The EBTA response to a review article by Novak et al 2013

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The EBTA response to a review article by Novak et al 2013

Gill Stern recent past President European Bobath Tutors’ Association on behalf of the EBTA Executive Committee

We are writing in response to the review paper by Iona Novak et al (DMCN 2013), a conclusion of which is to give the ‘red light, don’t do it’ to NDT-Bobath. Before accommodating this drastic step of outlawing a particular approach, we believe it is important to attempt to clarify exactly what the Bobath approach or concept is, and to correct some misunderstandings about it, using previously published material.

Dr Karel Bobath, a medical doctor, and his wife Berta, a physiotherapist, developed the Bobath approach 70 years ago in the United Kingdom at a time when it was thought that little could be done to alter the pathology or the participation of people with stroke or children with cerebral palsy. Neuro-Developmental Treatment (NDT) is a name coined by Mrs Bobath, and used by ‘Bobath’ practitioners in the USA and elsewhere (Mayston 2004).

Dr and Mrs Bobath were among the very first to recognise and write about plasticity within the nervous system as well as the relevance of sensory disturbances, sensorimotor learning, individualised goal setting, outcome measures, activity limitation, functional participation, home programmes and parental education long before these terms were officially coined. (Bobath B and Bobath K in Foreword to Finnie 1968, Bobath B 1970, Bobath & Bobath 1984)..

The Bobaths also wrote in 1958 about the importance of motor learning based on a child’s own activity “…therefore one of the greatest art of the treatment is to know where and for how long to take our hands away, or to release our hold, so that the child has a chance of his own control whenever possible, even if only for a moment at first. This has been reaffirmed in current models by authors in the field of Motor Learning such as Schmidt and Lee 2005 “…learning cannot be measured directly – instead it is inferred based on behavior.” *

In her editorial in Physiotherapy Research International 2008, Margaret Mayston a Senior Teaching Fellow at University College London, as well as a Senior Bobath Tutor who has worked with Dr and Mrs Bobath, states that ‘there is an urgent need for an integrated approach to neurorehabilitation that is not based on approaches, but rather is client based with a sound theoretical, and where possible, evidence base. This does not negate the practice and teaching of Bobath-based therapy, but requires a shift in focus to recognize Bobath as a contributor to client-based neurorehabilitation, not the leading actor who wishes to be centre stage at all times.’

Mayston,(2008) gives the current view of the Bobath Concept and a reasoned argument for continuing use of a Bobath-based approach; an approach which has given thousands of therapists worldwide a framework and a sound basis for analysis of the complexities of cerebral palsy, a heterogeneous group of conditions, as well as empirically observable results, often transferable to improved levels of activity and participation (Bain 2012, Knox 2002).

Bobath analysis as a tool, can be used with every type of neuro-disability. It involves ‘observation, analysis, interpretation, experimentation, outcome measurement’ (Figure 1, Mayston 2008). A unique aspect of Bobath is the close experimental relationship between assessment and treatment (Bobath B 1978, Bobath B 1990). In other words Bobath practitioners aim through ‘trial and error’ to find what makes a new skill or part of a skill, possible or easier to achieve. They do this using the client’s own active or active assisted movements. Uniquely developed specialised handling to reduce hypertonia is used where appropriate, but this is not ‘passive’, and to describe Bobath as ‘passive handling’ Table 1 (Novak et al) is inaccurate.

The Bobath approach is holistic, covering all areas of daily life and includes advice and carer training regarding handling, equipment and other modalities.(Bobath & Bobath 1984). This is reflected in Nancy Finnie’s well-known illustrated book ‘Handling the young child with cerebral palsy at home’, first published in 1968, the third edition published in 2009. Finnie was a physiotherapist and one of Mrs Bobath’s early protégés, who worked and taught with Dr and Mrs Bobath for many years. Nancy Finnie dedicated her early editions to Berta Bobath and acknowledged her years of invaluable experience to them both. Her practical and parent friendly book, remains a standard volume on paediatric therapists bookshelves.

