Volume 30, No,2,December, 2007

Title: Bobath Approach and EBM; Strategy Based on Brain Plasticity and Motor Learning Theory

Organization: Teikyo Heisei University
Author: Yasutomo Sakai, RPT, PhD
key word: the Bobath, evidence, and motor learning

Abstract: The Japanese guidelines for the treatment of strokes have evaluated that there is a low level of evidence of Evidence-Based MedicineiEBMjin Neuro-Developmental TreatmentiNDTj.
The author considers that the low level of evidence is caused by the following three points:
1. Randomized controlled trial (RTC) reports adopted for evaluating the evidence level of the NDT were published in 1990 or before.
2. Therapeutic regimens used in those reports were ambiguously described.
3. Therapeutic effects in those reports were evaluated based on the changes in activities of daily living (ADL).
In contrast, the evidence level of the motor relearning program (MRP) and constraint-induced movement therapy (CIMT) is high.
There is no significant difference in techniques among the MRT, the CIMT, and NDT.
A common point between the MRP and the CIMP is that they both apply the latest motor learning theories.
The MRP recommends random exercises and variation exercises in a task-oriented approach for the affected side in order to optimize and automatize motor skills.
The CIMT focuses on a learning phenomenon referred to as"learned non-use", emphasizing an increased amount of exercise experienced in the affected side by means of limiting movements in the less-affected side.
A clinical project for the CIMT was strategically conducted across the United States of America based on a RTC research design.
This CIMT research strategy will be a reference example to be considered when performing research projects on the NDT.
The NDT is proficient at movement analysis and therapeutic techniques, though its weakness is in maintaining obtained functions and carrying those functions over to daily lives.
The author believes that it is necessary to perform clinical trial design which discusses the therapeutic effects of the NDT in order to raise the evidence level of research relating to the NDT based on the following methods:
Firstly, extract techniques and theories believed to be effective in the NDT.
Following this, research those techniques and theories in the design of clinical meta-analysis.

Title: Establishment of Evidence Based Physical Therapy for Cerebral Palsy

Organization: (1) Faculty of Rehabilitation, School of Health Sciences, Kanagawa University of Human Services, (2) Graduate Course of Rehabilitation Science, Division of Health Science, Kanazawa University Graduate School of Medical Science
Author: Ryo Yonetsu1) RPT, MS, and Junichi Shimizu2) OTR, PhD
Key words: Evidence, Case report and Cerebral Palsy

To establish the Evidence-Based Physical Therapy (EBPT) for children with cerebral palsy (CP), we believe that the accumulation of case reports is important, because results from high-evidence-level research studies which are useful in clinical settings may be limited.
Additionally, the case reports will give us some more specific suggestions for planning and implementing physical therapy treatments than the high-evidence-level research studies.
We should establish the EBPT for CP in consideration of the difference between research and clinical settings.
The purpose of this paper is to suggest a method by which universal hypotheses concerning the Bobath approach would be brought about based on case reports.
The method is as follows; (1) we should characterize case reports in terms of the attributes of subjects, the contents of treatments based on the Bobath approach, and the results of the treatments; (2) we should compare case reports and find out common hypotheses in more than two case reports.
As a result of the analysis of six case reports based on the Bobath approach, we found out four common hypotheses concerning the Bobath approach.
Through such analyses based on case studies, we can accumulate common hypotheses concerning the Bobath approach, which seem to become universal hypotheses for the CP treatments.
Based on such universal hypotheses, we should carry out research studies with a higher evidence level.
Therefore, the accumulation of case studies is a premise for a higher-evidence-level research study for CP.

Title: An Approach for Determining Therapeutic Effects by Using Quantitative Assessment \Based on the Walking Ability of a Patient with Left Hemiplegia Caused by a Stroke\

Organization: Kiyose Rehabilitation Hospital
Author: Akinori Yamasaki, RPT, and Tunenori Miyata, RPT
Key words: outcome evaluation, qualitative evaluation, and quantitative evaluation

