A recent meta-analysis on the efficacy of NDT/Bobath has just been published.
It's a big deal!
This new meta-analysis not only concludes that NDT is not effective, but goes further, calling for the de-implementation of NDT/Bobath from policy, from funding and from training. And a meta-analysis is king of the evidence based practice (EBP) pyramid, and excellent for determining efficacy.
But here's the thing - determining efficacy is not the same as determining effectiveness. Particularly in our world of neuro-rehabilitation.
If you didn't know there was a difference between efficacy and effectiveness, you're not alone. I had to look it up when I first started doing my PhD because these words are so often used interchangeably (as they are in this meta-analysis) - but in health research it matters. In rehabilitation research it matters. And in pediatric neuro-disability research it matters even more.
Efficacy is the power to produce an effect, and effectiveness is the degree to which something is effective. In research, we tend to lean towards efficacy as the preferred term because – well – who doesn’t want the power to produce an effect!
But in health, the definition of Efficacy is the capacity of a given intervention under ideal or controlled conditions whereas Effectiveness is the ability of an intervention to have a meaningful effect on patients in normal clinical conditions.
And that is where we are all hanging out. In real life. In "normal clinical conditions".
Efficacy does not equal effectiveness and meta-analyses are problematic in this regard.
I know we all agree that in real life our clinical work requires a patient-centric, individualized approach. And although we also all agree that research is important in moving our practice forward, systematic reviews and meta-analysis frequently leave us dissatisfied in their ability to provide definitive answers for our clinical concerns.
Cochrane has started a working group to try and address this problem. Looking at how to review treatment approaches in real-word clinics with real people, where effective therapies have loosely defined parameters and large heterogeneity. And a shift in research from looking at treatments to looking at process has started (see here and here) exactly for this reason. Because academics are starting to recognize that in rehabilitation and disability, we do not work in a disease > medicate > cure paradigm, where efficacy can be determined in a laboratory. Doctors who are diagnosing and prescribing may need to know about efficacy. As ALLIED health professionals however, we need research methodologies that prioritize effectiveness.
We need research that allows for tailored approaches to therapy in real world settings.
We need to understand what works for which patient in what context - and how to combine effective approaches and tease out the process that underpins effectiveness - so that we can maximise outcomes for the unique individual standing in front of us in our clinic.
We all know this!
We see a meta-analysis as gold standard and we are conditioned to accept it’s finding as valid and definitive. We seem to compartmentalize the “knowing”. Ignoring the significant, gaping holes and questionable applicability of medico-centric solutions to our family centered, context-dependent real-world rehabilitation concerns.
After all, it’s a META-ANALYSIS and that’s a significant, rigorous scientific undertaking with high efficacy.
It reminds me of the persistent popularity of weight-loss shakes. It seems like such a good idea to contain your meal to a calorie controlled drink (they don’t work people!)
So let’s make this practical by taking a closer look at how this meta-analysis represents our real-world clinical practice and then you can decide for yourself if their authoritative conclusion is warranted.
The authors of the meta-analysis begin their publication by stating that NDT is often considered standard practice across the world and reference an excellent 2017 Delphi study that defines contemporary NDT/Bobath ...
... and then go on to define NDT/Bobath in their own words - emphasizing the old narrative that NDT is about passive handling to 'normalize' movement and 'train' quality. (It is not - but let's move on... )
2017 Delphi Study Definition
2022 Meta-Analysis Definition
The Bobath concept is an individualized problem-solving treatment approach. It provides the therapist with a unique set of skills particularly with respect to movement analysis and the use of sensory input, can be applied to a broad range of clients with movement disorders, and can be combined with other interventions. The goal of the Bobath concept is to minimize activity limitations and impairments within the context of the individual’s environment and participation goals. Clinical practice of the Bobath concept is based on the understanding that sensation, action, perception, cognition, and emotion are interlinked and interactive.
3 primary principles of NDT, are
(1) movement analysis of task performance,
(2) interdependence of posture and movement, and
(3) the role of sensory information in motor control.
Facilitation is the skilled interaction between the therapist, the client, and the client’s body.
Facilitation includes therapeutic handling, manipulation of the environment, task selection, and appropriate use of verbal and nonverbal cues in order to potentiate self-initiation/termination of movement and/or create the necessary conditions for a movement experience that the client can not yet do alone.
In practice, the elements of NDT are (1) therapist-controlled facilitation of movement via handling to provide optimal sensory input to improve postural control and (2) training movement quality to normalize motor patterns, currently termed regaining “typical motor behavior” and minimizing “atypical motor behavior.” This involves training movement quality rather than using compensatory or atypical strategies to complete a task which is discouraged in NDT
The objective of the academic research was to determine the efficacy of NDT in CP using a systematic review and meta-analysis.
