ndtpdf-230719112920-6401dd92.pptx. .

Neuro developmental therapy

1. Neurodevelopmental Therapy Presenter : A shik D h akal M ode r ator : M r . S ydney R os h an R ebe ll o

2. Content History Introduction Basic principles Assumptions Examination and evaluation Treatment plan

3. H is t o r y NDT was developed by Berta Bobath, German physiotherapist and her husband Karel Bobath who was psychiatrist and neurophysiologist. Developed approach in 1948 , when Berta Bobath using different therapeutic technique showed that abnormal tone can be altered in hemiplegic or stroke patients. She was the first pt who showed, in hemiplegic patients not only abnormal tone can be influenced but also normal movement patterns can be re trained. Bobath rejected the concept of compensatory training.

4. Bobath approach was based on reflex- hierarchal theory. Brain damage = lower center take charge = development of abnormal tone Bobath through neuroplasticity showed, brain has capacity to regain control over the lower center and there by resulting in regulation of tone and production of normal movement patterns It is changing and new treatment method are added in the approach.

5. Introduction NDT is a problem solving approach to the examination and treatment of the impairments and functional limitations of the individuals with neuropathology, primarily children with CP, adults with stroke or traumatic brain injury. These individuals have dysfunction in posture and movement that lead to limitations in functional activity. NDT focuses on the analysis and treatment of sensorimotor impairments and functional limitations that physical, occupational, and speech therapies can address.

6. CP C V A TBI Social pa r ticipation Can be treated Secondary impairments F unctional activity Abnormal posture and movement

7. Development and philosophy Bobaths believed that the individual with CNS lesions is related, directly or indirectly to their posture and movement dysfunction. The goal-directed examination and intervention leads to the best functional outcome that minimizes impairments and prevents secondary disability.

8. It is a living concept, an approach that continues to evolve even today. Bobaths discarded the belief that voluntary movement was built on reflexive movement and that treatment must follow the normal developmental sequence. Currently they accept that neural control is not a simple hierarchial function but is multiple body systems participating in executing movement that is organised by the specific task constrained by physical laws and the environment. There is a recognition that both feed-forward and feed-back sensory mechanism are equally important in different types of movement control.

9. The NDT approach considers the individual as a whole and recognizes that every expression of the person-psychological, emotional, cognitive, perceptual and physical has value and contributes to the overall level of function. Examination and evaluation lead to the establishment of treatment goals and the development of treatment strategies. Therapeutic handling is integral part of NDT approach Feel the patient’s response to change in posture or movement. Facilitate postural control and movement synergies Provide boundaries for movements that distract from the goal Inhibit or constrain those motor patterns that if practice leads to further disability.

10. NDT therapy Therapy in t e r vention Making of problem list and goals therapy Examinatio n and I nformation gathering

11. The evolution of the Bobath approach

12. General assumption in the NDT approach

13. Impaired patterns of postural control and movement co-ordination are the primary problems in patients with CP or stroke These identifiable system impairments are changeable and overall function improves when the problems of motor coordination are treated by directly addressing neuromotor and postural control abnormalities in a task specific context. Sensorimotor impairments affect the whole individual — the person’s function, place in the family and community, independence, and overall quality of life. A working knowledge of typical adaptive motor development and how it changes across the life span provides the framework for assessing functions and planning intervention.

14. NDT clinicians focus on changing movement strategies as a means to achieve the best energy-efficient performance for the individual within the context of age- appropriate tasks and in anticipation of future functional tasks. Movement is linked to sensory processing in two distinct ways. Intervention strategies involve the individuals active initiation and participation, often combined with the therapists manual guidance and direct handling . NDT intervention utilizes movement analysis to identify missing or atypical elements that link functional limitations to system impairments. Ongoing evaluation occurs throughout every treatment session. The aim of NDT intervention is to optimize function.

15. These 10 assumptions are the characteristics that identify and separate NDT from other approaches. These ideas were set forth by the Bobaths and have been modified over the past 50 years to reflect changes in emphasis and terminology. The additional assumptions (11-19) that are part of NDT best practice standards have been incorporated more recently from the motor sciences to complete the current therapeutic model of NDT. NDT accepts that human motor behaviour/ function emerges from ongoing interactions among multiple internal systems of the individual, the characteristics of the task, and the specific environmental context, each contributing different aspects of motor control. Movement is organised around behavioural goals. All individuals have competencies and strengths in various systems.

