What is Bobath? A survey of UK stroke physiotherapists' perceptions of the content of the Bobath concept to treat postural control and mobility problems after stroke

Objective.?The aim of this study was to identify which interventions used to treat postural control and mobility are considered part of the Bobath concept (BC).

Design.?Hospital-based UK stroke physiotherapists identified interventions which they perceived to be part of the BC from a pre-published list of interventions used to treat postural control and mobility problems. Interventions that >75% of participants felt were part of the BC were classified as ‘definitely Bobath’. Interventions that <25% felt were part of the BC were classified as ‘definitely not Bobath’. Other interventions were classified as ‘unsure’; those indentified by 50–74% of participants as part of the BC were classified as ‘probably Bobath’ and those indentified 26–49% were classified as ‘probably not Bobath’.

Results.?Seventy-four physiotherapists from 33 hospitals participated. Facilitation, mobilizations and practicing components of activities were most strongly associated with the BC. Exercise and the use of equipment were identified as ‘not’ or ‘probably not Bobath’. There was uncertainty about practicing activities, teaching patients and carers and arranging independent practice.

Conclusions.?UK stroke physiotherapists perceive that the BC involves interventions that focus on facilitating movement, mobilization, practicing components of activities and some whole activities. Their views about what is not part of the BC and the areas where they are uncertain contrast with British and international teachers of the BC. Consequently, it was not possible to define a ‘typical package’ of treatment for postural control and mobility that represents the BC. Future research into the BC should focus on the effectiveness of specific, well-defined interventions.     

Palliative cancer patients in the acute hospital setting – Physiotherapists attitudes and beliefs towards this patient group

Abstract

Background

With advances in medical technology, increasing numbers of patients are ‘living with’ a terminal cancer diagnosis for longer periods; this coupled with changes in government policy is resulting in patients being treated closer to home rather than in specialist centres, bringing acute hospital physiotherapists into increasing contact with this patient group.

Aim

To describe the experience of acute hospital physiotherapists with palliative cancer patients.

Design

Semi-structured interviews analysed utilizing Colaizzi's method of analysis, reported using the COREQ guidelines.

Setting

Acute Hospital in the UK.

Participants

The first 12 physiotherapists who volunteered for the study who met the inclusion criteria.

Results

Two main themes were identified, attitudes and issues, with four sub-themes in attitudes (terminology, physiotherapists perceptions, other professionals perceived attitudes towards physiotherapists, and patients and families perceived attitudes towards physiotherapists'); there were six sub-themes in issues (communication, education, emotions, boundaries, referring onward from the acute setting, and time).

Conclusions and implications for practice

Some physiotherapists understand and apply their skills to improve the quality of life of palliative cancer patients. However, it is suggested that the majority of physiotherapists regard these patients as ‘dying from’ rather than ‘living with’ a terminal cancer diagnosis. Referral protocols and service pathways are lacking. There is an opportunity to improve how the profession promotes itself to other professionals, the public and physiotherapists of the future, to facilitate palliative cancer patients' access to rehabilitation when and where they need it, and to deliver services in line with government policy.     

Physiotherapists' clinical reasoning about patients with non-specific low back pain,as described by the International Classification of Functioning,Disability and Health

Purpose.?To explore and describe what physiotherapists experience they need to know about patients with non-specific low back pain (NSLBP) to make decisions about intervention.

Method.?Four focus groups containing a total of 21 physiotherapists were carried out in Sweden. Interviews were transcribed and qualitative content analysis performed. The manifest content was coded and categorised, and a theme emerged. Extracted symptoms and signs were linked to ICF codes.

Result.?Physiotherapists' clinical reasoning represented a broad view on low back pain (LBP) including codes from all ICF components. The participants argued for individualisation of intervention to a specific patient's problems. A theme of case complexity emerged, involving three levels: easy case, characterised by impairment in body function with close relation to specific body structures; complex case, characterised by impairments in body function, particular mental functions, activity limitations and participation restrictions, particular management of activity level and very complex case, characterised by impairments in body function, activity limitations and participation restrictions, and contextual factors, with help-seeking behaviour as a particular feature.

Conclusion.?The physiotherapists' clinical reasoning reflected a broad view on patients with NSLBP, with variations related to case complexity. The use of ICF codes contributed to understanding that the physiotherapists applied a broad perspective on NSLBP as a health condition as well as to knowledge about how physiotherapists' understand patients with NSLBP. Physiotherapists' use of the ICF in clinical practice might facilitate identification and assessment of specific patient's back pain problem as they occur in daily life and therefore be helpful in rehabilitation planning. Findings might also have an educational value.     

