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Bobath y Reaprendizaje Motor
Bobath y Reaprendizaje Motor
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What is This?
Received 28th October 1999; returned for revisions 17th December 1999; revised manuscript accepted 2nd February
2000.
Follow-up 1 Follow-up 1
Materials and methods n = 30 n = 27
Total
n = 61
Group 1 Group 2
MRP Bobath
n = 33 n = 28
Figure 2 Patients included in the study and randomized into two groups, stratified according to gender and
hemisphere lesion.
the last test was performed at three months fol- tional therapists and speech therapists according
low-up. Information concerning the physiother- to recommendations for stroke units in Norway.9
apy used was known only by the therapists who After discharge, the patients received physio-
treated the patients and the secretary of the therapy in their homes, at rehabilitation centres
ward, who was in charge of the randomization. in the community or in private outpatient depart-
The two physiotherapy programmes were ments. The aim was that every patient should
standardized as follows; a manual describing the continue the same type of physiotherapy that he
main philosophy behind the two physiotherapy or she had received during the hospital stay.
methods was produced according to background Thus, individual treatment programmes and
literature.7,8 Workshops were organized with instructions were sent from the physiotherapist in
stroke patients not included in the study, and the hospital to the patient’s physiotherapist out-
physiotherapists, in order to coordinate treat- side the hospital. All physiotherapists involved
ment according to the Bobath and MRP manu- were invited to meetings in the hospital where
als. These treatments were discussed among the the purpose of the study, design and methods
physiotherapists and the project leader in order were presented and discussed. There were also
to coordinate and as far as possible identify treat- several informal meetings between the project
ment variables in a ‘Bobath respectively MRP leader and the local physiotherapists as a follow-
manner’ and as described in the manuals true to up of these meetings. Some patients, however,
the background literature. This procedure was did not receive any follow-up physiotherapy.
continued throughout the project period, in order These patients were considered independent in
to keep the methods up to date. The patients daily life activities and had minor physical prob-
included in the study were given physiotherapy lems at discharge. Patients with major physical
five days weekly with a minimum of 40 minutes problems who were totally dependent on per-
duration as long as they were hospitalized.1 sonal care in their daily life activities after sev-
Besides physiotherapy the patients received the eral weeks in hospital were transferred to nursing
same comprehensive, multidisciplinary treatment homes, and because of staff shortages few of
for stroke patients from doctors, nurses, occupa- these patients had further physiotherapy.
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364 B Langhammer and JK Stanghelle
The patients were tested three times: (1) three client. A score of 0 (complete dependence), 5, 10
days after admission to the hospital, (2) two or 15 is assigned to each level, for a total score
weeks thereafter, and (3) three months post of 100 (normal function).
stroke. The tests were conducted by the project NHP is a life quality test which is structured as
leader who had no information about which a questionnaire with yes or no answers and
group the patient belonged to. The tests used divided into two parts. The questionnaire is
were Motor Assessment Scale (MAS) (all designed to measure social and personal conse-
times),10–12 Sødring Motor Evaluation Scale quences of disability. NHP 1 contains 38 yes/no
(SMES), (all times),13–15 Barthel ADL Index16–18 statements on energy, pain, emotional reactions,
(first and third time) and Nottingham Health sleep, social isolation, and physical mobility.
Profile (NHP) (only third time).19–21 All tests are NHP 2 contains seven yes/no statements on prob-
tested for reliability and validity. lems concerning paid employment, housework,
MAS is a test of motor function. MAS regis- family life, sex life, social life, hobbies and holi-
ters eight functional activities: turning in bed, sit- days. The ratings on each component are
ting, standing up, walking, balance in sitting, weighted to give a score from 0 to 100; higher
activities of the upper arm, the wrist and the scores indicate greater problems.
hand. Each item is scaled from 0 to 6. Hence In addition, the length of stay in hospital, the
scores range between 0 and 48 (normal function). use of assistive devices for mobility and the des-
MAS is supposed to test on a disability level tination after discharge were registered.
