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Ranjana Pandey -> rood's approach (December 3, 2001 11:34:00 AM)

hi ,
i want to know whether the rood's approach for treatment of hemiplegisc gives good results? has anyone compared this approach with the other approaches? any good reading material, articles , researches on rood's approach?



Hirsch -> Re: rood's approach (December 4, 2001 1:10:00 AM)

RE: Roods approach.

In scientific studies, the Rood approach, named after Margaret S. Rood, has not been shown to produce any meaningful long term results for post-stroke patients. The same can be said for the Bobath, PNF or Brunnström approach. None of these approaches has been shown to be more effective than the other in randomized controlled trials. Doing a Bobath approach or doing a PNF approach is equally (in)-effective if you go by studies comparing these techniques to one another. If I were cynical I'd say, "let the patient decide which appraoch he/she want's or pull it out of a hat before therapy begins". Just kidding. You may want to go to Medline and do a search using key words such as Rood, Physical Therapy and Stroke. I came up with 5 papers using this approach:

1: Hummelsheim H, Mauritz KH. Related Articles

[The neurophysiological basis of exercise physical therapy in patients with central hemiparesis].
Fortschr Neurol Psychiatr. 1993 Jun;61(6):208-16. Review. German.
PMID: 8330831 [PubMed - indexed for MEDLINE]

2: Nielsen AJ, Grady S, Sussman C, Henry M, Feichtmann C, Dodge M, Pigeon Y. Related Articles

A brushup on Rood's technique.
Phys Ther. 1986 Apr;66(4):579-80. No abstract available.
PMID: 3960988 [PubMed - indexed for MEDLINE]

3: Goff B. Related Articles

The application of recent advances in neurophysiology to Miss M. Rood's concept of neuromuscular facilitation.
Physiotherapy. 1972 Dec 10;58(12):409-15. No abstract available.
PMID: 4668364 [PubMed - indexed for MEDLINE]

4: [No authors listed] Related Articles

Margaret S. Rood, Sixth Mary McMillan lecturer.
Phys Ther. 1969 Jun;49(6):632-3. No abstract available.
PMID: 4892173 [PubMed - indexed for MEDLINE]

5: Stockmeyer SA. Related Articles

An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction.
Am J Phys Med. 1967 Feb;46(1):900-61. No abstract available.
PMID: 6023297 [PubMed - indexed for MEDLINE]


As you can see, there's not much on Mrs. Roods "neurophysiological" approach, these papers are pretty old and none of them are scientific studies. So as far as we know from what we know, doing nothing may be just as beneficial for patients as doing the Rood approach.

Actually, what I would suggest is that you list your (and the patients) goals for therapy. What do you wish to change/improve on etc.? Lets start there, rather than with an approach not validated in science. Looking forward to hearing from you. Mark Hirsch



Joy Colangelo -> Re: rood's approach (December 4, 2001 7:27:00 AM)

Hello,

I cannot add more than Mark re: studies but I often ponder a story about the Bobaths. It may be urban legend but the story goes that the Bobaths Switzerland clinic was their laboratory for stroke rehab outcomes using their approach. Yet when she had her stroke (albeit she was very aged), the Bobaths commited murder/suicide.

Interesting reading Ram Dass after his severe stroke and Kubler-Ross after her illness. Suddenly, their professional/personal theories (Zen meditation/grief) were debunked -- by themselves. Kubler-Ross was very vocal about how the grief cycle was a farce, yet she was the theorist.

I agree with Mark -- and something Butler says early on in Sensitive Nervous System -- evidence does nothing for us if we can't get it into the clinic -- I hope that is a close match to what he said, I don't have the book in front of me.

------------------
Joy



Hirsch -> Re: rood's approach (December 6, 2001 4:26:00 AM)

Hi Joy,
did you know that the Bobaths were suffering from depression prior to their suicide...Thats what pushed them over the edge.



manoonbun -> Re: rood's approach (December 18, 2001 12:11:00 AM)

[QUOTE]Originally posted by Hirsch:
RE: Roods approach.

