Saturday, January 5, 2013

Neuro-Developmental Treatment: meh.

I'm going to copy some of my favorite quotes about NDT/Bobath. The quotes themselves are links that will take you to the reference.

"The NDT approach was not found effective in the care of stroke patients in the hospital setting. Health care professionals need to reconsider the use of this approach."

"Results show no evidence proving the effectiveness of NDT or supporting NDT as the optimal type of treatment..."

"There was no evidence of superiority of Bobath on sensorimotor control of upper and lower limb, dexterity, mobility, activities of daily living, health-related quality of life, and cost-effectiveness."

"There is now a growing body of research and opinion saying Bobath is out of date and obsolete, not least because of emerging data from neurosciences and should be abandoned in favour of an evidence-based approach."

"Families continue to be advised that they should seek Bobath- or NDT-trained therapists and avoid those who are not, which unfairly and, I would contend, unethically discredits those therapists and programs providing evidence-based treatment but are not using NDT."

"The Bobath concept is now so diverse that it can be difficult to know where it came from and what it is: there are so many derivatives of it that it could be considered a disservice to ... Bobath to continue to practise under the Bobath name."

(NDT trained therapists) "talk about quality of motor control and motor performance, but they do not understand how to measure quality... observation is not an appropriate way to say this works."

"It is hard to justify continuing to use Bobath nowadays, when the evidence to support other treatments is so much stronger.’

"It is almost impossible to define what Bobath/NDT is in current times given that the approach has become so diverse, and in all probability, one needs to go back to the original Bobath ideas to understand what it is."

The following quote is my personal favorite. NDT has a long history of taking the hard work of researchers and exclaiming "That's NDT!" They then proceed to screw up a perfectly good treatment option by smearing Bobath/NDT all over it.

"I refer to (followers of Berta and Karel Bobath) as the ‘torch carriers’, likening them to those who ‘carry a torch’ for someone in a romantic sense, something which is typically not reciprocated or based in present day reality."

"A disconcerting facet of the torch bearer approach is that therapy principles and programs developed by other innovative clinical researchers or scientists are now considered an integral part of NDT or Bobath. Why does this method have the right to pull in everything that comes into its path like a supernova that becomes a black hole?"

systematic review
systematic review
systematic review
a great non-scientific discussion here

Neuro-Developmental Treatment. That's a lot of syllables. Very scientific sounding. It was developed by Berta Bobath, and for a long time was called The Bobath concept. Let’s just call it NDT/Bobath.

NDT/Bobath has been used on stroke survivors for decades and decades. When I was in school professors talked about it as if it was the most awesomest thing that had ever been awesome. It was the pinnacle. But it was complicated. It was so complicated you couldn't even learn it in school. You have to learn it from other NDT/Bobath practitioners. You could've gone to the Harvard school of physical therapy (if there was one -- which there isn't) and you still couldn't learn NDT/Bobath. Which is a red flag right there. If it works so well it would be required.

Instead, after graduating you have to go and get "certified" by NDT/Bobath gurus. Those gurus would've learned from other gurus, and up the pyramid it goes. NDT/Bobath training is expensive. We're talking about thousands of dollars and weeks of a therapist's life.

What could they possibly be teaching for that amount of time and money

NDT/Bobath uses "patient handling" where if you touch the patient in a particular way the patient would get better. Which makes no sense. If you could touch somebody and make them better that would be really nice. Touching is great. "Hands-on" is something that no therapist seems to be able to get enough of. But does this hands-on treatment work for stroke? Is NDT/Bobath effective?

No and not really.

And how do I know this? Systematic reviews.  Systematic reviews can be used to figure out if anything is effective for anything -- at least in medicine. If you want to be sure that something is effective you turn to systematic reviews. It's basically a study of all the qualified studies of whatever the subject is. This study of studies either says the thing works, the thing doesn't work, or they don't know yet.

NDT/Bobath always does poorly in systematic reviews. And that should be the end of it, right? It doesn't work. Goodbye. But not so fast.

Imagine if you'd spent thousands of dollars and weeks of your life in training. And in some fancy underpantsy researcher comes up and says "That doesn't work." What would you do? I've been doing talks for years to therapists. I've heard every justification for continuing NDT/Bobath.

Here are some arguments made by NDT/Bobath therapists:

1. "There's research that says it works, and research that says it doesn't work. Its 'he said she said' I choose to believe the research that says it works."

There are individual studies that say that NDT/Bobath works. But this is why scientists insist that studies be replicated. Individual studies prove little. The real question is, what do all the studies say? Large groups of studies, from researchers around the world, can be looked at and analyzed en masse. These "studies of studies" are called meta- analyses and systematic reviews. For NDT/Bobath there are quite a few; links below. They all come to the same conclusion: NDT is not particularly effective.

2. "NDT incorporates all the latest research into NDT. Therefore NDT is research-based."

I call this the "Horshella." 

Person 1: "I love horseradish."  
Person 2: "Well I love Nutella!" 
Person 1: "Oh, horseradish tastes great with Nutella." 