The author treated a patient with left hemiplegia caused by a stroke 5 months after its onset based on the Bobath concept.
In this report, while verifying the effects of the therapy, a method to determine these effects when the degree of independence of a patient does not change (that is, in this case, no change in his level of independence while walking indoors) is discussed.
ƒMethod„ In order to determine therapeutic effects, gait analysis was used as a qualitative evaluation, and the loading rate of the lower limbs on the affected side (hereinafter "loading rate"), 10m walking time (hereinafter "walking time") and 10m step number (hereinafter "step number") were used as quantitative evaluations.
Results over 72 days were classified into those for the entire period, initial stage, mid stage and latter stage. The results from each stage were compared and therapeutic effects were evaluated.
ƒResults„ In the qualitative evaluation, improvements in both the antigravity extension activities in the stance phase and the propelling force of the affected side were observed.
In the quantitative evaluation, comparisons from before and after the entire period showed that the loading rate changed from 66.5% to 75.8%, walking time from 20.6 seconds to 18.18 seconds, and step number from 27.51 steps to 26.19 steps.
When comparing the initial stage to the mid stage, the loading rate was improved significantly from 62.5% to 80.4%, walking time was improved significantly from 22.92 seconds to 19.83 seconds and the step number was improved significantly from 28.83 steps to 26.0 steps.
When comparing the mid stage to the latter stage, the walking time was improved significantly from 19.83 seconds to 14.41 seconds and the step number was significantly improved from 26.0 steps to 23.83 steps.
However, the loading rate decreased from 80.4% to 78.1%.
ƒDiscussion„ Both the qualitative evaluation and quantitative evaluation prove that the walking ability of the patient has improved, thus showing the usefulness of the therapy performed for this case.
The walking time and step number, which are quantitative evaluations, are useful for determining therapeutic effectiveness because they can reflect the supporting ability of the affected lower limb, which is a qualitative evaluation.
The author believes that, as shown in this study, it is desirable that the quantitative evaluation measures not only quantitative changes but also reflects qualitative changes.

Title: Bobath Approach and EBM

Organization: Kansai University of Health Sciences
Author: Toshiaki Suzuki, RPT, DMSc
Key words: science, the Bobath approach, and evidence-based medicine

The typical research method for Evidence Based MedicineiEBMjis Randomized Controlled TrialsiRCT).
However, the author believes that the RCT method is not appropriate for proving the effectiveness of the Bobath approach. The reasons are as follows:
1. Comparing approaches which have different therapeutic aims and strategies is meaningless.
2. Quantitative changes in activities of daily living (ADL) have been used as criteria in many assessments. Therefore, the effectiveness of the Bobath approach which tries to bring about not only quantitative changes but also qualitative changes is not appropriately assessed.
Bobath therapists should work on the following three areas in order to gather evidence for the Bobath approach:
1. Add objective assessments to case reports based on the Bobath approach.
2. Research on specific therapeutic techniques of the Bobath approach scientifically.
3. Devise new RCT designs which could show the therapeutic effectiveness of the Bobath approach.
To begin with, we should treat patients based on an appropriate analysis of their movement problems in daily clinical settings in order to gather evidence for the Bobath approach.
In addition, changes in patients which the Bobath approach has brought about should be clarified by objective data.
Bobath therapists should reaffirm that these activities are fundamental to obtaining evidence of the Bobath approach.

Title: Evidence-Based Medicine (EBM) in Pediatric Bobath Approach

Organization: National Rehabilitation Center for Disabled Children
Author: Tatsuyuki Kaneko, RPT, MSc
Key words: the Bobath approach, EBM, and narrative-based medicine (NBM)

The term "medicine" in Evidence-Based Medicine (EBM) is a generic term referring to the assistance, behavior, and theory for patients, and includes a part of "Ryoiku" (a system in which medical careAchild care guidance and education are provided at the same time).
The therapy which supports medicine with evidence is medical science. Medical science refers to reproducible and logical diagnoses and treatments based on the natural scientific methodology.
If the Bobath approach is developed in the medical field, EBM of the Bobath approach must be considered.
However, present medicine has not been being always supported by evidence.
Furthermore, it is difficult to support with up-to-date evidence on a constantly advancing therapy such as the Bobath approach.
Because of this, there is widespread, global criticism which argues that the Bobath approach has no effect, and it is in a critical situation.
In addition, there are, unfortunately, unfounded criticisms in Japan that the Bobath approach should not be practiced. Therefore, evidence for the Bobath approach must be gathered in order to counter those criticisms.
All Bobath therapists in Japan should have so much crisis in the current situation.
To begin with, in order to gather evidence regarding the Bobath approach, we must understand the considerable misunderstandings that exist concerning EBM, and have a proper understanding of the real purposes of EBM. This report consists of two parts.
In the first part, current misunderstandings of EBM and its real purposes, as well as problems regarding statistical methods are explained.
In the second part, a general explanation of Narrative-Based Medicine (NBM) is given and a case report based on NBM is provided.
This article proposes a method to construct evidence for the Bobath approach .