Correspondence: Re: Scrivener et al

Systematic reviews are important summaries of the evidence; however, significant flaws in the methodology of the review by Scrivener et al limit the usefulness of the results. 1 Protocol registration in PROSPERO was undertaken after formal screening of search results against eligibility criteria was completed.This order does not guarantee transparency of the search strategy, as the criteria originally planned for including publications in the review can be changed.The inclusion criteria for Bobath interventions used outdated theoretical frameworks, so the review reports findings from 16 outdated studies of 22, which bear no resemblance to current Bobath clinical practice.Eight studies referenced a Bobath publication from 1990, [27,[29][30][31][42][43][44][45] two studies referenced a Bobath publication from 1978, [25,26] and one study referenced a Bobath publication from 1960. [24] ive studies provided no reference to Bobath.[28,32,35,39,41] Only two studies based their Bobath intervention on a Bobath reference published after 2000.[33,36] Three publications from the same study were included [29][30][31] and two [29,31] were used separately for analysis, despite recommendations that multiple reports of the same study should be collated, and review authors should choose and justify which primary report they use as a source for study results. 2 Eight of 22 studies scored 4 on the PEDro scale, [25][26][27]30,34,[36][37][38] which is considered poor quality.3 Only six of the 22 primary studies met the criteria of concealed allocation of patients to treatment groups and blinded outcome assessment. [33,39,41][42][43][44] Therefore, the meta-analyses of the remaining studies potentially overestimated the treatment effects, and the findings should be considered with caution.4 Causality determinations depend on aspects of study fidelity, including intervention description, therapist adherence and expertise. 5 Ony four studies identified individualisation of interventions, [33,35,37,44] seven did not describe the intervention [24,28,[29][30][31]42,43] and 11 provided no description of the therapists' skill level.[24][25][26]28,32,36,38,39,41,43,45] Only two studies explicitly stated that therapists delivering the Bobath intervention had formal training in the Bobath concept. [33,44] In fourtudies that identified the therapists' skill level, [33,35,37,44] Bobath demonstrated superiority compared with other approaches.No studies reported clinical adherence.The search strategy did not identify a large randomised trial investigating strength training of the lower limb in stroke (n = 109), 6 which demonstrates that strength training is less effective than the comparator for improving gait speed.The Discussion section of this paper acknowledges that the comparator treatment was based on the Bobath concept.The same investigator evaluated strength training for sit to stand (n = 93), 7 showing no between-group difference, with a near identical description of the comparator treatment to the first study.However, when contacted by the systematic review group, the authors did not acknowledge this connection to the Bobath concept.One wonders if Bobath may be explicitly stated when the results are unfavourable and implicitly when the results are more favourable or equivocal.Given the recent systematic review publication by Diaz-Arribas et al, [13] we question the need for a second Bobath systematic review in less than a year, especially because the authors failed to address the above methodological flaws.We trust that the educated reader will interpret the findings of this review with caution.

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