dear Editor, We would like to respond to the letter written by R. Shepherd and J. Carr concerning our paper in Journal of Neurology, Neurosurgery and Psychiatry 2005, 76, 503-508. Our comment that the study provided no evidence that one treatment led to better outcomes than the other and so for the present, therapists could use either treatment, is the natural conclusion from our findings. However, as we point out, the study by Langhammer and Stanghelle [1] found a positive outcome for motor relearning compared to Bobath. We expect that readers will take a close look at the methodology and interventions of both studies and decide for themselves which treatment to use, based on the current evidence. There are also other studies looking at some of the individual components of the interventions, which will assist therapists in making decisions about their interventions. Clearly overall there is not enough evidence at present to categorically support one or the other of the treatment packages that we compared. The comment that the treatments were administered in the same environment was a limitation which we also acknowledged in our discussion. However, the alternative, to deliver the two treatments in two different settings would have introduced a more serious problem, in that it would have introduced confounding variables connected with the different staff, resources and physical environment in the two settings. We judged it better to have both treatments occurring on the same ward and made efforts to ensure patients received their allocated treatment by writing guidelines which each group of therapists adhered to. Secondly, we conducted an observation study which examined the content of the treatment.[2] This study revealed that there were differences in the treatments, so we concluded that any contamination effects were not too severe. In response to the observation that the physiotherapists delivering both interventions may have similar backgrounds, we can say that both groups did have some experience of Bobath-based (BB) treatment. This was a problem with conducting the study in the UK, where Bobath is the most commonly used intervention.[3] To overcome this problem, we employed one physiotherapist who had experience of the Movement Science-based (MSB) treatment, and gave MSB training to another therapist. The treatment was standardised so far as could be achieved by the process of writing treatment guidelines and agreeing to adhere to these during treatment. The guidelines for treatment were written collectively by the group of therapists delivering the treatment. Each patient in the BB group received treatment based on the same set of guidelines, and the same applied to the MSB group. The MSB treatment did include task-oriented training, and an emphasis on analysis of movements based on biomechanics and increased amounts of practice. There was insufficient space to include these guidelines in the previous papers, but these are available to anyone who is interested and can be obtained from Dr van Vliet (paulette.vanvliet{at}ntlworld.com). We agree that the amount of treatment was small and acknowledged this in our paper. This was a pragmatic decision made to ensure that the treatment received by both groups was the same, i.e. the MSB treatment was matched to the amount of BB treatment given routinely at the time in the hospital. Resources were not available to increase the amount of therapy in both groups. The amount received by patients was probably typical of UK hospitals.[4] Ongoing research indicates that in the UK, patients receive less therapy than their European counterparts (De Wit et al In Press). Therefore, our results are applicable to actual working conditions in the UK. Our results indicate that with a median 23 minutes per day, there was no difference in outcome. We recommended in our discussion that future studies increase the dose to see whether differences occur with more treatment. We stand by our assertion that it is necessary to examine the effect of the overall treatment package as well as individual components of treatment programmes. Otherwise, the effect of combining individual components will not be known. Another direction for future research is to combine individual interventions for which positive effects have been demonstrated into an overall treatment package [5], and contrast this with current treatment. It seems to us this would also be a useful direction. There are considerable pragmatic difficulties to be overcome in conducting a study such as the one we presented. Although not ideal the methodology was designed to be as robust as possible within the constraints of conducting research in healthcare settings. We have the greatest respect for the work of Professors Roberta Shepherd and Janet Carr, whose work has transformed much of the physiotherapy intervention for stroke patients. And we welcome the opportunity to contribute to the continuing discussion about the most profitable directions for future research on this topic. Yours sincerely, Paulette van Vliet, Nadina Lincoln and Andrew Foxall References 1. Langhammer B, Stanghelle JK. Bobath or Motor Relearning Programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clinical Rehabilitation 2000;14:361-369. 2. vanVliet PM, Lincoln NB, Robinson E. Comparison of the content of two physiotherapy approaches for stroke. Clinical Rehabilitation 2000;15:398-414. 3. Lennon S, Baxter D, Ashburn A. Physiotherapy based on the Bobath concept in stroke rehabilitation: a survey within the UK. Disability and Rehabilitation 2001;23:254-262. 4. Tinson DJ. How stroke patients spend their day: an observational study of the treatment regime offered to patients in hospital with movement disorders following stroke. International Disability Studies 1989;11:45-49. 5. Weerdt WD, Feys H. Assessment of physiotherapy for patients with stroke. The Lancet 2002;359:182-183.
