Neurodevelopmental Therapy (NDT)

This is the neurological approach used to treat patient in rehabilitation ward.

1. Neurodevelopmental
Therapy
Presenter : Ashik Dhakal
Moderator : Mr. Sydney Roshan Rebe!o

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

3. History
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
CVA
TBI
Social
participation
Can be treated
Secondary
impairments
Functional
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
intervention
Making of problem
list and goals therapy
Examinatio
n and
Information
gathering

11. The evolution of the Bobath approach

15. General assumption in the NDT approach

16. 1. Impaired patterns of postural control and movement co-ordination are the
primary problems in patients with CP or stroke
2. 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.
3. Sensorimotor impairments affect the whole individual — the person’s function,
place in the family and community, independence, and overall quality of life.
4. 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.

17. 5. 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.
6. Movement is linked to sensory processing in two distinct ways.
7. Intervention strategies involve the individuals active initiation and
participation, often combined with the therapists manual guidance and direct
handling.
8. NDT intervention utilizes movement analysis to identify missing or atypical
elements that link functional limitations to system impairments.
9. Ongoing evaluation occurs throughout every treatment session.
10.The aim of NDT intervention is to optimize function.

18. •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.
11.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.
12.Movement is organised around behavioural goals.
13.All individuals have competencies and strengths in various systems.

19. 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.
15.NDT uses the model of enablement/disablement based on the ICF 2001 developed by WHO (2001) to
categorize the individuals health and disability.
16.Clinicians can best design intervention by establishing functional outcomes in partnership with the
client and caregivers
17.Intervention programs are designed to serve clients throughout their lifetime.
18.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

20. PRINCIPLES AND PROCESS OF
EXAMINATION

21. 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

22. 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.

23. Dynamics in NDT examination and intervention.
1. The NDT examination process evaluates each client as a unique person
with multiple competencies and limitations.
2. NDT examines each client in a life-cycle framework
3. 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.

24. 4. 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.
5. NDT examination and intervention incorporate principles from the study
of motor control, motor learning, and motor development.
6. 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.

25. EXAMINATION PROCESS

26. 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

27. 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.

28. 1. 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.
2. Observation of posture and movement
3. Individual system review related to function

29. Evaluation

30. 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

31. Plan of care

32. 1. Recommendation for intervention in a care plan follow each discipline’s best standard
of practice
2. The team sets functional outcomes and goals.
3. 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
4. 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.
5. The care plan describes the role of family and other medical and educational
professionals involved in the care
6. Re-examination is an ongoing part of the plan of care

33. Principles and process of NDT intervention

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

35. 5. 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
6. Treatment strategies often include preparation and simulation of critical
foundational elements (task components) as well as practice of the whole
task.

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

37. 13. Knowledge of the development of posture and movement components used in
designing treatment strategies
14. A single treatment session progresses from activities in which the patient is most
capable to activities that are more challenging.
15. NDT therapy sessions provide motivation and purpose to engage the patient fully
in developing and reinforcing movement responses.
16. 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
17. As a patient is able to perform movements independently, the therapist provides
time during a treatment session for a patient to move freely.
18. Individual treatment sessions are designed to evaluate the effectiveness of
treatment with the session.

38. 19. Recognise and respect the communicative intent of the patient’s motor
behaviour.
20. Families receive information regarding the patient’s problems and
management of those problems as they are able to understand and assimilate the
information.
21. In an NDT approach, suggestion to the family are as practical as possible.
22. NDT recommends an interdisciplinary model of service.
23. 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.

39. Treatment implementation

40. 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

41. 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.

42. 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.

43. 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.

44. 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

45. 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.

46. 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

47. 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.

48. Base of support
Alignment is assessed by starting at the patient’s base of support, which
influences all superior structures.
1. 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
2. Bench or Bolster Sitting
The base of support in sitting includes the feet, femurs, hips and the
pelvis.

49. 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.

50. 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.

51. 4. 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.
5. 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.
6. 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

52. 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.

53. 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.

54. 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.

55. 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.

56. Recent advances

57. 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

58. 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

59. 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.

66. 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

67. Thank you