In scientific studies, the Rood approach, named after Margaret S. Rood, has not been shown to produce any meaningful long term results for post-stroke patients. The same can be said for the Bobath, PNF or Brunnström approach. None of these approaches has been shown to be more effective than the other in randomized controlled trials. Doing a Bobath approach or doing a PNF approach is equally (in)-effective if you go by studies comparing these techniques to one another. If I were cynical I'd say, "let the patient decide which appraoch he/she want's or pull it out of a hat before therapy begins". Just kidding. You may want to go to Medline and do a search using key words such as Rood, Physical Therapy and Stroke. I came up with 5 papers using this approach:

1: Hummelsheim H, Mauritz KH. Related Articles

[The neurophysiological basis of exercise physical therapy in patients with central hemiparesis].
Fortschr Neurol Psychiatr. 1993 Jun;61(6):208-16. Review. German.
PMID: 8330831 [PubMed - indexed for MEDLINE]

2: Nielsen AJ, Grady S, Sussman C, Henry M, Feichtmann C, Dodge M, Pigeon Y. Related Articles

A brushup on Rood's technique.
Phys Ther. 1986 Apr;66(4):579-80. No abstract available.
PMID: 3960988 [PubMed - indexed for MEDLINE]

3: Goff B. Related Articles

The application of recent advances in neurophysiology to Miss M. Rood's concept of neuromuscular facilitation.
Physiotherapy. 1972 Dec 10;58(12):409-15. No abstract available.
PMID: 4668364 [PubMed - indexed for MEDLINE]

4: [No authors listed] Related Articles

Margaret S. Rood, Sixth Mary McMillan lecturer.
Phys Ther. 1969 Jun;49(6):632-3. No abstract available.
PMID: 4892173 [PubMed - indexed for MEDLINE]

5: Stockmeyer SA. Related Articles

An interpretation of the approach of Rood to the treatment of neuromuscular dysfunction.
Am J Phys Med. 1967 Feb;46(1):900-61. No abstract available.
PMID: 6023297 [PubMed - indexed for MEDLINE]


As you can see, there's not much on Mrs. Roods "neurophysiological" approach, these papers are pretty old and none of them are scientific studies. So as far as we know from what we know, doing nothing may be just as beneficial for patients as doing the Rood approach.

Actually, what I would suggest is that you list your (and the patients) goals for therapy. What do you wish to change/improve on etc.? Lets start there, rather than with an approach not validated in science. Looking forward to hearing from you. Mark Hirsch[/QUOTE]
HI
PNF tecniques and Bobath 's approaches
were working good if the initial assessment you found these criterias
1Slightly voluntary extension of fingers
2 Some movements of the affected shoulder
3 Healthy person before onset
In the other words the initial FMS( Fugl-Meyer Score )of the upper limb should be 29 - 31 to
train upper extremitiy and hand functions.
Someone used right tecniques with wrong patient that why the outcome of rehabilitation showed not effective.
I never apply PNF and Bobath to patients who do not meet the criterias, I mentioned because PNF is the whole patterns of movement not some patterns.



Mark Hirsch -> Re: rood's approach (December 18, 2001 7:21:00 AM)

Hi Back Manoonbun,

I appreciate what you're saying about treating patients using Bobath and PNF techniques. I dont apply Bobath or PNF at all but the "why" is a different story.

I know there are alot of PNF/Bobath enthusiasts/users out there, and for certain dysfunction it may be the best and only alternative -- but for neurological patients there are alternatives to these approaches, and I think PT's and OT's should consider offering their patients these alternatives because experience and science has shown that other treatment techniques are superior to Bobath/PNF.

In your eyes and from your experience, Bobath may work "good" but other techniques such as Forced-use are far superior to the "Bobath concept" or PNF. Not ny opinion...this has been validated through numerous research studies.

You are saying that these techniques would produce better functional results in upper limb rehabilitation for the patient if certain criteria are fullfilled, right? I mentioned in an earlier post that seveeal studies with close to 300 patients total have shown that one approach PNF/Bobath/Conventional PT/Brunström is not superior to the other(Logigian 1983 (42 patients), Dickstein 1986 (131 patients), Lord and Hall 1986 (39 patients), Stern 1979 (62 patients), Quin 1971 (4 patients), Wagenaar 1990 (7 patients).

Have you heard of force´-use training, also called constraint induced movement therapy? If I had patients with the minimum functional criteria you say Bobath and PNF would work best, FU is still a superior treatment for upper limb and hand function than Bobath or PNF.

Food for thought:

Page SJ, Sisto SA, Levine P, Johnston MV, Hughes M.Modified constraint induced therapy: a randomized feasibility and efficacy study. J Rehabil Res Dev 2001 Sep-Oct;38(5):583-90

Outcomes Research Department, Kessler Medical Rehabilitation Research and Education Corporation, West Orange, NJ 07052, USA. spage@kmrrec.org

This case series examined the feasibility and efficacy of a modified constraint induced therapy (CIT) protocol administered on an outpatient basis. The Fugl-Meyer Assessment of Motor Recovery After Stroke (Fugl), Action Research Arm Test (ARA), Wolf Motor Function Test (WMFT), and Motor Activity Log (MAL) were administered to six patients between 2 and 6 months poststroke (CVA) exhibiting stable motor deficits and learned nonuse of the affected limb. Two patients then participated in half-hour physical and occupational therapy sessions three times/week for 10 weeks. During the same period, their unaffected arms and hands were restrained 5 days/week during 5 hours identified as times of frequent use. Two other patients received regular therapy and two control patients received no therapy. The ARA, Fugl, WMFT, and MAL were again administered after 10 weeks. Patients receiving modified CIT exhibited substantial improvements on the Fugl, ARA, and WMFT, as well as increases in amount and quality of use of the limb using the MAL. Patients receiving traditional or no therapy exhibited no improvements. Results suggest that modified CIT may be an efficacious method of improving function and use of the affected arms of patients exhibiting learned nonuse.