Mayston writes “Bobath (1990) stated that ‘the emphasis in treatment is now on the active participation of the patient with the therapist…’. The current emphasis on active participation was an integral part of the Bobath Concept even back then.” The Bobaths themselves did not claim that the Bobath approach was the only one ‘on the market’. Mayston (2008) refers to Karel Bobath, who in his speech of response on receipt of the Harding Award in 1975, said that ‘there are other methods and ways of treatment and that these should be explored’ (Bobath 1975). Additionally Mayston quotes Berta Bobath who, in at least two publications (Bobath 1970; Bobath 1978), explained that other techniques described by other workers may also need to be used at certain stages of treatment.

Mayston notes that Mrs Bobath’s other important statement, can be found in the Introduction to the third edition of the book ‘Adult Hemiplegia: Evaluation and Treatment’ (Bobath, 1990): ‘We all learn and change our ways of treatment according to our growing knowledge and experience. . . for better or for worse. Such changes are good and necessary and will continue. But the Concept from which they have evolved should remain intact . . .’ According to Jay Schleichkorn (1992), Mrs Bobath attributed the continuing positive impact of NDT (Bobath) to ‘ I think I learned all the time; I changed it according to what I learned….it wasn’t static’.

Due to the heterogeneous nature of cerebral palsy, Bobath ‘therapy’ involves using personalised combinations of specific analysis with clinical decision making and empathetic advice. So therapy sessions may vary from therapist to therapist, and each session may be different, depending on the needs, priorities, and responses of the client and their carer at that time. This can make comparisons of Bobath ‘therapy’ difficult and confusing as noted by both Novak et al and Mayston in their papers.

The effects of many localised interventions such as botulinum toxin, are not sufficient on their own, but are usually optimised by physiotherapy. The effective outcomes of such localised interventions, are also much easier to measure as they work at only one level of the ICF, than of an analysis tool such as Bobath, which may be applied over several domains of the ICF..  .

As Mayston (2008) also writes ‘it is also important to bear in mind that aspects of the Bobath approach could be useful, and a lack of evidence does not mean that empirical strategies that seem to work should be discarded. Rather, the challenge is to provide the evidence for their efficacy.’

As Bobath tutors and practitioners, we constantly strive to improve our standards of training and treatment, so that Bobath practitioners are a credit to the name of NDT-Bobath. Berta and Karel Bobath have provided a lasting legacy which we would be foolish to discount.

References

  1. Bain K & Chapparo C (2012) The impact of neurodevelopmental treatment on the performance of daily living tasks by children with cerebral palsy. Dev Med Child Neurol54: Concurrent Free Papers (s5): 51.
  2. Bobath B and Bobath K (1958) Principles of treatment. Bobath Manuscript
  3. Bobath B  (1970) Adult Hemiplegia: Evaluation and Treatment. 1st Heinemann
  4. Bobath K and Bobath B (1984) in Scrutton. MacKeith Press
  5. Bobath B Adult Hemiplegia (1990) Evaluation and Treatment. 3rd edition. Oxford: Butterworth Heinemann
  6. Bower E (2009) Finnie’s Handling the Young Child with Cerebral Palsy at Home, Elsevier
  7. Finnie N (1968) Handling the Young Cerebral palsied Child at Home Heinemann
  8. Knox V (2002) Evaluation of the Functional Effects of a Course of Bobath Therapy in Children with CP: a Preliminary Study DMCN 2002 44: 447-460
  9. Mayston M (2004) in Scrutton MacKeith Press
  10. Mayston M (2008) Editorial: Bobath Concept: Bobath@50: mid-life crisis –What of the future? Physiotherapy Research International 13:131-136
  11. Novak I et al (2013) A systematic Review of interventions for children with cerebral palsy: state of the evidence.Dev Med Child Neurol.Oct;55(10):885-910
  12. Schleichkorn J (1992) The Bobaths a Biography of Berta and Karel Bobath Therapy Skill Builders
  13. Schmidt R and Lee T (2005) Motor Control and Learning, a Behavioral Emphasis. Human Kinetics 5th Edn.

 

*Acknowledement: Evi Sideri Senior Bobath tutor and the Spanish Tutors Organisation, who linked and used the references in paragraph 4 for their presentation at the EBTA Congress in Madrid 2010.

