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Advances in Physiotherapy 2002; 4:23–36
Diversity in Neurological Physiotherapy: A
Content Analysis of the Brunnstrom/ Bobath
Controversy
ANT T. LETTINGA
Institute of Human Movement Sciences, University of Groningen, Groningen, The
Netherlands
Abstract language in order to prevent the partici- ordering therapeutic techniques, goals
pants from talking at cross-purposes. and rationales in a specic way. This
Physiotherapy offers a great variety of This paper, however, introduces an al- ‘‘discourse analytical approach throws
movement therapies for patients with ternative approach to clarifying dis- a new light on the nature of diversity
the same medical diagnosis, some of agreements in physiotherapy by articulated in neurological physiother-
which appear to be diametrically op- presenting an analysis of a well-known apy.
posed to each other. Many therapies controversy – the Brunnstrom:Bobath
have branched out into new derivative debate – as an example. Rather than KEY WORDS: Content analysis – con-
forms of treatment without settling the applying a single language believed to troversy – discourse – effectiveness re-
arguments with their predecessors. beneutral to both therapies, the content search – history – movement therapy –
Many experts argue that the initial step of Bobath and Brunnstroms textbooks philosophy of science and medicine –
in dealing with this problem of diversity has been contrasted as if these were stroke rehabilitation – uniform lan-
is to establish a uniform, unequivocal written in two different languages, each guage.
researchers also compare diverging therapies in terms
INTRODUCTION of general oppositions. Particularly in stroke rehab-
Physiotherapists who want to train the loss of move- ilitation, competing movement therapies have been
ment skills of patients following stroke can choose compared as if they were closed packages (5–8).
from a variety of treatment possibilities. There are Nowadays more and more professionals are starting
indeed many alternatives in physiotherapy, not only to question the value of effectiveness research in
for patients with neurological disorders (1,2), but which the relationships between the therapies com-
also for many other diagnostic groups (3,4). The pared are so vaguely dened (9–14). According to
difculty, however, is that differences and similarities these authors, effectiveness research is not just a
between available therapies are seldom mapped out matter of methodological and statistical expertise,
in detail. In movement therapy for patients following but requires a detailed understanding of the content
a stroke, for instance, controversies are articulated in and assumed working mechanisms of the therapies
general opposing standpoints such as muscle educa- scrutinized.
tion vs. neurophysiological facilitation, inhibition vs. It has been argued that physiotherapy should map
stimulation of spasticity, or authority-based vs. evi- out its content and articulate the differences and
dence-based. Hence public debate between propo- similarities between competing therapies in a uni-
nents of diverging therapies often end up highlighting form, unequivocal professional language. Rose (15),
the strengths of their own preferred therapy and for instance, wrote in 1986 that common terms such
attacking the others on their weaknesses. as movement dysfunction, muscle imbalance, weak-
Over the past two decades clinical researchers have ness and spasticity must be claried and opera-
been called in to objectify which therapy produces tionally dened before the content of therapies can
the best effect. More often than not, however, these be exposed and systematically described. Contempo-
© 2002 TAYLOR & FRANCIS ISSN 1403-8196 23
ANT T. LETTINGA Advances in Physiotherapy 4 (2002)
rary experts seek alliance with internationally ac- this tradition, the ‘‘real meaning of a text is recog-
cepted health classications, such as the International nized as an illusory or at least as an innitely renego-
Classication of Impairments, Activities and Handi- tiable concept (21).
caps (ICIDH2) and attempt to adjust these to the In abandoning the notion of writers of texts as
specic requirements of physiotherapy (16,17). central ‘‘meaning makers I adopt the notion of
Heerkens et al. (16), for instance, expected that the decentred subject as elaborated by the French
1
use of such a uniform language ‘‘facilitates develop- philosopher Foucault. In his ‘‘discourse analyses of
ments, for example, in the areas of registration medicine he did not attempt to understand the mean-
(record-keeping), treatment protocols, and research ing of a statement by focusing on ‘‘the treasure of
into the effects of physical therapy interventions (p. intentions that it might contain, revealing and con-
431). cealing, but by the difference that articulates it upon
In this article I will introduce an alternative ap- the other real or possible statements, which are con-
proach for mapping out the contents of movement temporary to it or to which it is opposed in the linear
therapies, one that is more or less at odds with the series of times (20, p. xvvii). A discourse can be
establishment of a uniform professional language. articulated as a system of linguistic and material
Rather than trying to capture the relations between entities mutually informing and performing on each
diverging therapies in a single, so-believed ‘‘neutral other (23). Like Foucault I make no attempt to
language, their competing knowledge claims and re- understand statements (for instance, those of Bobath)
lated practices will be analysed as if these were on the basis of the wealth of intentions they contain,
described in different languages, each ordering thera- but rather on the basis of the difference with other
peutic reality in their own specic way. To demon- possible statements of the same subject matter (for
strate this discourse analytical approach, the example instance those of Brunnstrom). That is, I shall com-
of two seemingly opposite views on the treatment of pare the content of Bobath and Brunnstroms text-
patients with spastic hemiplegia, namely Brunnstrom books as different discourses, each ordering the
(18) and Bobaths view (19), will be used, but rst a movement problems of stroke patients, the therapeu-
brief account of the background of discourse analysis tic techniques, the desired outcomes and accompany-
will be presented. ing rationales in a particular way. Thus, rather than
trying to understand key words in neurological phys-
DISCOURSE ANALYSIS iotherapy from a referents point of view, I attempt
There is a traditional trend in analytical work to explore them by analysing how they are both
whereby the content of texts is interpreted with the similar to, and different from, key words in other
purpose of detecting the ‘‘real message of the statements about the same subject matter. Here I will
writer. According to this tradition I could, in the new show how such a comparative, discourse analytical
millennium, argue with the defenders or critics of approach may clarify disagreements in neurological
Bobath and Brunnstrom therapies about what these physiotherapy without using predetermined opera-
tional denitions of terminology. This means that we
authors exactly meant by their statements about have to begin with uncertainty, and little by little
movement therapy for stroke patients in the 1970s. attempt to understand how terms and techniques,
But I have no desire to join in an argument about words and things, dene one another within particu-
what Bobath and Brunnstrom did or did not really lar discourses, in this case the Brunnstrom and Bo-
say in their textbooks. In addition I do not intend to bath ‘‘discourses.2
spend time assessing the value of their statements.