Outcome measures in physiotherapy management of patients with stroke: a survey into self‐reported use,and barriers to and facilitators for use

Objective . To investigate physiotherapists' self‐reported use of outcome measures as recommended in the Dutch Clinical Practice Guideline on Physiotherapy Management of Patients with Stroke (CPGPS) and to assess perceived barriers to and facilitators for the use of outcome measures in everyday practice. Method . A 41‐item survey, including the barriers and facilitators questionnaire (BFQ), was sent by post to 400 physiotherapists in each of the following settings in the Netherlands: acute care hospitals (ACH; n = 100), rehabilitation centres (RC; n = 100), nursing homes (NH; n = 100) and private physiotherapy practices (PPP; n = 100). Results . One hundred and eighty‐nine physiotherapists returned the survey (47%; ACH, n = 57; RC, n = 67; NH, n = 26 and PPP, n = 39) and the surveys of 167 physiotherapists involved in stroke settings were analysed. These physiotherapists reported regularly using three (median; range 0–7) of the seven recommended outcome measures, with those working in RC or ACH reporting a significantly higher use than their colleagues in PPP (4 vs. 0 and 3 vs. 0; p < 0.001 and p = 0.02, respectively). The BFQ revealed that there were setting‐specific facilitators, such as ‘a positive attitude towards outcome measures’ (as mentioned by 93% of the physiotherapists) and ‘acquaintance with outcome measures’ (90%), and barriers such as ‘changing routines’ (32%), ‘time investment’ (29%) and ‘financial compensation’ (21%). Conclusion . Despite an almost uniformly positive attitude, physiotherapists infrequently use the outcome measures recommended in the CPGPS. Robust setting‐specific tailored implementation strategies based on the reported barriers and facilitators are needed. Copyright © 2008 John Wiley & Sons, Ltd.     

Perceived value of stroke outcome measures across the post-acute care continuum: A qualitative case study

Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice.     

The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part I: conceptual perspectives

Abstract

Objective: The study’s purpose was to describe the range of knowledge pertaining to the Bobath concept/NDT in adult neurological rehabilitation, synthesize the findings, identify knowledge gaps and develop empirically based recommendations for future research. This article explores the conceptual literature. Methods: A scoping review of research and non-research articles published from 2007 to 2012. Two independent reviewers selected studies based on a systematic procedure. Inclusion criteria for studies were: electronically accessible English language literature with Bobath and/or neurodevelopmental therapy (NDT) as the subject heading in the title/keyword/abstract/intervention comparison with respect to adult neurological conditions. Data were abstracted and summarized with respect to study purpose, defining and operationalizing the Bobath concept, therapist demographics, recruitment, discussion and conclusions. Results: Of the 33 publications identified, 14 publications sought to define the theoretical foundations and identify key aspects of clinical practice of the contemporary Bobath concept. The publications comprised three theoretical papers, four surveys, a Delphi reported through two papers, one qualitative study, three letters to the editor and one editorial. Conclusions: Knowledge derived from review of the conceptual literature provides clinicians with an updated Bobath clinical framework as well as identifying aspects of Bobath clinical practice that require careful consideration in future effectiveness studies.

• Implications for Rehabilitation

• The integration of posture and movement with respect to the quality of task performance remains a cornerstone of the redefined Bobath concept.

• A key fundamental principle of the clinical application of the Bobath concept since its inception is the selective manipulation of sensory information, namely, facilitation, to positively affect motor control and perception in persons post-central nervous system lesion. This is an aspect of Bobath clinical practice that requires further investigation.

• Study and treatment fidelity issues such as therapist expertise, the use of treatment logs to document individualized clinical practice, as well as therapist supervision and evaluation require careful consideration in the implementation of Bobath effectiveness studies such that causality can be determined.

     

To what extent are family members and friends involved in physiotherapy and the delivery of exercises to people with stroke?

Purpose. To examine the views of people with stroke, their ‘family members/friends’ and physiotherapists on the role of the family in physiotherapy and the delivery of exercises following stroke.

Methods. A self-report questionnaire was administered to 100 ‘family members/friends’ and 75 people with stroke. Two focus groups were conducted with 10 expert physiotherapists working in the area of stroke rehabilitation.