 

 

 

 

Base de Evidências para a eficiência clínica do Tratamento Neuroevolutivo Bobath

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Estudo realizado por Virginia Knox, Instrutora Sênior ,PHD, Bobath Centre, Londres
A terapia em crianças com paralisia cerebral tem como objetivo otimizar o seu potencial de habilidades funcionais, prevenir e minimizar deformidades secundárias e fraquezas musculares, além de orientar manejo diário. A terapia Bobath (Tratamento Neuroevolutivo) dá ênfase à observação e análise do atual desempenho de habilidades funcionais do paciente e à identificação de metas claras . Os objetivos do tratamento são trabalhar para a melhoria da participação ativa e a prática de habilidades funcionais relevantes além influenciar o tônus muscular aprimorando o alinhamento postural através de técnicas específicas de manuseio do paciente. (Mayston, 2001b; Mayston 2001a).

Pesquisas gerais sobre terapias para crianças com paralisia cerebral

Houve várias revisões de estudos sobre terapia para crianças com paralisia cerebral recentemente:

NDT/Bobath: (Ottenbacher et a/., 1986; Royeen & DeGangi, 1992; Butler & Darrah, 2001)
Other therapy interventions: Hourcade & Parette 1984; Parette & Hourcade 1984;
Tirosh & Rabino 1989; Campbell 1990; Turnbull 1993
Research methodology: Vermeer & Bax 1990; (Hur, 1995)

Quando as revisões da pesquisa em relação à eficiência da fisioterapia para crianças PC são analisadas, fica difícil determinar se diferentes tipos de fisioterapia são mais efetivos, por causa de:

  • Má qualidade de pesquisa
  • Grupos de estudo pequenos
  • Medidas de má qualidade
  • Dificuldade de coincidência entre grupos
  • Dificuldade de criação de grupos de controle
  • Falta de descrição detalhada de métodos de intervenção
  • Diferenças de frequência e intensidade da terapia
  • Outros problemas técnicos e éticos ( Siebes et al.,2002)

A opinião mais aceita dos terapeutas experientes é que a terapia é um benefício e que o tratamento apropriado aplicado o quanto antes possível vai diminuir os efeitos da paralisia cerebral. Existem evidências dentro da literatura demonstrando a efetividade do Tratamento Neuroevolutivo Bobath:
Revisão de pesquisas sobre Bobath(NDT) Therapy

Ottenbacher (1986) conduziu uma análise completa do uso do NDT (tratamento neuroevolutivo) em crianças incluindo 37 revisões, e descobriu que pacientes recebendo o NDT ou combinações do NDT com outras intervenções tiveram performance 62% melhor que pacientes recebendo outros métodos de tratamento.

Royeen & DeGangi (1992) conduziram revisões em 19 estudos publicados investigando os efeitos do Tratamento Neuroevolutivo e consequentemente encontraram evidências que sugerem um ganho imediato da amplitude de movimento em crianças tratadas com o NDT.

Butler & Darrah (2001) Reanalisaram 21 pesquisas com evidência de nível II. Comentários dos autores dizem que apesar de não haver evidência forte para sugerir que o NDT foi mais eficiente que qualquer outro método, também não há evidência de que ele foi menos efetivo. As evidências para a eficácia do NDT são:

  • 4 estudos: ganho imediato de Amplitude de Movimento (ADM)
  • 8 estudos: evidencia de alguns ganhos na qualidade de respostas motoras nos aspectos da marcha

==A maioria de estudos publicados depois de 1990 favorecem o NDT comparado a antes de 1990

  • Pequenas amostras podem ter reduzido o poder de detectar um efeito (número total de pacientes em 21 estudos = 416)
  • Houve questionamentos sobre a validade e sensibilidade das medidas resultantes que foram utilizadas
  • Heterogeneidade da paralisia cerebral pode ter ofuscado os efeitos do tratamento

Franki et al., (2012) investigou a base de evidências para abordagens formais e terapias adicionais focando na funcionalidade de membros inferiores em crianças PC, com uma revisão sistemática utilizando a Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) como modelo. Isso inclui 37 estudos em NDT, Educação Condutiva (Petõ), Vojta, Integração Sensorial e Terapia orientada para tarefa. 11 Estudos sobre o NDT estavam inclusos (com 181 pacientes).