according to the WHO criteria.6 The results were analysed in a SPSS pro-
SMES is a test of motor function after stroke. gramme with Student’s t-test for evaluation of
The main difference between SMES and MAS is group differences. Group differences between
that SMES only assesses the unassisted perfor- test 1 and test 2 were also tested by comparing
mance of the patient. The scoring reflects a com- test 2 minus test 1 differences. ANOVA for
bination of the quality and the quantity of the repeated measurements, with Bonferroni correc-
movements. At the lower score levels, the ratings tion was used to assess changes in motor and
reflect whether or not the movement can be car- ADL function from test 1 to test 3 between the
ried out (against or not against gravity), whereas groups. Differences between results in groups of
at the higher score levels the degree of motor men and women, length of stay in the hospital,
control (the qualitative aspect) is emphasized. destination after discharge, use of assistive
The instrument has 32 items which distribute on devices and NHP were tested using the
three subscales, measuring leg function (SMES Mann–Whitney nonparametric test.
1), arm function (SMES 2) and functions con- The study was acknowledged by the Regional
cerning trunk, balance and gait (SMES 3). The Committee of Medical Research Ethics of Nor-
arm and leg subscores should be considered as way, and all patients participated voluntarily,
measures of impairment, whereas the trunk/bal- signing a written agreement after being informed
ance/gait subscores are close to disability. orally and in written form about the intentions of
Barthel ADL Index is a test of primary activ- the study.
ities of daily living (P-ADL). The index was
developed to monitor functional independence
before and after treatment, and to indicate the Results
amount of nursing care needed. The index
includes 10 activities of daily life: feeding, trans- There were a few drop-outs during the study
ferring from wheelchair to bed and back, per- mainly due to death or because patients moved
sonal hygiene, getting on and off toilet, bathing, to another community (Figure 1). There were no
walking on level surface/propelling wheelchair, significant differences in MAS, SMES or Barthel
ascending and descending stairs, dressing, con- ADL Index between the two groups in the acute
trolling bowels, controlling bladder. The items stage (Tables 1–3). Both groups improved in
are weighted differently. The scores reflect the MAS and SMES from the first to the third test.
amount of time and assistance required by a However, the MRP group improved more than
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Bobath or Motor Relearning Programme? 365
Test 1 Test 1
versus test versus test
2, p-value 3, p-value
Test 1 Test 2 Test 3 Student´s Student’s
Mean/median Mean/median Mean/median t-test t-test
Group 1/group 2,
p-value 0.44 0.05 0.31
Student´s t-test
Group1/group 2,
Repeated measurementsa p = 0.016
a
Corresponds to group and testing session interaction, i.e time between tests 1 and 2 (2 weeks) and time between
tests 2 and 3 (3 months).
the Bobath group both in MAS and SMES part were used by 36% in the Bobath group versus
2, while SMES parts 1 and 3 showed the same 24% in the MRP group (NS). NHP 1 tested three
improvement in the two groups (Tables 1 and 2). months post stroke showed no significant differ-
This finding was statistically significant both by ences between the two groups (Table 4). There
using Student’s t-test between absolute values was, however, a significant difference between
and with repeated measurements; also when men and women in both groups, indicating bet-
comparing differences between tests. When com- ter subjective life quality in men (Table 4). NHP
paring test 2 minus test 1 differences a tendency 2 showed median value 52 (range 14–69) in group
towards difference was found in MAS (p = 0.06) 1 and median value 58 (range 21–67) in group 2
and SMES part 2 (p = 0.078), but no difference (NS).
was found between test 2 and 3 when using this
method. Both groups showed significant
improvement in Barthel ADL Index from the Discussion
acute stage to three months follow-up (Table 3).