Instead I will begin my analytical work by placing THE CONTENT OF THE
the questions concerning the ‘‘real meaning and BRUNSTROM/ BOBATH CONTROVERSY
‘‘validity of their statements in parentheses. In do- The content of Bobath and Brunnstroms textbooks
ing so I am following another trend in textual analy- will be compared as different discourses by: (i) trac-
sis set by theorists of science and medicine who ing their adversaries; (ii) focusing on the key terms in
regard texts as having a life of their own (20–25). In which the competing treatment views are formu-
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Advances in Physiotherapy 4 (2002) DIVERSITY IN NEUROLOGICAL PHYSIOTHERAPY
lated; (iii) unravelling the intertwinement of terms what muscle re-education implies; she does no more
and techniques; and (iv) exploring the different ways than indicate that it is applied in the training of
scientic principles nd a place in, and give shape to, patients with lower motor neuron lesions, and we
the content of both therapies. know that hemiplegia is usually the result of lesions
in the upper motor neuron.
Strength is a poor criterion In chapter 2 Brunnstrom returns to this issue by
Like many innovations, new movement therapies do explaining why muscle tests – originally devised by
not appear out of the blue. More often than not they Dr R. W. Lovet to assess progress in post-poliomyeli-
come into being as a reaction to limitations of previ- tis patients – are poor tests for assessing progress in
ous endeavours to counter particular problems. Trac- patients with hemiplegia. The testing criterion of the
ing these adversaries and analysing the arguments well-known muscle test is strength as measured by
advanced for or against them is a way of opening up the patients ability to perform individual joint move-
the content of therapies. In both Brunnstrom and ments with gravity eliminated, against gravity, and
Bobaths textbooks traces of arguments with their against gravity and added resistance. Brunnstrom
predecessors can be found, and it is with some of articulates, however, that: ‘‘In hemiplegia individual
these arguments we begin this discourse analysis. joint movements cannot be performed as long as
spasticity is present; therefore movement patterns,
Brunnstrom. ‘‘This book is the outcome of a special not individual joint movements, must be tested (18,
interest in patients with neuromuscular disorders, p. 35). Clinical experience also indicates that
which dates from World War II. After the war, the strength might vary a great deal according to numer-
large number of stroke patients encountered in reha- ous circumstances, such as the lying, sitting or stand-
bilitation clinics prompted me to turn my attention ing position of the patient with spastic hemiplegia
particularly to the problems of patients with hemi- and the position of limb segments with respect to
plegia who seemed to respond poorly to conven- each other. According to Brunnstrom, strength per
tional techniques. In these two sentences taken from se, therefore, cannot be used as a testing criterion for
the preface to her textbook Movement Therapy in patients with hemiplegia. Instead it should be based
Hemiplegia: a Neurophysiological Approach (18), on the typical recovery stages of these patients, as
Signe Brunnstrom describes her motives for develop- described by the neurologist, Twitchel (28).
