I read with great interest the stream of dialogue that occurred on the neuromuscular list serve sponsored by the Neurology Section (NeuroPT@yahoo.groups) between September and October 2008 on a treatment technique called Neuro-Integrative Functional Rehabilitation and Habilitation (Neuro-IFRAH). The discussion started with an academic faculty member who teaches neuromuscular physical therapy content in the curriculum and was questioning the value of including this approach in the neuro curriculum. Although the Neuro-IFRAH website claims that this approach was “originated by Waleed Al-Oboudi, MOT, OTR/L,” the Neuro-IFRAH approach clearly has its roots in neurodevelopmental treatment (NDT), a therapeutic approach developed by Berta and Karl Bobath in the 1940s. Two of the many courses offered by Neuro-IFRAH, a for-profit organization, are Advanced Handling and Problem Solving and Facilitating Normal Movement During Functional Activities (http://www.neuro-ifrahproducts.com/productcart/pc/view).
In fairness to those who support the NDT approach, I went to both the North American NDTA Association and the Bobath Centre London websites to get their perspectives on the Bobath approach (both are not-for-profit organizations). The Bobath Centre is more committed to the purer teaching of the original Bobath concepts supporting statements such as “Each child's postural (muscle) tone is changeable, not only in relation to activity and moods, but also in response to being handled” (http://www.bobath-ndt.com/main.html). In contrast, the NDTA states “the Bobaths developed the NDT/Bobath approach to address these problems [sic dysfunction in posture and movement]. The NDT/Bobath approach continues to be enriched with the emergence of new theories, new models, and new information in the movement sciences. In addition, as the characteristics of the population with central nervous system pathophysiology change, the approach continues to evolve (https://www.ndta.org/whatisndt.php).”
These three examples represent to me the dilemma that our profession and educational programs are facing. Whether (1) promoting an approach with no scientific evidence for predominantly personal financial gain, (2) holding on to a therapeutic approach that derives from scientific perspectives of the past, or (3) retaining a commercial label but actively evolving toward an approach that reflects current scientific perspectives, each contributes to confusion and lack of clarity regarding the current scientific basis of neurologic physical therapy practice. One source of confusion is the argument by individuals who claim that “many misconceptions of NDT exist” (quote from discussant on neuromuscular list serve). However, this is understandable when you have some therapists and organizations who support, practice, and teach based on some of the original Bobath principles such as “Bobath proposed that the main reason for reduced functional ability resulted from abnormalities of tone eg, spasticity was thought to be due to abnormally increased tonic reflex activity and, therefore, could be inhibited” (http://www.bobath-ndt.com/main.html). To many of us, this is a major premise of the Bobath, NDT, and Neuro-IFRAH approaches that is not supported by current scientific perspectives.
Sir Charles Sherrington was one of the more influential neurophysiologists throughout the late 1800s and early 1900s who influenced neurologic physical therapy. In 1906, he published The Integrative Action of the Nervous System, which was a compilation of lectures he gave at the Yale University in 1904. These lectures described Sherrington's theories related to movement. He proposed that reflexes were the basic structure that allowed for coordinated action and function of the body. He described the influence of postural reflexes, stretch reflexes, and proprioception on muscle action. It is easy to see how the neurophysiologic approaches such as NDT, proprioceptive neuromuscular facilitation, and the Brunnstrom approach evolved from Sherrington's perspective.
The evolution of neurologic physical therapy has consistently been influenced by advances in neurophysiology and the neurosciences. Advances in the scientific foundations of physical therapy, particularly neurologic and pediatric physical therapy, have been marked in time through a series of summer educational institutes known as the STEP conferences. The 1966 NUSTEP, 1990 IISTEP, and 2005 IIISTEP summer conferences were educational institutes to gather physical therapy educators and clinicians together with basic and clinical scientists to discuss current advances in neurophysiology and neuroscience. Over the course of more than four decades, these conferences have put into perspective the “science of the time” and its present-day impact on physical therapy education and practice.
Keeping with tradition, scientists, physical therapy educators, and clinicians gathered in group discussions to debate the relative merit and clinical applicability of the day's presentations. One of the important outcomes of the IIISTEP conference was a working group summary of the implication of IIISTEP presentations on future directions in neurorehabilitation, basic research, clinical research, and clinical practice. The Top 10 messages from IIISTEP summarizes the major outcomes and areas of further integration needed in the application of conceptual models to guide research, education, and practice, selection of appropriate physical interventions with defined practice parameters and relevant outcome measures to justify care and reimbursement for services, evidence of sufficient validity to impact practice, and finally, several recommendations to facilitate the translation of science and technology to practice.
In summary, my perspective is that we value our past and appreciate that science and practice evolve in any healthcare profession. Concepts such as movement analysis, the importance of postural control, and the use of handling techniques that allow us to intervene for those with the most severe movement dysfunction are elements of what physical therapists do that cannot be attributed to just one neurophysiologic approach. Furthermore, with our current understanding of motor control, motor learning, and neuroplasticity, to embrace just one approach would be a disservice to our patients. If you took the original teachings of the Bobaths, Brunnstrom, or Knott and Voss and applied them without consideration of neuroplasticity, motor skill acquisition, and motor learning, it would not be an exemplar of current evidence-based practice. The time has come to let go of the neurophysiologic approaches as a basis for neurologic physical therapy education and practice. Instead, we should discuss the therapeutic principles that drive the nervous system to respond and adapt. Perhaps the Top 10 messages from IIISTEP is a place to begin as we continue the discussion of what constitutes neurologic physical therapists practice today.