  • Estrutura e função corporal : evidência de nível IV para a eficácia do DNT em postura (n=1), espasticidade (n=1), amplitude do movimento (n=1) e eficiência mecânica (n=1)
  • Nível de atividade:
  • Evidências de nível I e II para a eficácia do NDT em habilidade motora grossa (n=3)
  • Dois estudos não mostraram nenhum efeito significativo na habilidade motora.
  • Dois estudos focados no contexto do tratamento e sua intensidade mostraram efeitos significativos na habilidade motora em grupos de intervenção, mas não entre diferenças de grupo.
  • Nível de participação: evidência de nível III para autocuidado e assistência de cuidador (n=1) Franki (2011) comentou que revisões de estudos anteriores do NDT usaram estudos mais antigos e que havia pouca justaposição. (Butler & Darrah 2001- one study; Brown and Burns, 2001 — two studies)

Ensaios clínicos do NDT e estudos de caso: evidencia de melhora do paciente:

  • Habilidade motora grossa, habilidades de autocuidado e redução da ajuda do cuidador. (Knox & Lloyd-Evans, 2002; De Gangi, 1994)
  • Aperfeiçoamento da habilidade de andar demonstrado pelo aumento da duração da caminhada, da amplitude de movimento, da força, reduzindo a espasticidade e outros parâmetros de marcha (Desloovere ef a/., 2012)
  • Progresso motor com NDT mais intensivo seguido de blocos intermitentes de terapia (Tsorlakis et at., 2004; Trahan & Malouin, 2002; Mayo, 1991)
  • Caminhada, largura do passo, contato do calcanhar e velocidade da marcha (Adams ef a/., 2000; Embray ef a/., 1990; Laskas et at., 1985)
  • Alcance, abertura e uso da mão (Jonnsdottir et a/., 1997; Kluzik et a/., 1990; Chakarian & Larson, 1993)
  • Melhora no controle postural em crianças prematuras (Girolami & Campbell, 1994)
  • Melhora das habilidades de vida diária (videoed GAS goals) (Bain & Chaparro 2012)
  • NDT intensivo tão efetivo quanto a terapia de movimento induzida por restrição (CIMT) (Acar et at 2012)

Nenhuma diferença entre uso de gessos seriados e NDT(Law et al 1991) Law et al 1997

Menos eficiente: Palmer (1988) investigou 48 crianças de 12 a 19 meses com diplegia espástica leve ou severa. As crianças foram aleatoriamente designadas ao grupo NDT ou ao currículo de jogos de aprendizado (grupo controle). O grupo controle teve avanço mais significativo do que o grupo NDT. Nesse ensaio (Trial) o NDT focava em aprimorar o retificação e reações de equilíbrio. As medidas resultantes utilizadas não testaram retificação e reações de equilíbrio e foram descriminalizados e não avaliados. A credibilidade dos testes não foi demonstrada na pesquisa. Houve evidência de que o grupo NDT estava mais neurologicamente envolvido.

Aspectos chaves do tratamento são:

1. Programas de tratamento são focados em metas, e Terapia Bobath usa a aproximação à família com metas estabelecidas em colaboração com os pais. (Mayston 2001b). Estudos apoiam um serviço centrado na família e sugerem que este seja avaliado por pais e profissionais. O uso de objetivos específicos mostrou aumento na eficácia da terapia.

2. O tratamento no Bobath Centre é geralmente mais intensivo (sessões diárias durante duas semanas) do que a provisão típica local. Algumas comparações de diferentes intensidades de terapia têm mostrado uma correlação com um aumento no avanço em habilidades motoras: semanalmente mais efetivo que mensalmente (Mayo, 1991); diariamente mais efetivo do que duas vezes por semana ou menos (…); e blocos intermitentes intensivos deve ser uma estratégia eficiente para a produção de maiores ganhos a longo prazo (…). Alguns estudos não mostraram nenhuma diferença “
Uma meta análise de estudos de janeiro de 1996 até junho de 2007 de fisioterapia intensiva e não intensiva de crianças PC mostrou que a terapia intensiva tende a ter maiores efeitos do que a não intensiva em relação a habilidades motoras, e o efeito é maior em crianças de até dois anos. (…)