16. 14.A hallmark of efficient human motor function is the ability of the individual to select and match various global neuronal maps with a potentially infinite number of movement combinations that are attuned to the forces of gravity, forces generated by contracting muscles, and constraints posed by a variety of environmental conditions. NDT uses the model of enablement/disablement based on the ICF 2001 developed by WHO (2001) to categorize the individuals health and disability. Clinicians can best design intervention by establishing functional outcomes in partnership with the client and caregivers Intervention programs are designed to serve clients throughout their lifetime. Learning or relearning motor skills and improving performance requires both practice and experience 19.Treatment is most effective during recovery or phase transitions. 20. NDT clinicians assume the responsibility to provide clients with the available evidence related to all intervention methods, outcomes and service delivery system

17. PRINCIPLES AND PROCESS OF EXAMINATION

18. Problem solving Holistic: sensory - motor issues, also development cognition, perceptual, emotional and functional problems Interdisciplinary Interactive - family members involved Goal directed (function and participation key) Early intervention recommended Advocates use ICF as tool

19. The dynamic relationships among the various parameters that NDT’s clinical problem-solving model considers. Triangle : person with competencies and limitations. Square : events and contexts external but meaningful to the person. Circle : global view that NDT clinicians use when assessing and planning treatment.

20. Dynamics in NDT examination and intervention. The NDT examination process evaluates each client as a unique person with multiple competencies and limitations. NDT examines each client in a life-cycle framework The NDT examination process incorporates an interdisciplinary, therapeutic management team that includes and respects the client and the family as primary and active participants in decision making.

21. The NDT examination begins the problem-solving process that enables the clinician to make sound clinical decisions that combine evidence from clinical research with experience and judgement. NDT examination and intervention incorporate principles from the study of motor control, motor learning, and motor development. The distinguishing feature of the NDT examination is the emphasis on components of posture and movement that are efficient or inefficient in persons with stroke or CP.

22. EXAMINATION PROCESS

23. Data collection First part, during which the clinician defines the scope of the problems and determines the relevant procedures for examination. The information obtained in this initial stage of examination includes the following: Reason for referral Medical history General level of function Family and environmental characteristics

24. Examination It includes : Examination of the client’s functional skills or limitation of skills and their impact on participation in life roles, at the present time and in anticipation of the future. An in-depth look at the control of posture and movement components. Individual systems review, which includes a brief examination of the anatomical and physiological status of those critical systems.

25. Functional Skills Examination of functional skills gathers objective information about functional activities or limitations in functional activities. The clinician observes and identifies: Functional abilities that can be used as a foundation for interventions that relate to the problems and goals identified by the patients and family. The therapist identifies activities that the patient is unable to do and in what contexts. Observation of posture and movement Individual system review related to function

26. Evaluation

27. Evaluation consists of : Statements that accentuate the patient’s competencies in participation in society, functional activities, effective posture and movement, and system integrity Identifying and prioritising functional limitations and participation restrictions Relating the critical components of posture and movement to underlying system integrity/ impairments and hypothesising. Prioritising the structural and functional impairments of the multiple systems as they affect activity limitation Analysing the potential for change

28. P la n of ca re

29. Recommendation for intervention in a care plan follow each discipline’s best standard of practice The team sets functional outcomes and goals. The clinician identifies strategies the patient is currently using to accomplish functions as well as broad strategies that might be more energy efficient or successful in preventing the development of additional impairments The care plan identifies measures to promote health, wellness and fitness and provides means to prevent functional decline, secondary impairments, and need for additional services. The care plan describes the role of family and other medical and educational professionals involved in the care Re-examination is an ongoing part of the plan of care

30. Principles and process of NDT intervention

31. Principles of treatment Establish a treatment plan with anticipated outcomes that include specific, observable functions within a specific time frame under specific environmental conditions Design therapy to utilize the patient’s strengths, recognizing that each individual has competencies and disabilities Set anticipated outcomes and impairment goals in partnership with the family, the client, and the interdisciplinary team NDT treatment constructs a purposeful relationship between sensory input and motor output

32. Therapeutic handling is a primary intervention strategy that NDT therapists use to assist the patient in achieving independent function. Facilitation : Facilitation is the strategy of therapeutic handling that makes a posture or movement easier or more likely to occur Inhibition: Therapists use inhibition to restrict the client’s atypical postures and movements that prevent the development of more selective motor patterns and efficient performance Treatment strategies often include preparation and simulation of critical foundational elements (task components) as well as practice of the whole task.

33. NDT intervention is designed to obtain active responses from the client in goal oriented activities Whenever possible during treatment, movement is initiated and actively performed by the client. NDT intervention includes planning and solving motor problems NDT intervention allows the client to learn from errors that occur during movement. Repetition is an important component in motor learning Create an environment that is conducive to cooperative participation and support of the client’s effort.