Its not a large study, but probably not the last of its kind. Cheers. Mark


[This message has been edited by Mark Hirsch (edited December 18, 2001).]



manoonbun -> Re: rood's approach (December 21, 2001 6:40:00 PM)

Hi Mark
Thank you for your suggestions and CIT or UF for trainning hand hand function in stroke.I read some of CIMT since last year.It 's good to try some tecnique to bring back hand functions of the affected limb in stroke patients
after two to six months post onset.Not every stroke can be apply UF,they also had to meet some criterias.May someone answer me about initial FMS of those strokes two or three weeks after onset?
At this point can we assume that CIT or CIMT or UF ,they applied to the patients to gain hand function after 2 to 6 months after onset?
But PNF and Bobath should applied to the patients who meets criterias in two week to eight week after onset .
In fact the stroke recovery are concerned with many facters and damage of the brain.When rehabilitation started,the prognosis should be considered.
My own classification for stroke recovery are
1poor
2 fair
3good recovery
and PT treatments of motor recovery for these three are not the same.
Thanks you for your opinions anyways.



Mark Hirsch -> Re: rood's approach (December 23, 2001 12:14:00 PM)

Hi Manoonbun,

"At this point can we assume that CIT or CIMT or UF ,they applied to the patients to gain hand function after 2 to 6 months after onset?"

there is at least one study looking at FU with acute stroke patients, so, if they meet the inclusion criteria FU may be a good treatment option with acute and chronic patients.

"But PNF and Bobath should applied to the patients who meets criterias in two week to eight week after onset."

Bobath and PNF are equally ineffective at enhancing functional independence in stroke patients. This is not my opinion, but a statement which came out of research studies comparing Bobath with PNF and conventional physiotherapy in over 300 patients.
Mark



manoonbun -> Re: rood's approach (December 25, 2001 12:09:00 AM)

Hi Mark,
We 're still discussed about PNF and Bobath techniques that you said ,it's not effective in many referrences such as Logigian1983,Dickenstien1986,Lord and Hall1986,Stein1979,Quin1971and Wagenaar1990.
Did they set the criterias for those,whom they applied PNF and Bobath.Also duration after onset of those should be concerned.
I believe if we put the right technique and the proper time to the patients , the technigue of Dorothy Voss.and Bertha Bobath are effective.And the assessment should be FMS for accuracy.
If the patients cannot applied PNF ,usually I will assess their functions by SSS(The Scandinavian Stroke Scale)because more easy.
I 'm also waiting someone 's comments.



Mark Hirsch -> Re: rood's approach (December 27, 2001 2:18:00 AM)

Hi all,

The bobath and PNF approach are the most used techniques in neurological rehabilitation today (assumption?). The "motor-learning" approach to neurological rehabilitation /Carr and Shepherd), which is based on 21st century understanding of how the human brain learns, is slowly beginning to gain more acceptance among physical and occupational therapists. These two approaches are different in their philosophy, different in their understanding of how the central nervous system behaves, how the CNS is organized, how it responds to therapy, and how the CNS learns from experience and becasue of these differences there are certain things I don't do with patients (that a Bobath trained or PNF trained therapist would not think twicew about doing) and then again there are certain things I will allow the patient to do, that a Bobath or PNF trained therapist might say "don't ever do that...it's bad for the patient". I'm not sure what your philosophy of neurological rehabilitation is...I sort of have the feeling we are coming from different philosophical backgrounds.

I'm not saying the techniques of Voss and Bobath are NOT effective. What I am saying, and what the research in over 300 patients seems to suggest is that treatment with PNF and by the "Bobath approach" is equally ineffective, not simply statistically ineffective (although thats a statement which is enough for me to be confident enough to say that, in the long run, both PNF and Bobath are equally ineffective) but also ineffective for the majority of patients if we ask the patients themselves if they thought the therapy was effective or not or if therapy improved their quality of life. I make that statement with a great deal of confidence because I have personally observed the limitations of conventional PT in neurological patients and I have the luxury of reading the scientific literature in neurological rehabilitation, which makes me even more skeptical of the use of conventional physiotherapy in neurological patients.