3. Educação entre pais/cuidadores para capacitar os pais para manusear a sua criança e para que saibam lidar com as dificuldades apropriadamente. Facilitar a relação pais-filhos é um objetivo central (Mayston 1992). A educação entre pais e cuidadores maximiza as habilidades funcionais da criança para a participação de rotinas do dia a dia, facilita a relação entre familiares, melhora a qualidade de vida e ainda, evidencias mostram que cuidados centrados na família estão associados com aprimoramento do progresso de desenvolvimento, diminuição no estresse familiar e maior satisfação com os serviços terapêuticos.

Medidas de resultados são usadas para avaliar o progresso antes e depois do tratamento (apesar de que pode ser difícil encontrar medidas com sensibilidade suficiente para crianças participando do bloco de terapia intensiva de duas semanas). Objetivos específicos são colocados em conjunção com os pais e os resultados são incluídos nos relatórios. Atualmente usa-se uma variedade de medidas incluindo o Gross Motor Function Measure GMFM, Pediatric Evaluation of Disability Inventory PEDI, Melbourne Upper Limb Assessment, Assisting Hand Assessment e a medida Canadian Occupational Performance.
@VIRGINIA KNOX

EVIDENCE BASE FOR THE CLINICAL EFFECTIVENESS OF BOBATH (NEURODEVELOPMENTAL) THERAPY

Therapy for children with cerebral palsy aims to optimize their potential and function, prevent and minimize secondary deformity and weakness, and advise on daily management. Bobath (Neurodevelopmental) Therapy emphasizes observation and analysis of the client’s current functional skill performance and the identification of clear therapy goals. The aims of treatment are to work for better active participation and practice of relevant functional skills and to influence muscle tone and improve postural alignment by specific handling techniques (Mayston, 2001b; Mayston, 2001a).

General research into therapy for children with cerebral palsy
There have been several reviews of research into therapy for children with cerebral palsy:
NDT/Bobath: (Ottenbacher et a/., 1986; Royeen & DeGangi, 1992; Butler & Darrah, 2001)
Other therapy interventions: Hourcade & Parette 1984; Parette & Hourcade 1984;
Tirosh & Rabino 1989; Campbell 1990; Turnbull 1993
Research methodology: Vermeer & Bax 1990; (Hur, 1995)

When reviews of research regarding the effectiveness of physiotherapy for children with CP are analyzed, it is difficult to determine whether different types of physiotherapy are effective because of

• Poor quality of research
• Small study groups
• Poor qua1ity measures
• Difficulty with matching between groups
• Difficulties with the creation of control groups
• Lack of detailed description of intervention
• Widely differing frequencies and intensities of therapy
• Other technical and ethical problems (Siebes et at., 2002)

The widely held expert opinion is that therapy is of benefit and appropriate early treatment will lessen the effects of Cerebral Palsy. Some evidence exists within the literature demonstrating the effectiveness of Bobath therapy as follows:

Research reviews regarding Bobath (NDT) Therapy
(Ottenbacher et al., 1986) conducted a meta-analysis on the use of NDT in pediatric populations including 37 reviews, and found that clients receiving NDT or combination of NDT arid other intervention performed better than 62% of subjects receiving other services.

(Royeen & DeGangi, 1992) conducted reviews on 19 published studies investigating the effects of NDT. There was some evidence to suggest an immediate gain in range of movement in children treated with NDT.

(Butter & Darrah, 2001) reviewed 21 studies with level II evidence. Comments from the authors of this study included that although there was no strong evidence to suggest that NDT was more effective than any other approach, neither was there any evidence to suggest that it was less elective. The evidence for the efficacy of NDT was as follows:

• 4 studies: evidence of an immediate gain in range of movement
• 8 studies: evidence of some gains in quality of motor responses & aspects of gait
• A greater percentage of studies published after 1990 favored NDT compared with those prior to 1990
• Small sample sizes may have reduced the power to detect an effect (total subjects in 21 studies = 416)
• There were some questions about the validity & sensitivity of the outcome measures which were used
• Heterogeneity of CP may have obscured treatment effects

(Franki et at., 2012) investigated the evidence base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy with a systematic review using the international classification of functioning, disability and health as a framework. This included 37 studies on NDT, Conductive education, Vojta, Sensory integration, functional training and goal oriented therapy. Eleven studies of NDT were included (subjects =181).