34. Knowledge of the development of posture and movement components used in designing treatment strategies A single treatment session progresses from activities in which the patient is most capable to activities that are more challenging. NDT therapy sessions provide motivation and purpose to engage the patient fully in developing and reinforcing movement responses. NDT intervention methods include modifying the task, or the environment, to take into account the current level of the patient’s performance and capacity for function As a patient is able to perform movements independently, the therapist provides time during a treatment session for a patient to move freely. Individual treatment sessions are designed to evaluate the effectiveness of treatment with the session.

35. Recognise and respect the communicative intent of the patient’s motor behaviour. Families receive information regarding the patient’s problems and management of those problems as they are able to understand and assimilate the information. In an NDT approach, suggestion to the family are as practical as possible. NDT recommends an interdisciplinary model of service. Coordinate with the goals and activities of all other medical, therapeutic, social, and educational disciplines to ensure a life-span approach to solving the patient’s problems.

36. Treatment implementation

37. The therapist serves as a guide for teaching normal development patterns to patient with neurological disorders. Sensory Issues: The success of the facilitation techniques is greatly affected by sensory issues. Intrinsic sensory issues Extrinsic sensory issues

38. Intrinsic sensory feedback comes from the patient’s own visual, vestibular, and somatosensory systems. Visual system : The patient’s movements during facilitation can be affected by his visual gaze within the environment, visual attention to toys, and visual interaction with the therapist Vestibular system: It is used for orientation in all planes of movement and is affected by all of the movement that occurs during facilitation and by the varied positions that the client assumes Somatosensory systems: They are affected by tactile, proprioceptive and kinaesthetic input through weight bearing, weight shifting and guided and active movements.

39. Extrinsic sensory feedback comes from things like the placement and movement of the therapist’s hands, the movement of the therapist’s body, the speed of the body, the shape, firmness, and the texture of the equipment, and the visual and the auditory environment. The therapist places hands on specific parts of the patient’s body segments, stabilise body segments, initiate movement of a segment, and/ prevent movement of a segment. The therapist’s hands have a great sensory effect on the patient, they convey information to and receive information from the patient.

40. Guiding Hand and Assisting Hand Hands over joints helps for easier transitions. Hands over the muscles cause tactile stimulation to the muscles which might cause light contraction of the muscles, which is insignificant in a static position but may be very influential during a weight shift. Hands on proximal joints: The therapist’s hands are often placed across proximal joints or on the trunk. Both stability and mobility can be achieved when the patient is facilitated through a sequence of movements.

41. Hands on distal joints: Distal facilitation points are usually used when the patient has some proximal control, and may also be used for patient who dislike proximal handling. The therapist usually provides slow, careful traction to the extremities when distal facilitation points are used. Changing pressure and control of the therapist’s hands. Initially the therapist’s hands may control the patient’s alignment and movement through the entire technique. However the patient must still be participating actively, even when the therapists hands exert marked control of the his movements

42. Speed of movement : It is recomended that the technique be facilitated at avrious speed: slow, moderate, fast. It is important to monitor the patient’s response with regard to the speed at which each technique is performed . Speed must be fast enough to generator or stimulate a response and must be slow enough for the patient to respond and participate without fear.

43. KINESIOLOGICAL CONSIDERATIONS Range of Motion Specific muscle and joint range of motion is necessary for a movement to be performed efficiently. If the patient’s decreased range of motion limits movement, the facilitation techniques can be used to increase the range of motion

44. Alignment The initial step in each facilitation technique, before placing hands on the patient, is to observe the patient’s body and assess the his starting alignment. If the patient is out of alignment, the next step in facilitation is to align the patient as close to neutral as possible.

45. Base of support Alignment is assessed by starting at the patient’s base of support, which influences all superior structures. Prone In prone, the entire body assumes the base of support. If the patient cannot assume a full prone position (for e.g. limited hip extension), prone activities must be performed on a ball or bolster Bench or Bolster Sitting The base of support in sitting includes the feet, femurs, hips and the pelvis.

46. 3. Floor Sitting LONG SITTING : The base of support when long sitting on the floor includes the lower legs, femurs, hips and the pelvis. If the pelvis is not neutrally aligned, the trunk will compensate. RING OR TAILOR SITTING : The base of support when a patient is ring/ tailor sitting on the floor includes the lower legs, femurs, hips and the pelvis. Although ring or tailor sitting is a very stable posture because it blocks weight shifts of the center of mass, ring or tailor sitting must not be used for any of the floor-sitting facilitation techniques.