Results. Family members of people with stroke are willing to participate in the delivery of unsupervised exercises in the hospital and the home setting (n = 91). Furthermore, this is also acceptable to people with stroke (n = 65) as an adjunct to routine physiotherapy. Physiotherapists highlighted a number of factors that influenced participation in physiotherapy such as; level of interest and motivation of the family (n = 5), availability (n = 3) and importance of education (n = 2). ‘Family members/friends’ identified reasons that would also limit participation such as work commitments (n = 24), lack of confidence (n = 20) and unsuitable treatment times (n = 13). The expert practitioners outlined a number of areas that family involvement can have an impact, such as treatment carry-over, assisting the family unit to cope on discharge and improving handling skills.

Conclusions. Our study identifies an under-utilised role for ‘family members/friends’ in the rehabilitation of people with stroke. Family mediated exercises can maximise the carry-over outside formal physiotherapy giving patients the opportunity for informal practice. This study highlights the need to examine the value of a structured programme of exercises that can be delivered to people with stroke by their ‘family members/friends’.     

Promotion of healthy nutrition in clinical practice: A cross-sectional survey of practices and barriers among physiotherapists in southeast Nigeria

BackgroundHealthy diet counselling is an important concept in health promotion. Physiotherapists are well positioned to initiate or support healthy nutrition in addition to physical activity counselling, in routine patient consultation.ObjectiveTo determine the practices about and barriers to diet counselling practices among physiotherapists in Southeast Nigeria.MethodsIn this cross-sectional survey, a total of 140 questionnaires were distributed among physiotherapists.ResultsOverall, 103 physiotherapists responded. Physiotherapists are confident and consider the incorporation of dietary counselling very important and of high priority in their daily clinical work. They, however, assessed and counselled on dietary status opportunistically in patients. Notwithstanding, physiotherapists believed that the diet counselling they give could be effective in helping patients change their unhealthy dieting practices. Patients were also amenable to physiotherapists advocating on diet issues as part of their consultation. Several barriers to incorporating diet counselling into physiotherapy practice were identified, including lack of access to a dietician/health promotion staff/counsellors, lack of proper patient education materials, lack of expertise in relation to dietary risk factors' assessment and management, and uncertainty about what dietary services to provide.ConclusionAlthough physiotherapists consider it important to incorporate diet counselling in their daily clinical practice, development and implementation of strategies to improve physiotherapists' diet counselling knowledge, competence, skills, and practice are warranted.     

Physiotherapists’ perceptions of patient adherence to prescribed self-management strategies: a cross-sectional survey of Australian physiotherapists

Purpose: Physiotherapists often prescribe self-management strategies for their patients. However, the effectiveness of these strategies in improving patient outcome is related to the rate of patient adherence. The aims of this study were to explore physiotherapists’ views on the importance and perceived rates of patient adherence to physiotherapist prescribed self-management strategies; the perceived importance of methods physiotherapists can employ to aid patient adherence and the barriers to employing these methods.

Method: A cross-sectional web-based survey was emailed to 808 physiotherapist members of the Australian Physiotherapy Association. To maximize response rates, two reminder emails were utilized.

Results: In total, 352 physiotherapists completed the survey (response rate 44%). A majority of physiotherapists (89%) believed that patient self-management strategies were important in improving patient outcomes; however, the mean perceived rate of patient adherence across all strategies was only 67%. Physiotherapists reported that there were a number of important methods that can be employed to aid patient adherence such as providing patient education and allowing time for patient practice; with minimal perceived barriers to employing these methods.

Conclusions: Results indicate that physiotherapists perceive that patient outcomes can be positively impacted by patient adherence to a range of self-management strategies. Physiotherapists should be encouraged to implement into their routine clinical practice evidence-based methods to aid patient adherence.

• Implications for Rehabilitation

• Physiotherapists believe that patient self-management strategies are important for improving patient outcomes, however, the perceived rates of patient adherence could be improved.

• Physiotherapists should adopt a collaborative approach with their patients to address any barriers to adherence to positively impact on patient outcome.

• Physiotherapists perceive that there are a number of modifiable characteristics which determine patient adherence including patient self-efficacy, physiotherapist communication skills and the complexity of the self-management strategy.

• Methods that physiotherapists can employ to positively influence patient adherence may include individualizing the strategy to the patient, education and supplementary written information.

     

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence

Purpose.?To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

Introduction.?Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

Method.?A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

Results.?Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

Conclusions.?The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.     

Adaptation of the person centered therapeutic relationship patient version (PCTR-PT) to a version for physiotherapists (PCTR-PHYS) and evaluation of its psychometric properties

Background and Purpose

The therapeutic relationship is a central component for developing person-centered care within physiotherapy services. However, it is necessary to understand how this relationship is perceived by both parties involved. The Person Centered Therapeutic Relationship-Patient scale (PCTR-PT) was constructed to identify patients' perceptions. No instruments are currently available to correlate patients' and physiotherapists' perceptions of the therapeutic relationship. This study sought to adapt the PCTR-PT to develop a version for physiotherapists, the Person Centered Therapeutic Relationship Scale for Physiotherapists (PCTR-PHYS) and to determine its psychometric properties.