ing a new therapy for patients with hemiplegia. But it Let us now return to our questions. Which training
is not the intention here to explore further her mo- is insufcient, according to Brunnstrom, for the treat-
tives and intentions – for example by attempting to ment of patients with hemiplegia? The answer is the
answer the question why this Swedish educated ther-
apist went to America and decided to combine her muscle re-education techniques employed for the
therapeutic work with research activities. Rather we treatment of the movement problems of post-
will explore in more detail the content of her sen- poliomyelitis patients. And why are they insufcient
tences by focusing on such questions as ‘‘which for training patients with hemiplegia? Because they
training techniques are conventional according to focus their attention on individual joint movements,
her? and ‘‘why does she label them as poor and andexperiencetellsusthatindividualjointmovements
conventional? cannot be performed as long as spasticity is present
Chapter 1 of her book contains an answer. There in hemiplegic patients. Furthermore muscle re-educa-
we encounter a conventional type of training that is tion makes use of muscle strength for assessing pro-
conceived of as being ‘‘poor for training patients gress, but the strength of individual muscle groups
with hemiplegia. In Brunnstroms words: ‘‘patients cannot be reliably tested in patients with spastic
with hemiparesis did not respond very well to ‘mus- hemiplegia. Assessment and treatment of patients
cle re-education as employed by physical therapists with spastic hemiplegia should therefore concentrate
in the training of patients with lower motor neuron on movement patterns, which manifest themselves
lesions (18, p. 22). She does not explain, however, during the typical recovery stages of these patients.
25
ANT T. LETTINGA Advances in Physiotherapy 4 (2002)
Bobath. In the post-war years the physiotherapist involved in strengthening muscles reinforces the few
Berta Bobath, supported by her neurologist husband abnormal postural patterns of exor and extensor
Karl Bobath, also developed a movement therapy for spasticity, which leads to a static function at the
patients with lesions of the upper neuron. It has been expense of dynamic control.
said that it was in the same period that they began a So which conventional training is, according to
new life in Britain. But in this case too I will not go Bobath, insufcient for treatment of patients with
into the personal circumstances and historical forces hemiplegia? The answer is the heavy resistance exer-
that made the Bobaths decide to leave the European cises employed to counter reduction of muscle vol-
continent to go overseas and develop a movement ume in the weakened muscles of post-poliomyelitis
therapy for patients with central neurological disor- patients and patients with orthopaedic conditions.
ders. Instead I will concentrate on the content of And why are they regarded as contra-productive in
Bobaths textbook, entitled Adult Hemiplegia: Eval- patients with spastic hemiplegia? Because the effort
uation and Treatment (19,29), looking for state- used only adds to the dominance of the abnormal
ments in which she relates her new therapy to that of patterns of exor and extensor spasticity, and thus
conventional therapy. One conventional therapy, prevents patients from employing more normal
which she labels as ‘‘the concept and assessment of movements. Thus also Bobath states in her textbooks
muscle power (19, p. 18), resembles muscle educa- that therapists should understand hemiplegic pa-
tion therapy as articulated in Brunnstroms book.3 tients movement behaviour in terms of movement
Bobath argues – as does Brunnstrom – that: ‘‘The patterns rather than in terms of muscle strength.
testing of muscle power of individual muscles, such
as done in poliomyelitis and other conditions of Spasticity is not the issue
muscle weakness, is unreliable for hemiplegic pa- Bobath and Brunnstrom thus developed their move-
tients (19, p. 18). Weak muscles of patients with ment therapies as a reaction to limitations of conven-
spastic hemiplegia may be capable of contracting tional muscle strengthening exercises. However, they
strongly when participating in a mass exion or not only had an enemy in common: they were also
extension movement pattern, but at the same time each others adversaries. Although both authors kept
may be incapable of generating strength in move- patterns of movement in mind rather than localized
ments that deviate from these spastic patterns. Ac- muscles when assessing the movement problems of
cording to Bobath: it is the counteraction of spastic patients with spastic hemiplegia, they dealt with the
antagonists rather than the disuse atrophy that patterns in two contradictory ways. In public debates
should be held responsible for the weakness of the this contradiction is often articulated in the trade-off
hemiplegic muscles. ‘‘Atrophy of muscles through ‘‘discouraging vs. ‘‘encouraging spasticity. Here
inactivity can develop very quickly in traumatic and we will try to gain a deeper insight into this contro-
in some orthopaedic conditions, especially after long- versy by focusing on the key terms and exploring
term immobilization in casts and braces. It is rare in how they are both similar to and different from one
cases of spasticity where the peripheral nerve supply another. Thus we will not concentrate rst and fore-
is intact and circulation to muscles not interfered most on the conicting statements themselves but
with (19, p. 19). For these reasons, she considers more on their constituent elements. In doing so we
the weakness of muscles in hemiplegia and the need dissociate ourselves from the idea that in order to
for strengthening exercises as a problem secondary to clarify the dispute key terms must have a clear mean-
that of abnormal co-ordination in postural control ing set in advance.
and movement. The patients primary problem is
‘‘not a lack of muscle power on the affected side, but ‘‘Spasticity. ‘‘Heavy resistance exercise (31), irradia-
the inability to direct the nervous impulses to his tion (32), and the use of associated reactions and
muscles in the many varied ways and in the different mass synergies (33) may be useful means of strength-
combinations of patterns used by a person with an ening weak and unresponsive muscles, but should be
intact central nervous system (19, p. 59). The effort avoided in the case of patients with upper motor
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