Process was followed and rigorous methodology to eliminate bias was used. The authors pre-defined their criteria for article inclusion and exclusion. Any article that referenced the therapy approach as NDT, Bobath or neurodevelopmental therapy was included (intervention or control arms of an RCT). In addition, but at odds with how NDT/Bobath is practiced in our real clinical world, articles were excluded if the research combined NDT with any adjunct therapy.
I think researchers have a really hard time getting their heads around the idea that we use eclectic approaches in the real-clinical world
Despite having the recent Delphi consensus on what NDT actually is, articles included in this meta-analysis did not need to meet any level of fidelity or align with the 2017 Delphi definition of NDT/Bobath. I was therefore naturally curious about how the included articles applied NDT in their RCTs. So I did what anyone with unrestricted library access does - I pulled the articles listed in the meta-analysis to review.
I limited my article review to publications from the last 10 years, mostly for pragmatic reasons related to time, but also because the most recent traffic light report from Novak at al published in 2019 (with many of the same authors as the meta-analysis in question) had categorized NDT ABOVE the "possibly worth doing it line" for the treatment of tone in CP.
I was curious to know what new research shifted the narrative from NDT moving up to the "possibly worth it" rating in the 2019 Traffic Light article, to this new meta-analysis making recommendations to de-implement NDT?
That's a big jump!
Considering very few meta-analyses in rehabilitation make definitive statements, one would assume that there had to have been some robust new research to support such a stance.
(Just an aside, the Novak traffic light article took care to differentiate the ‘original passive form’ of NDT from contemporary NDT. Not withstanding the fact that NDT was never passive and this is an historical miss-representation of NDT repeated through years of academic literature, nonetheless it represented a shift in the research away from this old narrative of what NDT is. However with this newer research hot on it's heels, that shift appears to have been a momentary glitch in the academic narrative - hopefully not )
The meta-analysis included six articles published between 2012 and March 2021 and I have captured the publication descriptions of NDT from the six articles in the tables below with comments.
In a nutshell, of the six included RCTs over the last 10 years, one was possibly close to meeting something I would recognize as an NDT treatment, if not an NDT approach.
Q: Does this published meta-analysis meet sufficient standards for good research?
A: Yes it does, 100%
Q: Does this meta-analysis meet sufficient standards for determining the effectiveness of NDT?
A: How can it? None of the included articles being analyzed describe an NDT approach in clinical practice.
In the last 10 years (from 2012 to 2022), only six RCTs met criteria for this meta-anlaysis. These are the most recent articles that recommendations to de-implement NDT are based on, none of which align with a 2017 Delphi study description of NDT/Bobath.
There are not many clinicians who have the time, or the library access to analyze all the articles presented in a meta-analysis like this one. Clinicians would predominantly take the recommendation to de-implement NDT at face value.
The big question is...
What are we de-implementing exactly?
The 2017 Delphi consensus on NDT/Bobath says you would be de-implementing a problem solving, clinical analysis approach concerned with understanding postural control and task performance with a specific focus on the quality of task performance and the integration of sensory information in motor control and perception.
But what the academics are really calling to de-implement is a network of highly passionate and dedicated clinicians who are committed to improving pediatric therapy across the globe.
These university-trained, master clinicians are dedicated to a systematic, interdisciplinary approach of practical skill development that teach therapists fundamental movement analysis, and clinical problem solving skills related to development, neurological function and rehabilitation; in line with contemporary science and best practice. It's were I first learned about the ICF and the dynamic systems approach more than 20 years ago! It's where I first learned to see movement synergies and understand how to optimize motivation for movement. It's where I honed my skills and sharpened my understanding of the complexity of pediatric neuro-muscular development and movement quality. It's where I learned skills that have significantly improved my training from undergraduate PT school and post-graduate studies, and it's how I have improved my clinical skills immeasurably over the years as a practicing clinician working in pediatric neuro.
The call to de-implement NDT makes ZERO sense to me.
It seems to be based on historical misinformation and studies that are not representative of how NDT trained therapists should be practicing in the real world with their real patients. It is a massive disservice to our pediatric rehabilitation community, both the clinicians, the children and the families in their care.
Over 85% of clinician's who undertake NDT training find it enhances their clinical analysis and problem solving skills as well as providing them with fundamental knowledge to draw on in more effectively applying all of the techniques (task-specific training, goal-directed training, treadmill training, constraint- induced movement therapy, action observation, and bimanual therapy) recommended as 'alternatives to NDT' in the meta-analysis conclusion. Why would we want to de-implement that?
As clinician’s we rely on our academic colleagues to guide our practice. This meta-analysis that calls for the disestablishment of a highly valued organization of our peers is an excellent example of why excellent Evidence Based Practice is not necessarily excellent for therapists and patients dealing with the reality of real-world clinical problems.
Read it with caution!
References: Blue underlined text link to relevant references
Missed part-1? Go HERE