Wednesday, 2 January 2008

CE: a lesson from Bobath?

An authoritative statement

I implore you to … push on. We’ve given you what we know. Learn… look at other methods… we hand you the torch.’ (Bobath and Bobath, 1979)

These words stand as epigraph to the recent guest editorial of the prestigious international paediatric journal Developmental Medicine and Child Neurology (Damiano, 2007). The author of this editorial is Diane Damiano, no less prestigious in her field, having this Autumn been elected to be President of the American Academy of Cerebral Palsy and Developmental Medicine. Diane Damiano is a physical therapist and only the second non-physician in the Academy’s sixty-one years to hold this position.

Diane Damiano’s opinion the present state of ‘Bobath’, published as an editorial in this context, is no lightweight matter. It was Rony Schenker who sent me a copy of this article shortly after I returned from Israel. Thank you Rony, I might otherwise not have spotted it.

This tightly argued one-page article should be compulsory reading for everyone involved in the countless inter-professional wrangles between conductivists and therapists. Conductors and therapists directly involved in such fire-fights, parents desperately trying to construct informed choice in the face of self-declared experts and bemused observers, media-people, budget-holders and decision-makers who are as at sea in all this as anyone, won’t find a simple answer here. They may, however, see a balance in the positions of the two sides rather different from how the conventional wisdom of the existing system would like to have it.


Torching Bobath

I would like here to provide a link to this editorial on line but the copyright-holders, Ingenta, are not part of the open-access movement. If you want to read the article in full you will have to borrow a subscriber’s copy (your local paediatric service ought to have a copy) or obtain one through inter-library loan. More immediately you will have to make do with my own brief summary.

The author begins with a heartfelt acknowledgement of the Bobaths’ innovative methods and its long domination of neuro-rehabilitation. In recent years, however, developing understandings (for example, of cortical control) and lack of empirical evidence for the efficacy of this approach have begun to weaken this position.

Diane Demiano proposes that there have been three distinct responses to this change amongst therapists, creating rifts urgently in need of resolution.

First are those who cling fervently on to the traditional approach, continuing to practice ‘in a time warp’.

I refer to this group as the torch carriers, likening them to those who ‘carry a torch’ for someone in a romantic sense, something that is typically not reciprocated or based on present-day reality.

She regards such ‘myopic allegiance’ as emotional rather that rational.

Secondly there are those who retain the name but allowing modifications, incorporating newer methods that fit with modern thinking and assimilating newer theories and practices into their work.

I refer to this group as the ‘torch bearers’ who basically consider the Bobaths as the source of the flame, rather than the scientific knowledge they imparted.

Decisions about what stays and what goes are made by national or local groups, or even by individual therapists, so the method’s identity then becomes blurred.

Many therapists purport that they use an ‘eclectic’ approach and pick and chose techniques from multiple sources, as if there were a therapy method buffet table.

Further, she notes, other people’s innovations then get sucked into an unjustified therapeutic black hole, by being presented as part of the Bobath approach, which ‘may serve the therapists who have invested their careers in this method’ [Bobath], but not anyone else

The third response, espoused by the author among others, she terms that of ‘torch passer’.

We fully recognise that we have benefited from the legacy of the Bobaths but believe instead that they have handed us their torch of knowledge and enquiry and now it is our opportunity and responsibility to contribute to the scientific basis of therapy, before we too pass it on to the next generation.

I hope that I have done justice to her well stated position. As ever, there is no substitute for reading the original. Do try and get one.


Casting light on CE

So what has all this to do with Conductive Education?

Well, as stated at the start of this posting, here is as authoritative figure as you could find from within the ranks of physical therapy (physiotherapy), one of theirs at the top of their tree, with a trenchant and highly critical analysis of what to outsiders may look a monolithic and unmoveable institution. Be reminded: it isn’t. There will be many therapists who do not agree with what she says, fair enough, but her analysis cannot be dismissed without well substantiated argument. The letters pages in the next couple of issues of Developmental Medicine and Child Neurology may prove instructive!

That aside, her analysis reminds us that everything has a history, Bobath, Conductive Education, everything, and what we perceive at any given time, in the opening years of the twenty-first century in this instance, is but one point in a long story. And stories have a beginning, and a middle – and an end.

I think that this is what Rony Schencker had in mind when she posed her awkward question towards the end of my pre-conference workshop in Rishon LeZion, about whether it might be time for people in CE to consider ‘changing the name’. Certainly there are some interesting parallels about what Diane Demiano wrote about ‘Bobath’ in her editorial with what can be said about ‘Pető’. You might like to try ‘torching’ Conductive Education in a similar way, assigning practices, people and institutions, to the same three groups as defined above.

The history of the Bobaths’ methods has of course been rather different from Pető’s approach. Not least this has been because only in the last twenty years or so has Conductive Education begun to be exposed to the harsh stimulus of the international professional-academic complex, to which the former has been subject for much of its existence. As a result, for good or for ill, the Bobaths’ approach has proceeded rather further along the line of modern professional-academic development than has Pető’s. And also for good or for ill, Conductive Education is goimng to have to catch up.

Conductive Education’s international period has seen torch-carriers aplenty and the torch-bearers now begin to appear everywhere too, creating ever greater difficulties in defining the boundaries of what constitutes Conductive Education. My personal historical analysis, expressed often enough in this blog and elsewhere, is that Conductive Education now faces a historical crisis with the emergence of a new globalised period in which it will generate and generalise new formulations of the essences of Conductive Education.

This is not quite the same as what the torch-passers are doing within Bobath therapy (nor need it be, they have their own path to tread) but it is certainly parallel enough to permit a far better modus vivendi between therapy and conduction. And it does raise the question of the ultimate historical fate of Conductive Education which, like all good stories, will have to come to an end some day. Passing on the torch of knowledge to a later generation, to be incorporated into some as yet unknown future aapproach with as yet unknown theories and unknown practices, and therefore ceasing to exist in its presently recognisable form – that, I suspect, will the time that the name will fall away, living on only in the history books.

In the meantime, as I think I replied to Rony in the workshop, my present view is that it is possibly rather early to junk about the only commonly acceptable descriptor that we currently have.


Bobath and Pető

Diane Damiano opened her editorial with a quotation from the Berta and Karel Bobath. Here to close this posting is something that András Pető wrote:

Nehmt das, was Ich begonnen habe, nutzt es und entwickelt es weiter… (Take what I have started, use it and develop it further…)

Not exactly the same, I know, but the two sentiments are very close. Perhaps the founders of both systems left a common message about future development of their respective ideas.


References

Bobath, K., Bobath. B. (1979) Award-acceptance speech at First Curative Foundation Awards Dinner, Milwaukee

Damiano, D. (2007) Pass the torch, please! Developmental Medicine and Child Neurology, vol. 49, p. 723

Pető, A. Letter to Ester Cotton

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