Methods

A three-stage study was performed: (1) item generation, (2) pretesting of the questionnaire, (3) analysis of psychometric properties. Factor validity and psychometric properties were analyzed by confirmatory factor analysis (CFA). Convergent validity was calculated. Internal consistency was verified using the Cronbach's alpha coefficient. The intraclass correlation coefficient (ICC) was used to examine temporal stability.

Results

Thirty-three physiotherapists participated in two rounds of cognitive interviews and 343 participated in the analysis of psychometric properties. The CFA confirmed the four-structure model. Reliability of the tool was confirmed by Cronbach's alpha (α = 0.863) for all four dimensions, as all were above 0.70, ranging from 0.704 (relational bond) and 0.898 (therapeutic communication). Test-retest was performed with 2-week intervals, indicating an appropriate stability for the scale (ICC = 0.908).

Discussion

The Person Centered Therapeutic Relationship Scale for Physiotherapists is a useful, valid and applicable instrument to evaluate the person-centered therapeutic relationship during physiotherapy interventions. It will enable the comparison of patients' and physiotherapists' perceptions. To provide person-centered care in physiotherapy services, there is a clear need to incorporate specific resources into clinical practice to evaluate the quality of the therapeutic relationship from the perspective of both the persons being treated and the professionals providing care.     

The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part II: intervention studies perspectives

Abstract

Objective: The study’s purpose was to describe the range of knowledge pertaining to the Bobath (NDT) concept in adult neurological rehabilitation, synthesizes the findings, identify knowledge gaps and develop empirically based recommendations for future research. Methods: A scoping review of research and non-research articles published from 2007 to 2012. Two independent reviewers selected studies based on a systematic procedure. Inclusion criteria for studies were electronically accessible English language literature with Bobath and/or Neurodevelopmental Therapy as the subject heading in the title/keyword/abstract/intervention comparison with respect to adult neurological conditions. Data were abstracted and summarized with respect to study design, theoretical framework, clinical application including population representation, study fidelity, intervention comparison, duration of care, measurement and findings. Results: Of the 33 publications identified 17 were intervention studies (11 RCT’s/1 prospective parallel group design/5?N-of-1). One other paper was a systematic review. Conclusions: The intervention studies, primarily RCT designs, have serious methodological concerns particularly related to study/treatment fidelity and measurement resulting in no clear clinical direction. Aspects such as theoretical framework, therapist skill, quality of movement measurement and individualized interventions require careful consideration in the design of Bobath studies.

• Implications for Rehabilitation

• Future intervention studies should be based on the current Bobath theoretical framework and key aspects of clinical practice.

• Study and treatment fidelity issues need to be carefully considered when interpreting the results of existing RCT’s evaluating the Bobath concept.

• N-of-1 randomized, observational, factorial and mixed method study designs should be considered as alternative study options.

     

Physiotherapy based on the Bobath concept in stroke rehabilitation: a survey within the UK

Purpose : The Bobath concept is one of the most widely used approaches in stroke rehabilitation within Europe. This survey aimed to provide an expert consensus view of the theoretical beliefs underlying current Bobath practise in the UK. Method : Questionnaires (with sections related to: therapist background, physiotherapy management, theoretical beliefs and gait re-education strategies used) were posted to all senior level physiotherapists working in stroke care ( n = 1022). Results : The majority of respondents had more than 10 year's experience overall and at least 5 years experience in stroke care. The Bobath concept was the preferred approach ( n = 67%) followed by an 'eclectic' approach ( n = 31%). Despite a high level of consensus between groups, there were 13 significant differences highlighted between Bobath and 'eclectic' groups related to recovery, control of tone, the analysis and facilitation of normal movement and function. In summary, Bobath therapists considered that patients needed to have normal tone and use normal movement patterns in order to perform functional tasks. They would delay patients from performing tasks independently if abnormal tone and movement would be reinforced by task practice. They were not opposed to the use of walking aids and orthotics. Conclusions : This survey has raised several issues for debate within physiotherapy such as the automatic translation of movement into function, carry over outside therapy, and the way in which tasks should be practiced. The dominance of the Bobath concept needs to be justified by establishing that it is both effective and efficient at achieving its treatment aims of: normalizing tone, improving intrinsic recovery of the affected side and function within everyday tasks.