• Body structure & function: Level IV evidence for effectiveness of NDT on posture (n=1), spasticity (n=1), range of motion (n=1) and mechanical efficiency (n=1)
• Activity level:
• Level II & III evidence for effectiveness of NDT on gross motor function (n=3).
• Two studies showed no significant effects on motor function
• Two studies focusing on treatment context & intensity of treatment showed significant effects on motor function in intervention groups, but no between group differences
• Participation level: Level III evidence on self-care and care giver assistance (n=1) Franki et at (2011) commented that previous reviews of studies of NDT used much older studies and that there was little overlap (Butler & Darrah 2001- one study; Brown and Burns, 2001 — two studies)

NDT Clinical trials and single subject design studies
Evidence for improvement

• gross motor function, self-care skills and reduced caregiver assistance
(Knox & Lloyd-Evans, 2002; De Gangi, 1994)

• improved walking demonstrated by improving stride length, range of movement, strength, reducing spasticity and other gait parameters (Desloovere ef a/., 2012)

• motor progress with more intense NDT and following intermittent blocks of therapy (Tsorlakis et at., 2004; Trahan & Malouin, 2002; Mayo, 1991)

• stride, step length, heel contact and velocity of walking (Adams ef a/., 2000; Embray ef a/., 1990; Laskas et at., 1985)

• reaching, hand opening and hand use (Jonnsdottir et a/., 1997; Kluzik et a/., 1990; Chakarian & Larson, 1993)

• improved postural control in premature infants (Girolami & Campbell, 1994)

• Improved daily living skills (videoed GAS goals) (Bain & Chaparro 2012)

• Intensive NDT as effective as Constraint Induced Movement therapy (CIMT) (Acar et at 2012)

No difference between Casting alone V casting and NDT or Intensive NDT & Casting V General OT and casting (Law et at., 1991)

Less effective (Palmer ef a/., 1988) investigated 48 infants 12-19 months with mild to severe spastic diplegia. They were randomly assigned to NDT or learning games curriculum (control group). The control group improved more than NDT group. In this trial, NDT was aimed at improving righting and equilibrium balance reactions. The outcome measures used did not test righting & equilibrium reactions and were discriminative not evaluative. The reliability of tests was not demonstrated. There was some evidence that the NDT group may have been more neurologically involved.

Key features of the approach are as follows:

1. Treatment programmes are goal focussed, and Bobath therapy follows a family centred approach with goals being set in collaboration with parents (Mayston, 2001b) Studies support a family-centred service and suggest it is valued by parents and professionals. Use of specific goals have been shown to enhance effectiveness of therapy, (Knox & Menzies, 2005; King et al., 2004; Bower et al., 1996).

2. Treatment at a Bobath Centre is usually more intensive (daily sessions over 2 weeks) than typical local provision. Some comparisons of different intensities of therapy have been shown to correlate with increased improvement in motor skills: weekly more effective than monthly (Mayo, 1991); daily more effective than twice weekly or less (Tsorlakis et al., 2004; Bower
& McLellan, 1992; Bower et al., 1996); and intermittent intensive blocks may be an effective strategy for producing long term gains (Trahan & Malouin, 2002; Gagliardi et al., 2008). A few studies have shown no difference (Ustad et al, 2009; Christiansen & Lange 2008; Weindling et al, 2007). A meta- analysis of studies from Jan 1996-June 2007 of intensive V non-intensive PT for children with CP showed intensive therapy tended to have a greater effect than non-intensive therapy on motor function and the effect was stronger for children 2 years of age, (Arpino et al, 2010).

3. Parent/carer education to enable the parent to handle and manage their child’s difficulties appropriately and facilitate the parent infant relationship is a central aim (Mayston, 1992). Parent/Carer education maximises the child’s functional abilities for participation in daily life, facilitates family relationships, improves quality of life and evidence suggests family centred care is associated with enhanced developmental progress, decreased parental stress and improved parent satisfaction with services, (Knox & Menzies, 2005; Law et al., 2003) Law et al, 1998. Research has shown the Bobath Centres to be family-centred in their approach (Knox & Menzies, 2005).