When you compare functional independence gained in patients treated with PNF or Bobath the outcomes (results) are SIMILAR. They are statistically similar and they are functionally similar, although there are exceptions. When you compare, for example, improvement of gait in patients unable to ambulate more than 10 meters without assistance or in patients unable to walk without a walker, and these patients are treated with a Bobath approach or an approach involving walking on a treadmill with partial body weight support, the results suggest treadmill training is superior to conventional gait therapy. Another example, when you compare Forced-Use treated patients with patients treated with conventional upper extremity rehabilitation methods, patients in the FU training program generally outperform those trained with conventional therapy. So I am extremely sceptical about the usefullness of PNF and Bobath, eventhough this is what is used with the majority of stroke patients.

That does not mean that you wont be able to measure improvement with your patients using PNF or Bobath...of course they improve...I'm not saying Bobath and PNF are totally worthless therapies...but it is much easier to fool yourself into thinking or seeing an improvement if you test one patient at a time and then another patient and then another and then say "oh, look, this one improved...it works!" -- without carefully controlling the extraneous variables.

I will give you that for certain patients (especially hypotonic upper extremity) the Bobath and PNF approaches are still state-of-the-art because science has not provided any alternatives...so in that case I cannot make a case against using these approaches...But, my own view (and the view of other clinicians and scientists) is that there are ALTERNATIVES to treating stroke patients, and for many patients these alternative approaches yield superior results to the conventional physiotherapy approaches such as Rood, PNF or Bobath.

I think its a good point to say that with proper time and greater intensity, Bobath and PNF would be more effective. But it is only an assumption (your opinion) unless we put it to the test of science...We need to test that assumption very carefully before we can be sure it is correct.

I think (my opinion)unless PNF exercises are done functionally, they are a complete waste of time for stroke patients -- for example if the goal of therapy is to improve gait in hemiparetic patients, training in the prone position on a mat will not contribute one iota of motor learning to upright gait. There may be good theroretical reasons for doing this with patients but not one study confirms the use of PNF in this manner.

I think it is good that you have the time to assess your patients before and after treatment. I dont use the FMS, so I can't comment on its use...but we need to look at what patients can actually do once they have left the clinic and not simply focus on improving function while IN the clinic. If there is limited carry-over to the real world then the therapy was fairly ineffective and I think we need to start using alternative approches with potential for long-term results.

I appreciate the fact that in clinical practice we see therapy is working and its effects are measurable; I appreciate the fact that there is no cookbook approach to neurological rehabilitation and that we use a variety of techniques to improve function; I believe one should always question authority.

Mark Hirsch


[This message has been edited by Mark Hirsch (edited December 27, 2001).]



Andrew M. Ball MS MBA PT -> Re: rood's approach (December 27, 2001 2:54:00 AM)

I'm with you Mark. I'd suggest that those tauting PNF, NDT, elitism, etc. go back to the literature and familiarize themselves with uncomfortable reality that with the exception of PWBTT, all PT treatments are equally ineffective.

In my experience, most of the loudest proponents of rank-and-file PT's have NEVER read any of this stuff. The PT's at Lennox-Baker/Duke, for example, have a PWBTT system, but NO IDEA what patients are appropriate for it, and by extention, an apparent incomplete understanding of the neuophysiologic strides in basic science that we've made over the past 10 years . . . not to mention applicablity to therapy. Those therapists, however, represent the cream of the rank-and-file crop.

Just because something appears to work, and is belived by all, doesn't mean that it's reality. We once thought that the moon was made of green cheese, that the world was flat, and that heavier objects fall faster than light ones. Cult-like approaches to therapy, any therapy, be it CST OR NDT, are a great way to be sliced and hacked by Ockham's Razor.

Drew



Mark Hirsch -> Re: rood's approach (December 28, 2001 3:16:00 AM)

What is Occam's Razor?
Occam's (or Ockham's) razor is a principle attributed to the 14th century logician and Franciscan friar; William of Occam. Ockham was the village in the English county of Surrey where he was born.

The principle states that "Entities should not be multiplied unnecessarily." Sometimes it is quoted in one of its original Latin forms to give it an air of authenticity.

"Pluralitas non est ponenda sine neccesitate"
"Frustra fit per plura quod potest fieri per pauciora"
"Entia non sunt multiplicanda praeter necessitatem"

In fact, only the first two of these forms appear in his surviving works and the third was written by a later scholar. William used the principle to justify many conclusions including the statement that "God's existence can not be deduced by reason alone." That one didn't make him very popular with the Pope.

Many scientists have adopted or reinvented Occam's Razor as in Leibniz' "identity of observables" and Isaac Newton stated the rule: "We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances."

