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Neurodevelopmental Treatment (NDT)

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Jennifer Fortuna

on 9 March 2015

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Transcript of Neurodevelopmental Treatment (NDT)

Neurodevelopmental Treatment (NDT)
What is NDT?
Neurodevelopmental Treatment (NDT) is a client-centered, hands-on, problem solving approach used to manage and treat individuals with central nervous system pathophysiology (NDTA, 2012).

The clients strengths/impairments are addressed in relation to functional abilities and limitations.

Treatment involves direct handling to guide normal movement patterns.

Intervention is guided by the client's reactions throughout every treatment session.

NDT can be used as a preparatory activity or as part of a functional intervention.


NDT was developed over by Berta and Karel Bobath. This approach has evolved over three paradigm shifts in the history of occupational therapy.

& Techniques
Using NDT principles and techniques,
the client’s physical response is changed through:

Upper extremity weightbearing
Therapeutic handling and mobilization
Breaking irregular movement patterns
Compensatory repatterning of primitive reflexes
Graded movement patterns (closed to open chain)
Heavy proprioceptive input to joints

Neural plasticity refers to physical changes in
the brain through both neurogenesis (the development of new neurons) and “the ability
of neurons to change their structure and relationships to one another in an experience-dependent manner according to environmental demands” (Cozolino & Sprokay, 2006, p.12).

NDT & the OTPF
NDT and the field of occupational therapy:

Rooted in holistic principles that incorporate
the subjective (psychological), and objective
(observable) aspects of performance.

Treatment is organized around occupation-based goals and practiced during functional activities.

Teddie Buchner & Jennifer Fortuna
Berta & Karel Bobath
1900-1940’s: Paradigm of Occupation
Holistic view of rehabilitation focused on occupation

1940’s: Berta’s philosophy on rehabilitation fits in well
“Give life, not exercise”

Mid-1940’s: Berta’s philosophy becomes ‘The Bobath Concept’
Maximize function, minimize impairment, prevent disability, and
enhance overall quality of life (NDTA, 2011).

1950’s: Mechanistic Paradigm
Promotes the medical model and “Fixing” the body with exercise.
Pressure to specialize
The Bobath's open a private practice.

1960’s: ‘Bobath Concept' renamed ‘Neurodevelopmental Treatment'
Change reflects recent developments in neurology.
Basic philosophy stays the same.

1980’s: New Emerging Paradigm
Renewed focused on occupations with a client-centered approach.
The Bobath’s holistic principles have never changed.

The NDT approach provides a way of observing, analyzing, and interpreting task performance. Treatment utilizes clinical reasoning rather than a series of standardized techniques (Vaughan-Graham, 2009).

Berta and Karel Bobath acknowledged the need
for their approach to remain dynamic and evolve as new evidence became available.
Therapeutic Handling and Mobilization
Therapeutic Handling and Mobilization
Graded Movement Patterns
Heavy Proprioceptive Movement to Joints
In handling, the therapist uses his or her body to promote efficient movement and avoid unwanted motor responses or alignments (Schultz-Krohn et al., 2013).
Weight bearing is often combined with movement over the base of support to encourage active extension of the UE for balance. This requires muscle activity in the arm, not passive positioning. (Schultz-Krohn et al., 2013).
A closed chain movement occurs when the distal part of a joint, or "chain" is fixed and the proximal part is moving (Schultz-Krohn et al., 2013).
Handling offers sensory input to the hemiplegic side, and assists in the coordination of movement patterns (Schultz-Krohn et al., 2013).
Mobilization prepares the client for normal movement patterns by increasing ROM before engaging in the task.
Breaking Irregular Movement Patterns
of Effectiveness
When the brain is damaged, maladaptive movement patterns and postures develop
as the brain creates new neural pathways to compensate for the lack of output from the injured area. New pathways interfere with functional performance in daily occupations.

NDT uses the brain’s own capabilities of creating new neural pathways through repeated movements to create adaptive movement patterns and postures that increase occupational performance.

Due to the developmental nature of NDT, it is commonly used in pediatric occupational therapy. In adult populations, NDT can be useful for clients recovering from TBI or CVA. For adults, treatment focuses on the development of new synapses in the brain to restore or remediate movement patterns affected by brain injury or ischemia.

NDT addresses sensory and motor consequences in posture and movement associated with cerebral palsy, TBI, CVA, and developmental disability (Mayston, 2008). Treatment incorporating NDT principles has improved the quality of life for many people living with functional limitations.

Voluntary Movement Control
Sensory Deficits
Loss of postural control (as in hemiplegia after a stroke) inhibits proprioceptive output, rendering clients unable to effectively shift weight and maintain balance.

NDT techniques enable clients to internalize sequences of stability and mobility through weight bearing, proper positioning, and repetitive movement, restoring lost equilibrium.

Loss of selective movement control, generally on the side contralateral to the brain injury, often results in neglect of that side and use of one handed/one sided compensatory techniques, further reducing function in the affected side.

NDT tries to avoid this by addressing abnormal sensation, movement, and tone in an effort to restore functional movement patterns.

Brain injuries often result in reversion to primitive reflexes on the side of the body contralateral to the injury. These reflexes result in “involuntary , nonfunctional movements on the affected side when moving the non-affected side” (Cole & Tufano, 2008, p.246) creating an overall dysfunctional movement pattern.

Weight bearing, skilled handling, positioning,
and repetitive movements can enable the client to have more control over purposeful voluntary movement.

Sensory deficits resulting from brain injury contribute to abnormal movement and posture. Deficits in vision, proprioception, and vestibular senses are particularly significant.

