G u e s t

E d i t o r i a l

I
n S eptem ber 1998 C ape Town 
hosted the Annual General M eeting 
and International Congress o f the 
In ternational B obath Instructors 

A ssociation, an association which pro­
motes the evaluation and treatm ent of 
adults with hem iplegia according to the 
neurodevelopm ental or Bobath concept. 
Sackley and Lincoln (1996), in a survey 
o f current practice in the treatm ent of 
stroke patients w hich was conducted in 
Britain found that 80% o f the therapists 
who treated these patients used the 
Bobath approach. However, they found 
that these same therapists rarely used 
standardised outcome measures and were 
reluctant to provide a reasoned account 
o f the theoretical basis for their choice 
o f treatment. This view is supported by 
Lennon (1996) in a critical review o f the 
theoretical assum ptions w hich guide 
physiotherapy practice in stroke rehabi­
litation. The Cape Town congress, how ­
ever, made it very clear that the current 
theoretical assumptions underlying NDT 
(or Bobath) philosophy have developed 
considerably during the last decade, 
both during the B obaths’ lifetime and 
since. C urrent th eoretical assum ptions 
cover not only neurophysiological sys­
tem s, but also b iom echanical, m otor 
control, motor learning, cognitive, beha­
vioural and em otional aspects

C ontrary to the claims o f proponents 
o f m otor retraining to the exclusion of 
other approaches, these updated theore­
tical assum ptions w ere adopted some 
years ago and continue to develop (Bly,
1991). Is it reluctance to publish which 
has prevented this from becoming com ­
mon knowledge?

P ractitio n ers in the n eu ro d ev elo p ­
m ental approach to the treatm en t o f 
patients with disorders o f the central ner­
vous system have also been criticised for 
their failure to publish outcom e studies. 
As in other fields o f physiotherapy, 
m any studies have been published on 
m easurem ent instrum ents but very few 
on the outcom e o f treatment. One o f the 
reasons cited for this failure is the diffi­

culty in m easuring quality o f movement. 
A nother is the difficulty in matching 
experim ental and control groups as well 
as the ethical dilem m a o f withholding 
treatment from a control group. The need 
for evidence-based practice cannot, how­
ever, be ignored. We can only justify our 
approach to treatm ent if we can produce 
outcome studies to support our theo­
retical assumptions. However, outcome 
studies must be well-designed, interven­
tion must be relevant and outcom e m ea­
sures must be valid. A recent study on 
task-orientated activity, published by pro­
ponents o f the m otor learning approach, 
failed sadly in these respects (Dean and 
Shepherd, 1997).

We should acknowledge the mistakes 
o f the past. The European Consensus 
M eeting o f Stroke (1995) came to the 
conclusion that there was little evidence 
that rehabilitation beyond six months 
after stroke could improve m otor or 
perceptual deficits. Watson (1997) has, 
however, cited several studies giving 
evidence for late-stage motor recovery 
in adults with severe traumatic brain 
injury. Other studies o f severely disabled 
patients also suggest that recovery may 
take place more slowly and for longer in 
this group than in less severely disabled 
subjects. Equally important, Lindmark 
and Hamrin (1996) have shown a signifi­
cant deterioration in stroke patien ts’ 
ability to perform everyday activities one 
and five years post-stroke. Most o f us can 
cite patients whom we started to treat 
long after six months post-insult, and in 
whom good results were achieved, but 
our failure to em ploy sound research 
methodology resulted in our inability to 
publish our findings.

A much neglected area in stroke reha­
bilitation is the upper limb. The majority 
o f outcom e studies have concentrated on 
achieving independent gait. A recent arti­
cle published by Hale and Eales (1998) 
in this country noted the recovery o f 
w alking function in a group o f patients 
from  an u n d er-serviced com m unity, 
despite minimal intervention. However,

independent walking by no means guar­
antees independence in activities of 
daily living, and the discussion article in 
this issue o f the Journal gives insight 
into the com plexities and lim itations of 
regaining satisfactory upper limb function.

The articles published in this issue 
represent a selection o f the papers pre­
sented at the IBITAH congress and 
d em o n strate the b alan ced  attention 
which therapists are starting to give to 
research into stroke and the outcomes of 
treatment. In addition to the discussion 
article they com prise the study o f a 
m easurem ent instrument, a random ised 
balanced study on the effects o f foot­
w ear on gait and, finally, a study on the 
problem s experienced by Black Stroke 
patients in Soweto, South Africa. □

SHEENA H. IRWIN-CARRUTHERS

REFERENCES

B ly L  (1991) A  historical a nd c u rre n t view  of 
the basis o f ND T, P ed ia tric  P h ysic a l Therapy 
3: 131-135

D ean C M , S h e p h e rd  RB (1997) T ask-related 
training im proves perform ance o f seated reach ­
ing tasks after stroke - a random ised controlled 
trial, S troke 28: 722-728

H ale L A , E ales C J (1998) R e covery o f  w alk­
ing fu nction in stroke p atien ts a fter m inim al 
rehabilitation, P h ysio th e ra p y  R esea rch  In te r ­
n a tional, 3: 194-205.

L e n n o n  S (1 9 9 6 ) T h e  B o b a th  c o n c e p t: a c ri­
tical review  o f the theoretical a ssu m p tio n s that 
guide physiotherapy practice in stroke rehabili­
tation, P h ysic a l T herapy R ev ie w s 1: 35-45.

L in d m a r k  B, H a m rin  R (1 9 9 6 ) S tro k e  
p a tie n ts’ ab ility to  perform  ev ery d a y  activities 
I and 5 years post-stroke, P hysiotherapy Theory 
a n d  P ractice 12: 97-101.

S a c k le y  C M , L in c o ln  NB (1 9 9 6 ) P h y s io ­
therapy trea tm e n t fo r stroke patients: a survey 
o f  c u rre n t practice, P h ysio th e ra p y  T h e o ry  a nd 
P ra c tic e  12: 87-96.

W atson M J (1997) E v id e n ce  fo r “ sig n ific a n t” 
late-stage m o to r recovery in p a tie n ts w ith 
sev ere brain injury: a lite ratu re  review  w ith 
re le v a n c e  fo r n e u ro lo g ic a l p h y sio th e ra p y , 
P h ysic a l Therapy R ev ie w s 2: 93-106.

2 SA Jo u r n a l  o f  Ph y s io t h e r a p y  1999 V o l  55 No 2

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