The most useful statement of the principle for scientists is,

"when you have two competing theories which make exactly the same predictions, the one that is simpler is the better."

In physics we use the razor to cut away metaphysical concepts. The canonical example is Einstein's theory of special relativity compared with Lorentz's theory that ruler's contract and clocks slow down when in motion through the Ether. Einstein's equations for transforming space-time are the same as Lorentz's equations for transforming rulers and clocks, but Einstein and Poincaré recognised that the Ether could not be detected according to the equations of Lorentz and Maxwell. By Occam's razor it had to be eliminated.

The principle has also been used to justify uncertainty in quantum mechanics. Heisenberg deduced his uncertainty principle from the quantum nature of light and the effect of measurement.

Stephen Hawking explains in A Brief History of Time:
"We could still imagine that there is a set of laws that determines events completely for some supernatural being, who could observe the present state of the universe without disturbing it. However, such models of the universe are not of much interest to us mortals. It seems better to employ the principle known as Occam's razor and cut out all the features of the theory which cannot be observed."

But uncertainty and the non-existence of the ether can not be deduced from Occam's Razor alone. It can separate two theories which make the same predictions but does not rule out other theories which might make a different prediction. Empirical evidence is also required and Occam himself argued for empiricism, not against it.

Ernst Mach advocated a version of Occam's razor which he called the Principle of Economy, stating that "Scientists must use the simplest means of arriving at their results and exclude everything not perceived by the senses." Taken to its logical conclusion this philosophy becomes positivism; the belief that there is no difference between something that exists but is not observable and something that doesn't exist at all. Mach influenced Einstein when he argued that space and time are not absolute but he also applied positivism to molecules. Mach and his followers claimed that molecules were metaphysical because they were too small to detect directly. This was despite the success the molecular theory had in explaining chemical reactions and thermodynamics. It is ironic that while applying the principle of economy to throw out the concept of the ether and an absolute rest frame, Einstein published almost simultaneously a paper on Brownian motion which confirmed the reality of molecules and thus dealt a blow against the use of positivism. The moral of this story is that Occam's razor should not be wielded blindly. As Einstein put it in his Autobiographical notes
"This is an interesting example of the fact that even scholars of audacious spirit and fine instinct can be obstructed in the interpretation of facts by philosophical prejudices."

Occam's razor is often cited in stronger forms than Occam intended, as in the following statements...

"If you have two theories which both explain the observed facts then you should use the simplest until more evidence comes along"

"The simplest explanation for some phenomenon is more likely to be accurate than more complicated explanations."

"If you have two equally likely solutions to a problem, pick the simplest."

"The explanation requiring the fewest assumptions is most likely to be correct."

... or in the only form which takes its own advice...
"Keep things simple!"

Notice how the principle has strengthened in these forms which should be more correctly called the law of parsimony, or the rule of simplicity. To begin with we used Occam's razor to separate theories which would predict the same result for all experiments. Now we are trying to choose between theories which make different predictions. This is not what Occam intended. Should we not test those predictions instead? Obviously we should eventually, but suppose we are at an early stage and are not yet ready to do the experiments. We are just looking for guidance in developing a theory.

This principle goes back at least as far as Aristotle who wrote "Nature operates in the shortest way possible." Aristotle went too far in believing that experiment and observation were unnecessary. The principle of simplicity works as a heuristic rule-of-thumb but some people quote it as if it is an axiom of physics. It is not. It can work well in philosophy or particle physics, but less often so in cosmology or psychology, where things usually turn out to be more complicated than you ever expected. Perhaps a quote from Shakespeare would be more appropriate than Occam's razor: "There are more things in heaven and earth, Horatio, Than are dreamt of in your philosophy.".

Simplicity is subjective and the universe does not always have the same ideas about simplicity as we do. Successful theorists often speak of symmetry and beauty as well as simplicity. in 1939 Paul Dirac wrote,


"The research worker, in his effort to express the fundamental laws of Nature in mathematical form should strive mainly for mathematical beauty. It often happens that the requirements of simplicity and beauty are the same, but where they clash the latter must take precedence"

The law of parsimony is no substitute for insight, logic and the scientific method. It should never be relied upon to make or defend a conclusion. As arbiters of correctness only logical consistency and empirical evidence are absolute. Dirac was very successful with his method. He constructed the relativistic field equation for the electron and used it to predict the positron. But he was not suggesting that physics should be based on mathematical beauty alone. He fully appreciated the need for experimental verification.

The final word falls to Einstein, himself a master of the quotable one liner. He warned,

"Everything should be made as simple as possible, but not simpler."