Maybe. But we should probably test it before we market "Horshella". Smearing NDT/Bobath all over well run clinical trials does not make NDT/Bobath research-based. In fact, it destroys the original research by adding a debilitating confounding variable. Adding NDT/Bobath to a well researched intervention may make that intervention better, worse, or not affect it at all. But the original research was never done with NDT/Bobath, so we'll never know. Stealing other people's research and glomming it does not make your intervention research-based. All you've done is hijacked well run clinical trials, and in the process made everyone look bad.

3. "I don't need research to tell me something works. I've seen it work."

The world is flat. And I can prove it. Look out the window. See? I know global warming is not happening. When I got out of the shower this morning I was freezing! The point is: Clinicians are not blinded, they don't gather and analyze data, they don't have a control group, there is no elimination of confounds and on and on. Simply: Clinical observation won't tell you if A works better than B.

4. "Research doesn't know what works so I can use anything I want."

Here is the American Heart Association Scientific Statement on the Rehabilitation Care of the Stroke Patient. It mentions constraint induced therapy, electrical stimulation, robotics, etc. It not only doesn't recommend NDT, it doesn't even mention NDT.

5. "What do I use for very low level survivors? They can't move and/or can't follow directions. So, I move them. At least I'm doing something."

Nothing else stops the plague so we're sticking with leeches. (The difference is that leeches may actually do harm. NDT does not do harm except in the sense that it leeches (!) $$ that could be better spent elsewhere.) 

Remember: There are only two kinds of true paralysis after stroke: Spastic and flaccid. Most survivors can move. Many, however are told not to move on their own because its bad movement, and will cause more bad movement. And who suggested bad movement will cause more bad movement (which is not true)? Bobath! Bobath called the movement after stroke "pathological" and insisted it be suppressed.  I call this the "The more you move the worse you'll get" philosophy.

Here are my suggestions:
  • If you have a therapist that's doing NDT/Bobath, have them read this blog entry. 
  • If you're a therapist doing NDT/Bobath, consider the evidence.


Leonard Williams said...

When I've asked about brunnstrom vs bobath, I get the look that it is above my paygrade or they don't know what l' m talking about. 16months and I'm just now starting to understand the difference. Ha I guess this is my crash course in strokology.I'll show this around next wk at camp

Kadima said...

Do you have any comment on Neuro-IFRAH? My wife is at a clinic using an offshoot of Neuro-IFRAH. As a caretaker non-professional, I really didn't know anything about NDT until I read your blog. Compared to hospital based therapy, OT therapy sessions are longer (2-3 hrs) with lots of stretching before trying to get movement, an emphasis on overcoming neglect, wearing a brace full time, and maybe a negative view of bilateral training and PT that might increase spasticity (e.g., treadmills).

Peter G Levine said...

To find if something has evidence, look in PubMed. For your question, past this in to your browser:

Kadima said...

Your last link doesn't work. Is Neuro-IFRAH same as NDT?

Kadima said...

That link does not work. Is Neuro-IFRAH a version of NDT?

Peter G Levine said...
This comment has been removed by the author.
Peter G Levine said...

Kadima: thanks for the heads up. I "fixed" the links. However, don't be surprised if they become "unfixed." The two links that were down are related specifically to NDT sites. Because I'm making a point they may not particularly like, they may be taking the linked images down.

"Is Neuro-IFRAH a version of NDT?" This is a long story, and I'm no expert. They were once related, but had an acrimonious breakup.

Kadima said...

Ignoring methodology, the distinguishing characteristic of the (Neuro-IFRAH based) clinic my wife goes to is that they provide 15 hours of OT/PT in one week, once a month as opposed to the usual once or twice a week 45 minute OT and PT sessions. Is there research and/or do you have an opinion on intensive physical therapy?


Peter G Levine said...

Kadima: BTW, to get the skinny on if neuroifrah works, the link I provided does work. Here it is again: When it says "The following term was not found in PubMed: Neuro-IFRAH." its because there is no independent evidence. This may be niggling, but this is not about methodology. This is about any research with ANY methodology. Is intensity good? Generally, yes. But there is nuance there. Intensity can be dangerous (make the infarct worse) at certain points in recovery. Great questions, thanks.

Unknown said...

Its funny, that within the musculoskeltal world they are slowly edging back to looking more closely at movement and movement control. Look at any recent research by Paul Hodges, Jull, McGill, Mark Comerford or Sarah Mottram and you will see that the basis of their expanding evidence based practice is 'control of movement'.....just to make it more efficient.......a similar concept to NDT. The difference?? Nothing really just the branding - if as therapists we are afraid to be the experts in what we were trained to do - look at movement, find the problems and help people move better - what are we becoming? Group running, same prescription exercises??? Surely we could train a monkey to do that? Looking at and analyzing movement is complex - but its our art to learn and change in our patients.

ARNI said...

Superb post, that, Peter - well done! I've just seen it and tweeted it.. all the best, Tom Balchin (ARNI, UK)

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