Key features of the approach are as follows:

1. Treatment programmes are goal focussed, and Bobath therapy follows a family centred approach with goals being set in collaboration with parents (Mayston, 2001b) Studies support a family-centred service and suggest it is valued by parents and professionals. Use of specific goals have been shown to enhance effectiveness of therapy, (Knox & Menzies, 2005; King et al., 2004; Bower et al., 1996).

2. Treatment at a Bobath Centre is usually more intensive (daily sessions over 2 weeks) than typical local provision. Some comparisons of different intensities of therapy have been shown to correlate with increased improvement in motor skills: weekly more effective than monthly (Mayo, 1991); daily more effective than twice weekly or less (Tsorlakis et al., 2004; Bower

& McLellan, 1992; Bower et al., 1996); and intermittent intensive blocks may be an effective strategy for producing long term gains (Trahan & Malouin, 2002; Gagliardi et al., 2008). A few studies have shown no difference (Ustad et al, 2009; Christiansen & Lange 2008; Weindling et al, 2007). A meta- analysis of studies from Jan 1996-June 2007 of intensive V non-intensive PT for children with CP showed intensive therapy tended to have a greater effect than non-intensive therapy on motor function and the effect was stronger for children 2 years of age, (Arpino et al, 2010).

3. Parent/carer education to enable the parent to handle and manage their child’s difficulties appropriately and facilitate the parent infant relationship is a central aim (Mayston, 1992). Parent/Carer education maximises the child’s functional abilities for participation in daily life, facilitates family relationships, improves quality of life and evidence suggests family centred care is associated with enhanced developmental progress, decreased parental stress and improved parent satisfaction with services, (Knox & Menzies, 2005; Law et al., 2003) Law et al, 1998. Research has shown the Bobath Centres to be family-centred in their approach (Knox & Menzies, 2005).

Outcome Measures are used to evaluate progress before and after therapy (although it can be difficult to find measures with sufficient sensitivity for those children attending a 2 week intensive therapy block). Specific goals are also set in conjunction with the parents and the results included in our reports. Currently we use a range of measures including the Gross Motor Function Measure, Pedriatic Evaluation of Disability Inventory, Melbourne Upper Limb Assessment, Assisting Hand Assessment and Canadian Occupational Performance measure.

Bibliography
Adams M, Changler S & Schuhmann K. (2000) Gait changes In children with cerebral palsy following a neurodevelopmental treatment course Paediatric Physical Therapy 12: 114-20.

Bower E & McLellan DL. (1992) Effect of increased exposure to physiotherapy on skill acquisition of children with cerebral palsy Developmental Medicine and Child Neurology 34: 25-39.

Bower E, McLellan DL, Arney J & Campbell MJ. ‹1gg6) A randomised controlled trial of different intensities of physiotherapy and different goal-setting procedures in 44 children with cerebral palsy Developmental Medicine and Child Neurology 38: 226-37.

Butler C & Darrah J. (2001) Effects of Neurodevelopmental Treatment (NDT).
Developmental Medicine and Child Neurology 43: 778-90.

Chakarian D & Larson M. (1993) Effects of Upper-extremity weight bearing on hand-opening and prehension patterns in children with cerebral palsy
Developmental Medicine and Child Neurology 35: 216-29.

DeGangi G. (1994) Examining the Efficacy of Short-Term NDT Intervention Using a
Case Study Design: Part 1
Physical & Occupational Therapy in Pediatrics 14: 71-87.

Desloovere K, De Cat J, G M, Franki I, Himpens E, Van Waelvelde H, Fagard K & Van den Broeck C. (2012) The effect of different physiotherapy interventions in post-BTX-A treatment of children with cerebral palsy. European Journal of Paediatric Neurology 16(1): 20-8.

Embray D, Yates L & Mott D. (1990) Effects of neuro-developmental treatment and orthoses on knee flexion during gait: a single-subject design. Physical Therapy 70(10): 626-37.