References:

W. M. Thorburn, "Occam's razor," Mind, 24, pp. 287-288, 1915.

W. M. Thorburn, "The Myth of Occam's razor," Mind, 27, pp. 345-353, 1918.

Stephen Hawking, A Brief History of Time.

Albert Einstein, Autobiographical notes

Isaac Newton, Principia: The system of the world


[This message has been edited by Mark Hirsch (edited December 28, 2001).]



Bobcat -> Re: rood's approach (December 28, 2001 8:54:00 PM)

One primary source is: [URL=http://www.public.iastate.edu/~physics/sci.physics/faq/occam.html.]http://www.public.iastate.edu/~physics/sci.physics/faq/occam.html.[/URL]

So, have you read much of Ernst Mach's work?



Mark Hirsch -> Re: rood's approach (January 2, 2002 12:08:00 AM)

No bobcat, I have not.



manoonbun -> Re: rood's approach (January 4, 2002 8:50:00 PM)

Hi and happy new year to all:

Thanks for all opinions because this forum opened for sharing physical therapists experiences.
Everybody accepted that stroke can be spontanious full recovery without treatments(very mild stroke).But in mild stroke,some patients cannot reached their full recovery because they developed spasticity in the affected limbs.If we apply PNF and Bobath in this group of patients,can we bring them to full recovery?.In the future,we may find some researchs in this field about this technique v.s. conventional approaches.
This for the stroke whose has good prognosis.
In "fair" prognosis,this group can walk with or without walking aids,wear or not wear AFO
but no return of hand functions of the affected side.Many forms of assessmets can be use for the initial assessment( NIHSS ,ESS and SSS ).We can apply "overflowed reaction"
for bigggg muscles around hip joint of the paretic leg( for initial hip abduction,flexion and extension ),then followed by PT conventional programs( active ,resisted exs. )
You can feel ,even the assessments for evaluate these two groups of stroke are difference ,the good one is FMS and the fair is
SSS or NIHSS or ESS.
We have difference in cultures,geography even climate but we have the same goal,give the best to our patients that why we shared our experience in this website.



Andrew M. Ball MS MBA PT -> Re: rood's approach (January 5, 2002 2:08:00 AM)

That's not quite what I'm saying. In the most involved of cases, where PT was unable to produce any functional improvements using traditional means, PWB-TT was effective in 6 weeks. Furthermore, fulxuations in ankle tone vaired wideley in each patient from week to week. The moral of the story --- tone is important ONLY in the hearts and minds of traditional therapists who don't know any better. The Hesse 1995 study shows quite clearly that tone has NOTHING to do with functional ambulatory improvments.

Ease of dressing, however, is a different story entirely.

Drew



Mark Hirsch -> Re: rood's approach (January 7, 2002 9:24:00 AM)

I wasnt only giving my opinion which, by definition, is a statement which cannot be verified scientifically. I am not communicating very effectively, I think. And I appologise for that.

It is not reasonable to use PNF or Bobath with most (many) stroke patients because there are much better alternatives. It's too bad -- for the patients -- that these approaches are not utilized to a greater extent in neurological rehabilitation today.

There is no scientific evidence that "stroke can be spontanious full recovery without treatments(very mild stroke)." I just don't buy the argument, that if you do nothing, mild stroke patients will spontaneously, magically recover. To be honest with you, I'm still pretty skeptical about the potential of neurological rehabilitation as a whole because there is still no published evidence that if we do nothing the patient is better off than if we deliver specific neurological rehabilitation intervention techniques. Of course PT it is extremely helpful and very important to the individual, but, speaking academically, I am still skeptical because there have been no randomized controlled trials showing no treatment to be any different from treatment. Of course we'll never see this study because its "ethically inappropriate" to withold treatment.

Id be very interested to discuss with you how, in your view, climate, culture and geography can have an effect on recovery....Theres some interesting unpublished work suggesting that chinese people process visual information differently from westerners...but im not aware of any cultural differences between Indian and Westerners that would affect recovery following CNS pathology.

I just get a little irritated when I hear the Bobath gospel being preached here. This is the 21st Century.

Mark Hirsch



manoonbun -> Re: rood's approach (January 11, 2002 8:24:00 PM)

Hi Mark

You're misunderstanding.Culture,geography and climate had no effect on the recovery of the stroke,or you have any referrence to claim this,just let me know.I never said most of the stroke should apply PNF and Bobath.Only those patients, whom met some criterias,I mentioned ,we should apply this technique.In my opinion,someone read much,truely he knows much,but it doesn't mean he learn much.Do you think so ?

manoon bunchorntavakul



Bobcat -> Re: rood's approach (January 12, 2002 6:47:00 AM)

That was quite profound M.B. Thank you.