No significant difference was recorded between The number of patients included in this study can
the two groups in total score. There was, how- be considered representative of the acute stroke
ever, a significant difference in favour of the population in the area of Asker and Bærum. It
MRP group in the part scores concerning blad- was a time-consuming process to enrol patients
der and bowel function, and also in independence who fulfilled the inclusion criteria: first-time ever-
in toilet situations at three months (Table 3). The stroke and no complicating other diseases, espe-
same significant differences in Barthel subscores cially since a large group of patients admitted
were also found when comparing test 3 minus test during this time had suffered from a previous
1 differences. stroke. A sample of 61 patients must, in this per-
The length of stay in the hospital was signifi- spective, be considered to be relatively large and
cantly shorter in the MRP group compared with sufficient to draw conclusions, especially since a
the Bobath group (21 versus 34 days, p = 0.008). power calculation made in advance of the study
Fifty-two per cent of the patients in the MRP- indicated a minimum of 55 patients. The average
group were discharged to their homes, versus age of the patients in this study was relatively
46% of the Bobath group (NS). Wheelchairs high, at 78 years. However, this high average age
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366 B Langhammer and JK Stanghelle
was relatively representative of the mean age of tion, the results indicated that women treated
all patients with acute stroke who were admitted with MRP improved more in ADL than women
to the same hospital during 1997 (n = 359), treated with Bobath. Thus, this study indicates
namely 74 years. that physiotherapy treatment according to MRP
The main findings in the present study were is preferable to Bobath in the rehabilitation of
that patients treated with physiotherapy accord- stroke patients. The Bobath group was slightly
ing to MRP had a shorter stay in hospital and more dependent at entry, a finding that could
improved more in motor function than patients explain a poorer outcome in this group. How-
treated according to the Bobath concept. In addi- ever, the statistical analysis showed no statistical
Table 2 SMES score (mean, median, range and standard deviation) at the three tests. Sumscores in SMES parts 1, 2
and 3 are given
Group 1
versus group 0.52 0.43 0.42
2, p-value
Repeated measurementsa p = 0.21
Group 1 versus
group 2, p-values 0.16 0.08 0.27
Student`s t-test
Repeated measurementsa p = 0.018
Group 1
versus group 0.65 0.64 0.79
2, p-values
Student`s t-test
Repeated measurementsa p = 0.51
a
Corresponds to group and testing interaction, i.e. time between tests 1 and 2 (2 weeks) and time between tests 2 and
3 (3 months).
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Bobath or Motor Relearning Programme? 367
Table 3 Barthel ADL Index score (mean and range) in the acute phase (test 1), and at three months follow-up (test 3)
Group 1 versus
group 2, p-value 0.32 0.20
Table 4 NHP 1 mean values (SD) and levels of significances between the groups and according to gender
difference between the groups in motor function improvement in both MAS and SMES, as
tests MAS, SMES or Barthel ADL Index at expected during rehabilitation after stroke.2,22
arrival. The difference between the two groups in favour
Patients in both groups showed significant of the MRP group, however, indicates that dif-
ferent physiotherapy approaches have an impact
on the results of the early rehabilitation of stroke
Clinical messages patients (Tables 2 and 3). The difference in
motor function between the two groups seemed
• This study indicates that physiotherapy to even out between the second and third tests.
with task-oriented strategies, represented The explanation may be that the treatment
by the Motor Relearning Programme regime after the hospital stay were more or less
(MRP), is preferable to physiotherapy with similar in both groups, as most patients were dis-
facilitation/inhibition strategies, such as the charged to their homes and tried to perform ‘nor-
Bobath programme, in the rehabilitation of mal activities’ during this period of time. An
acute stroke patients of a significant age. alternative hypothesis could be that the MRP is
• The study verifies that patients who suffer not more effective, but simply that it is effective
from first-time-ever stroke improve signifi- more rapidly, than the Bobath. Under this
cantly in motor function and activities of hypothesis, the treatment regime would not influ-
daily living during a comprehensive reha- ence the final status of the patient, but may mod-
bilitation programme, including regular ify the time-course of recovery. This would be in
physiotherapy. accordance with the shorter hospitalization dura-
tion found with the MRP.
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368 B Langhammer and JK Stanghelle
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