47. W SITTING In W sitting on the floor, the base of support includes the lower legs, femurs, hips and pelvis W sitting must not be used for any of the floor-sitting facilitation techniques. This lower extremity position blocks normal weight shifting and leads to undesirable hypermobility and dissociation between the ribcage and the pelvis, excessive internal rotation of the hips and undesired hypermobility of the medial soft tissues of the knees (tibial torsion). SIDE SITTING The base of support includes the lateral side of one lower leg and femur, the medial side of the other lower leg and femur, the hips and the pelvis. The hips and the pelvis usually bear weight asymmetrically. Side sitting must not be used for any of the floor-sitting facilitation techniques.

48. Quadruped In quadruped the base of support includes the hands, knees and dorsal surface of the feet. The hands must be aligned so that the fingers point forward. The knees must be adducted in line with the hips, and the feet must be plantarflexed. Kneeling In kneeling, the knees and the dorsal surface of the feet provide the base of support. The knees must be adducted in line with the hips, and the feet must be plantarflexed. Standing The base of support in standing is the feet, the posture of which has a great effect on the superior structures. If the patient’s feet are not aligned to neutral, all of the facilitation done in weight bearing will create compensatory movements at other joints, especially at the knees and the hips

49. Use of Adaptive Equipment with Facilitation Techniques Equipment is useful in assisting patient with the facilitation techniques— to help support the patient’s weight, to help accommodate for structural deformities, and to help move the patient.

50. Bench or Mat Table The bench or mat table is used for sitting and sit to stand facilitation techniques. This is the most stable piece of equipment. It provides a solid base of support and it can enhance the client’s proprioceptive awareness during weight shifting activities.

51. Bolster The bolster is used for prone, sitting and sit to stand facilitation techniques. The bolster must be firm, provides a mobile surface that is easy to control The mobility of the bolster assists the patient with weight shifts and thus aids therapist with management of the patient’s weight. The bolster provides a semistable, narrow base of support for sitting. The mobility of the bolster helps you to shift the patient’s weight backward and helps to elongate and maintain elongation of the patient’s muscles. For prone techniques, the bolster must be large enough to support the client’s upper body and pelvis to flex the client’s shoulders. An inclined bolster is often used to facilitate anterior weight shifts at the pelvis and to facilitate upper extremity reaching.

52. Ball The ball is the most challenging piece of equipment to use with the facilitation techniques because of its potential to move in any direction. The ball is used for prone, sitting and sit to stand facilitation techniques. A large ball provides a large surface from which to work and is thus more stable for both the therapist and the patient. Smaller ball provides less surface area and requires more skill to maintain postural control. It can be used when the facilitation includes a transition from the ball to another position. Patient must not be encouraged to perform independent movements on the ball unless they have sufficient postural control and upper extremity protective extension to protect themselves.

53. Recent advances

54. 1. Dickstein et al. PNF vs. Bobath vs conventional treatment Sample = N=131, recent sroke , E1=36, E2=38, C=57 Age in all groups = 70.5+-76.5 Intervention = E1: PNF, E2: bobath, C: conventional treatment (traditional exercise and functional activities) Treatment period = 6 weeks, 5 days/week, 30-45 minutes Outcome measures = Barthel index, MAS, ROM and muscle balance ,FIM, Results : no significant difference were found between the three groups

55. 2. Langhammer and stanghelle = bobath vs motor relearning program Sample : N= 53, stroke acute, C=24, E=29, age =78, time since onset =3 days Intervention : C=bobath, E1: motor relearning program. Treatment period = 2 weeks, 5 days/week, 6 hrs/sessions, follow up period=at baseline,at 3 and 6 weeks and after 6 moths and 1 year. Outcomes : motor assessment scale, Barthel index, nottingham health profile. The following parameters were also registered: length of stay in the hospital, use of assistive devices for mobility, and the patient's accommodation after discharge from the hospital. Results = no significant difference , MRP clinically better

56. 3. Effectiveness of the Bobath concept in the treatment of stroke: a systematic review , 2019 A systematic literature review was conducted on the Bobath concept Fifteen clinical trials were selected in two consecutive screenings. Results: The Bobath concept is not more effective than other approaches used in post- stroke rehabilitation. There is moderate evidence for the superiority of other therapeutic approaches such as forced use of the affected upper limb and constraint-induced movement therapy for motor control of the upper limb. Conclusions: The Bobath concept is not superior to other approaches for regaining mobility, motor control of the lower limb and gait, balance and activities of daily living of patients after stroke.

57. References Howle J M. Neuro-developmental Treatment Approach: Theoretical foundations and principles of clinical practice, 1st Edition. Osseum Entertainment. Jan 2002 Bly L, Whiteside A. Facilitation Techniques Based on NDT Principles, 1st Edition. Psychological Corp. Mar 1999

58. Thank you