While I agree with M.H. that there is really not much out there in terms of research validation of many therapy methods, this is more an indication that therapists don't do much research, or at least, don't do much really good research, because they don't have the skill and knowledge, rather than an indication that therapy methods may not be effective.

I also think, M.H., that you are living in a little bubble world. You can use logic to disprove the wacky theoretical approaches which Barrett Dorko and that whole anNOi group dream up, because those approaches are so amorphous and close to being ether you could whiff it and pass out in to la-la land, but for the physically sensible and visible methods used in many of these macroscopic methods attributed to Bobath or Rood, or whomever, there is evident mechanical change occuring, linked with some sort of as yet incompletely defined motor pattern output, changes which do not require use of an aura or a mystical practiced hand to detect.

I also think you don't have much clinical experience as it relates to use of these methods or perhaps may not have spent enough time developing a sense of what to look for during neuro rehab, otherwise, you would not be going to all these quotes from the bubble world of Medline. And these things to look for do not require psychic abilities. I can pretty much state them explicitly here.

The fact that the article doesn't exist on Medline doesn't signify the absence of an effect, or influence or phenomenon affecting a client during a particular treatment. And once again, the fact that research done by PTs to prove one thing or another, or research done by Neurologists to prove one thing or another, or to disprove whatever, do not require the nonexistence or existence of an effect.

I say this because most PTs, physiatrists, and neurologists doing rehab-related research as it pertains to motor control are doing CRAP work. I say "CRAP" because there has been, until recently, very limited awareness of the mechanical world as it influences motor control for accounting of the methods and results of this sort of research. This despite the fact the mechanical world has always been there, something of an invisible substrate, or at least, this substrate which such researchers wanted to deny from entering the research study because trying to accomodate for its effects was to dammed hard. (Math, you see.)

If you want to see good research, go to the ISB sites and scroll through their archives. The hard biomechanics journals (by hard, meaning, not the mushy biomechanics which avoid mathematical and instrumentation methods) are actually outputing small pieces of relatively absolute data. With some of these studies, you don't need to formulate a conclusion based on an assumption of effect. The effect is detectable, measurable and repeatable. So you can actually use it, like a wrench.

If you look at nearly all the PT related research, mechanics is lacking. Take the post you made above. In it your replicated P. Gibbs' interpretation of Occams' Razor and gave references citing Isaac Newton's "Principia" and Ernst Mach's "Science of Mechanics". These are both towering monoliths in the formation of modern science. And yet you don't seem to have read at least Mach's work.

I don't think you should be so absolute as it relates to commmenting on methods that use mechanical techniques until you have an understanding of the underlying mechanics, because you would be making assumptions of effect. And that would be as naughty as applying NDT without a clear understanding of what its effects are.

As a sidenote, I am by no means a proponent of NDT but I see some useful and valid pieces of handling and motor training in that approach. I would appreciate it if someone who is NDT trained would comment in some depth and specificity about how this method has been used in a very specific way to treat a client. I am personally sick of getting globally based vague response from NDT therapists when I ask for specific treatment methods. I also completely disagree that you must go through the whole training thing to make it work. The NdT method does not have a monopoly on the processes of the physical/physiological world.



Mark Hirsch -> Re: rood's approach (January 14, 2002 6:10:00 AM)

Mannon, sorry I *was* confused, I dont mean to be disrespectful. You dont have to insult me though, unles you are insulted that I challenge dogma and now ure trying to get even. Anyway, I think it was a misunderstanding. For the record, I think Rood is a waste of time for the patient. I tried to make that point in earlier posts. I failed to persuade you. Bobath and PNF are equally ineffective with most patients. I tried to make that point in earlier posts. I've failed, oh well. I can live with that. Perhaps I can succeed in helping you stay critical.

Hi Bobcat,

Hmmmmm....your post dissapointed me and at first I did not want to respond, but then I got creative...so here goes...I have no idea what exactly it is you are trying to say to me but I'm going to treat the majority of your post as a momentary lapse into insanity...would you talk to me that way if we were face-to-face? I don't think so, because if you would -- the conversation would be over in 2 seconds. I don't have time to listen to a finger waving, aura believing apostle, but I will debate the issues with anyone, even Guru Bobcat...There now that I have that of my chest I can get to commenting on the meat and potatoes of your post.

I'm somewhat suprised about how quick you are to make assumptions about my clinical experience or background, and then discredit it based on my previous posts, without first asking me what my clinical background is and then making a judgement... In my eyes your statement doesn't discredit me. I won't rush to judge you, either. I take issue with your statement that I live in a "little bubble world?" Not very nice. I think I think very multi and interdisciplinarily. I have plenty of clinical experience, though I only have a fraction of the posts to this BB that you do. Fact is, you don't know who I am, Bobcat, so please back off with the personal statements, finger waving, personal statements regarding my expertise or experience and judging without having more evidence.