Response to van Vliet et al. 19 April 2005
Roberta B Shepherd, Professor The University of Sydney, Janet H Carr Send letter to journal: Re: Response to van Vliet et al. R.Shepherd{at}fhs.usyd.edu.au Roberta B Shepherd, et al.	Dear Editors, Regarding the article by van Vliet et al. [1] reporting the results of an outcome study comparing two 'approaches' to physiotherapy following stroke: The authors make a common error in assuming that an outcome study provides evidence of effectiveness of an intervention. It does not, as Herbert [2] has recently pointed out - "outcome measures measure outcome. They do not measure the effects of intervention." (p.3). The authors have misrepresented their findings by concluding "our results indicate that physiotherapists may choose to use either BB or MSB treatment as neither was found to be more effective than the other". This is poor advice to clinicians, in particular because, without a control group, the authors present no evidence that either treatment was effective - their results could illustrate a natural improvement occurring over time. Overall the results were actually very poor, given that there was virtually no change on Rivermead Motor Assessment, Motor Assessment Scale and 6m walk after one month. If we take gait speed as an example, none of the subjects were walking at a speed considered fast enough for community competency (1.1-1.5m/s). The dismal results of the 6m walk test (at 6mths: 0.76 and 0.64m/s), shown to over-estimate walking speed [3], surely reflect the ineffectiveness of the gait rehabilitation given during this study. The authors also suggest that dose and timing might be more important than treatment given, another unwarranted conclusion- providing more of something that is not effective is not a good idea. Dose and timing, however, are probably critical. The study has a number of flaws that could have affected the results, not all of which are acknowledged in discussion of the limitations: - The two groups of patients were treated by physiotherapists in the same hospital environment (in the same ward). - Physiotherapists treating both groups are likely to have come from a similar professional educational background, which would have involved extensive experience of Bobath therapy. Those treating the 'movement science-based' group received some training from one of the authors. - No indication is given that treatment was standardised in any way and details of treatments themselves were not reported in the paper. The therapists used written guidelines but these are not provided. It is reported, however, that guidelines for each patient were prepared by the treating therapist. This could suggest that each patient had different treatment. The reader is referred to an earlier paper for information about treatment given [4] but this does not make the details any clearer. However, the descriptions, given by the 'trained observers', of treatment actually given make it clear that in neither group was treatment based on the sources cited and that the methods used were identical, different only in degree. We have some interest in this as early publications of ours are listed as source material. The only treatment method recognisable to us from our publications is 'feedback'. There is no reference to task-oriented or strength training, to applied biomechanics, to the need for intensive practice in groups and independently, or for the use of multiple repetitions in order to increase strength and control in the limbs- factors that are generally thought of as "movement science based". - The patients overall received very little treatment - a median time of 23mins (IQR 13-32mins) was spent on 5 days each week. This reinforces the well documented finding that little time is typically spent by patients in physiotherapy treatment while in rehabilitation. Patients received therapy for a variable number of days/weeks for "as long as was needed"- no details were given. - The Motor Assessment Scale is said to measure the consequences of motor impairment. It does not - it measures motor performance on several common functional actions (sit-to-stand, walking etc). It was not developed by therapists using the MSB approach- in 1985 there were few objective clinical tests that looked at functional movement, so we developed and tested one. This was before the suggestion that physiotherapists should develop new interventions out of the emerging findings from research into human movement coming from biomechanics and neuroscience - the so-called movement sciences. - The paper illustrates that it is hazardous to attempt to test "approaches" to treatment. The notion of an approach is vague and suggests subjectivity. This is why most studies of physiotherapy investigate specific treatments such as strength training, treadmill training, task-specific training, in randomised controlled trials. It could be argued that this study really tested the approaches of individual therapists since they apparently wrote their own guidelines "based on their own knowledge and experience and their interpretation of the literature". Since the therapists probably came from a similar professional background and worked in the same place it would not be surprising if they were found to give similar treatments. There is also little point in testing "whole treatment approaches" in order to "study the interaction of different treatment elements", as the authors suggest, if those elements themselves are not effective. Several recent randomised controlled investigations have shown that certain specific and standardised treatments are effective when studied in isolation and that therapy programs incorporating those specific treatments can also be effective. This is a very poor contribution to rehabilitation literature and it is disappointing to see it published in 2005. The Bobath approach has soldiered on for over 5 decades, with the name preserved regardless of what individual therapists are actually doing. It is a flaw in the delivery of therapy services that therapists are free to do what they like in clinical practice. It is not unrealistic to expect that they keep to a set of proscribed guidelines, based on sound scientific knowledge and the evidence available. The message from this paper is that physiotherapists can continue with what they are doing. This despite the findings that both groups improved very little. You might be interested that we have recently published a new textbook for physiotherapy undergraduates. It provides protocols and guidelines (science - and where possible evidence-based), with explanations about progressing dosage and with an emphasis on organising rehabilitation so a maximum time is spent by the patient in training and practice of everyday tasks to reduce the emphasis one-on-one therapy time (i.e. in groups and semi-supervised). A major focus is on strength training and exercise to improve cardiovascular fitness. This book in fact addresses many of the suggestions raised by Marsden and Greenwood in their excellent Editorial Commentary. With best regards Dr RB Shepherd Dr JH Carr References 1. van Vliet, Lincoln and Foxall (2005). Comparison of Bobath based and movement science based treatment for stroke: a randomised controlled trial. J Neurol Neurosurg Psychiatry 2005; 76: 503-508. 2. Herbert R, Jamtvedt, Mead J et al. (2005) Editorial: Outcome measures measure outcomes, not effects of intervention. Aust J Physiother 51, 3-4. 3. Dean CM, Richards CL, Malouin F (2001) Walking speed over 10m overestimates locomotor capacity after stroke. Clin Rehabil 15, 415-421. 4. Van Vliet PM, Lincoln NB, Robinson E (2001) Comparison of the content of two physiotherapy approaches for stroke. Clin Rehabil 15, 398-414.