Franki I, Desloovere K, De Cat J, Feys H, Molenaers G, Calders P, Vanderstraeten G, Himpens E & Van den Broeck C. (2012) The evidence base for conceptual approaches and additional therapies targeting lower limb function in children with cerebral palsy: a systematic review using the international classification of functioning, disability and health as a framework. Journal of Rehabilitation Medicine 44: 396-405.

Gagliardi C, Maghini C, Germiniasi C, Stefanoni G, Molteni F, Burt D & Turconi A. (2008) The effect of frequency of cerebral palsy treatment: a matchéd-pair pilot study. Pediatric Neurology 39(5): 335-40.

Girolami G & Campbell S. (1994) Efficacy of a Neuro-Developmental Treatment Program to Improve Motor Control of Preterm Infants. Pediatric Physical Therapy 6(4): 175-84.
Hur J. (1995) Review of Research on Therapeutic Interventions for Children with Cerebral Palsy Acta Neurologica Scandinavica 91: 423-32.

Jonnsdottir J, Fetters L & Kluzik J. (1997) Effects of Physical Therapy on Postural Control in children with Cerebral Palsy Pediatric Physical Therapy 9: 68-75.

King S, Teplicky R, King G & Rosenbaum P. (2004) Family-centred service for children with cerebral palsy and their families: a review of the literature Seminars in Pediatric Neurology 11: 78-86.

Kluzik J, Fetters L & Coryell J. (1990) Quantification of control: A preliminary study of effects of neuro-deveopmental treatment on reaching in children with spastic cerebral palsyn
Physical Therapy 70: 65-78.

Knox V & LlOyd-Evans A. (2002) Evaluation of the functional effects of a block of Bobath therapy in children with cerebral palsy: a preliminary study Developmental Medicine and child Neurology 44: 447-60.

Knox V & Menzies M. (2005) Using the Measure of Processes of Care to assess a
Paediatric Therapy Service British Journal of Occupational Therapy 68(3): 110-6.

Laskas C, Mullen S, Nelson K & Wilson-Broyles M. (1985) Enhancement of two motor functions of the lower extremity in a child with spastic quadriplegia Physical Therapy 65 11-6.

Law M, Cadman D, Rosenbaum P, Walter S, Russell D & DeMatteo C. (1991) Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy. Dev Med Child Neurol 33: 379-87.

Law M, Hanna S, King G, Hurley P, King S, Kertoy M & Rosenbaum P. (2003) Factors affecting family-centred service delivery for children with disabilities. child: Care, Health & Development 29: 357-66.

Mayo N. (1991) Effect of Physical Therapy for Children with Motor Delay and Cerebral Palsy: A Randomised Clinical Trial American Journal of Physical Medicine and Rehabilitation 70: 258-67.

Mayston M. (1992) The Bobath Concept — Evolution and Application. Basel. Mayston M. (2001a) The Bobath concept today Synapse Spring: 32-4.

Mayston M. (2001b) People with cerebral palsy: Effects of and perspectives for therapy
Neural Plasticity 8(1-2): 51-69.

Ottenbacher K, Biocca Z, DeCremer G, Gevelinger M, Jedlovec K & Johnson M.
(1986) Quantitative Analysis of the Effectiveness of Pediatric Therapy
Physical Therapy 66: 1095-101.

Palmer F, Shapiro B, Allen M, Mosher B, Bilker S & Harryman S. (1988) The effects of physical therapy on cerebral palsy:A controlled trial in infants with spastic diplegia. New England Journal of Medicine 318: 803-8.

Royeen C & DeGangi G. (1992) Use of Neurodevelopmental treatment as intervention: annotated listing of studies 1980-1990
Perceptual and Motor skills 75: 175-94.

Siebes R, Wijnroks L & Vemeer A. (2002) Qualitative analysis of therapeutic motor intervention programmes fo children with cerebral palsy: an update. Dev Med Child Neurol 44: 593-603.

Trahan J & Malouin F. (2002) Intermittent Intensive physiotherapy in children with
cerebral palsy: a pilot study.
Developmental Medicine and Child Neurology 44: 233-9.

Tsorlakis N, Evaggelinou C, Grouios G & Tsorbatzoudis C. (2004) Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy Developmental Medicine and Child Neurology 46 740-5.