"I say this because most PTs, physiatrists, and neurologists doing rehab-related research as it pertains to motor control are doing CRAP work."

Opinion, Bobcat, opinion. We live in a Democracy. I don't know what you mean by "CRAP". Pick a more professional 4 lettered word.

Regarding efficacy studies...there are a host of studies out there showing one technique to outperform the other (I'm talking about co0nventional PT versus Bobath, versus PNF versus biofeedback)....I undertand that you prefer to ignore this "fact" of life or that there are published studies on this.

"many of these macroscopic methods attributed to Bobath or Rood, or whomever, there is evident mechanical change occuring, linked with some sort of as yet incompletely defined motor pattern output, changes which do not require use of an aura or a mystical practiced hand to detect."

Incompletely defined? I'm not talking about whomever...I'm referring specifically to BB and NDT and Rood. Current definitions of why bobath or rood or ndt work are difficult to swallow based on our current understanding of the CNS...that is, if we are being critical and if we care about neurophysiological effects in neurological rehabilitation. Some therapists use technique "A" and see that it "works" and that all the evidence they need to see. Not me. Without a technique firmly rooted in theoretical framework use of the technique is tantamount to placebo. Thats my OPINION there, in case you missed that. Aura? You believe in auras? Really? Wow, no wonder I dont make sense to you. You're going to hate me for saying this maybe but, studies would suggest the belief in auras to be erroneous....

...read the studies on efficacy (there are plenty of tier one puiblications other than the journal of biomechanics and the JOB isnt that impressive either), look at the data and then judge for yourself, by the way, there is also mechanical change occuring in a placebo treatment, Bobcat, and the placebo is probably just as strong and long lasting as Bobath and PNF. I never said these approaches were totally inappropriate for all patients...just the majority of more functional stroke patients. I'm not sure what a patient learns with bobath or ndt or rood, both from clinical experience and reading the literature, a point I should have emphasized mkore in my previous posts.

Judging by the literature, which you discredit as "CRAP" not much is learned when using this approach.

Well, -- and I dont know what set you off Bobcat...not me...not me...you did it to yourself -- you've missed my point Bobcat, Research and prove shouldnt be used in the same sentence (allow me to wave my index finger at you)...research doesnt try to prove anything, never has proven anything and never will.

"If you look at nearly all the PT related research, mechanics is lacking. Take the post you made above. In it your replicated P. Gibbs' interpretation of Occams' Razor and gave references citing Isaac Newton's "Principia" and Ernst Mach's "Science of Mechanics". These are both towering monoliths in the formation of modern science. And yet you don't seem to have read at least Mach's work."

At least? You've read most of the PT related research? And you still have time to treat patients clinically? I have not read Machs work...so what? Whats the point to your statement? You're judging. So I posted an interesting thread from the internet. A thread I thought was relevant to this discussion! Is there a law against posting from the web to this Bulletin Board? Is it unethical, in your opinion? If so, then I apologize for not having submitted an original idea (not that your ideas are any more original than mine, Bobcat). Why not post a link showing where I can link to Machs work instead of trying to put me down, no, on second thought finger pointing is more fun. I tried to list citations when I posted on this thread...hoping the others would actually READ some of them and then make up their own mind about the evidence...I wonder - did you miss that point?

"I don't think you should be so absolute as it relates to commmenting on methods that use mechanical techniques until you have an understanding of the underlying mechanics, because you would be making assumptions of effect."

...I can be as absolute as I want to be, both here and now, and in the real world. I'm not going to waver in my absolutenes, as long as I can be true to myself that is all that counts to me. I think I have a good "understanding" of the mechanical effects...look who is behaving absolute! You're absoultely absolute.

"NDT without a clear understanding of what its effects are."

I still make the point that the "effect" of NDT is negligble. I've given my opinion based on clinical experience and reading the literature. You missed that point I think? But that does not mean I think we shouldnt be using it at all..of course not!! eventhough it's somewhat crazy to keep "doing" something without hard evidence. Since, right now theres nothing much better for peds we should keep using it until it gets discredited...

Oh and one final note Bobcat...I dont know what Barrett Dorko or the NOI group has to do with any of this? I see you are discrediting the entire NOI Bulletin Board. Well, one thing we have in common is that we are quick to discredit authority. If you have beef with either of these two whats it got to do with me? Frankly, I'm having trouble undertanding the connection...

Don't ask me to buy into your "bubble".

Mark Hirsch


[This message has been edited by Mark Hirsch (edited January 14, 2002).]



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