Visual deficits are addressed through multi-sensory exercises that provide input through other senses “explaining” what is perceived through vision, and retraining vision through association.

Proprioceptive input is gained from heavy work activities and through stimulation of joint receptors.

Vestibular input is provided through regular postural changes with alignment and stability provided by handling and pressure.

Clinical Reasoning
Compensatory Repatterning of Reflexes
The Landau reflex appears 4 weeks after birth and acts as a bridge to help baby pass from one stage to another. When a baby lifts his head up, the entire trunk flexes. This reflex is usually integrated by 3-1/2 years. If it remains present, difficulty with short-term memory, back pain, awkward movements, and low tone (hypotonia) may be present.
Neurophysiological Basis
Neurophysiological Basis
The occupational therapy profession’s domain supports health and participation
in life through engagement in occupation (AOTA, 2008).

NDT utilizes a holistic, problem solving approach to restore normal movement patterns, increase participation in occupations, and improve quality of life.

Connection to the OTPF
Connection to the OTPF
Connection to the OTPF
Connection to the OTPF
Connection to the OTPF
Occupational therapy intervention aims
to establish and restore performance skills/patterns and client factors (AOTA, 2008).

NDT promotes recovery. Treatment restores function and movement by identifying and correcting underlying impairment (Schultz-Krohn et. al., 2013).

Occupation-based activity analysis helps the client reach his/her goals through carefully designed evaluation and intervention (Crepeau, 2003).

NDT is incorporated into occupational therapy evaluation/intervention to address problems of motor control and functional movement.

Therapeutic use of occupations and activities are used as both a means and
an end throughout the occupational therapy process (Trombly, 1995).

Using NDT, motor output is organized around task goals and practiced during functional activities as much as possible (Schultz-Krohn et. al., 2013).

Collaboration between therapist and client is central to the interactive nature of service delivery of the occupational therapy profession’s process (AOTA, 2008).

A therapist using NDT identifies the client as a partner and rehabilitation as a 24/7 activity tailored to the client’s current situation (Tallis, 2009).

American Occupational Therapy Association. (2008). Occupational Therapy Practice Framework: Domain & Process (2nd Ed.). American Journal of Occupational Therapy, 62(6), 625-683.

Cole, M.B. & Tufano, R. (2008). Applied theories in occupational therapy: A practical approach. Thorofare, NJ: SLACK Incorporated.

Cozolino, L. & Sprokay, S. (2006). Neuroscience and adult learning. New Directions for Adult Learning and Continuing Education, 110, 11-19. doi:10.1002/ace.214

Eich, H.J, Mach, H., Werner, C, & Hesse, S. (2004). Aerobic treadmill plus Bobath walking training improves walking in subacute stroke: A randomized controlled trial. Clinical Rehabilitation, 18, 640-651.

Kerem, M., Livanelioglu, A., & Topeu, M. (2001) Effects of Johnstone pressure splints combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in spastic cerebral palsy. Developmental Medicine & Child Neurology, 43, 301-313.

Law, M., Russell. D., Pollock, N., Rosenbaum, P., Walter, s., & King, G.(1997). A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. Developmental Medicine & Child Neurology, 30, 664-670.

Mayston, M. (2008). Bobath concept: Bobath @ 50: mid-life crisis – What of the future? Physiotherapy Research International, 13(3), 131-136.

Neurodevelopmental Treatment Association. (2012). www.NDTA.org

Salter, J., Camp, Y., Pierce, L., & Mion, L.C. (1991) Rehabilitation nursing approaches to cerebrovascular accident: A comparison of two approaches. Rehabilitation Nursing, 16 (2), 62-66.

Tang, Q.P., Yang, Q.D., Wu, Y. H., Wang, G. Q., Huang, Z. L,. Liu, Z. L., Huang, X. S., Zhou, L., Yang, P. M., & Fan, Z. Y. (2005). Effects of problem-oriented willed-movement therapy on motor abilities for people with post stroke cognitive deficits. Physical Therapy, 85 (10), 1020-1033.

Trombly, C. (1995). Occupation: Purposefulness and meaningfulness as therapeutic mechanism. American Journal of Occupational Therapy, 49, 960-972.

Vaughn-Graham, J., Eustace, C., Brock, K., Swain, E., & Irwin-Carruthers, S. (2009). The Bobath concept in contemporary clinical practice. Topics in Stroke Rehabilitation, 16(1), 57-68.
Experiential Learning Activities using NDT Principles
NDT in Practice
Neurophysiological Basis
Neurophysiological Basis
Effects of problem-oriented willed-movement therapy on motor abilities for people with poststroke cognitive deficits – Quing, et al., 2005
This study explores the link between willed or purposeful, concentrated movement in addition to NDT therapy in stroke recovery. The authors hypothesized that adding relevance and function to traditional NDT repetitive movement would increase cognitive stimulation and involvement and improve recovery. This is very relevant to OT as client-centeredness and functionality are cornerstones to effective treatment.

Effects of Johnstone pressure splints combined with NDT on spasticity and cutaneous sensory inputs in cerebral palsy – Mintase, Livanelioglu, &Topeu, 2001
Johnstone inflatable splints were initially designed to provide proprioceptive input through deep pressure and keep the limb aligned correctly during OT intervention in treating adults with hemiplegia. This approach is being extended to addressing spasticity in children with CP. An example of using NDT in conjunction with another treatment approach.

Aerobic treadmill plus Bobath walking training improves walking in subacute stroke: A randomized controlled trial – Eich, H.J, Mach, H., Werner, C, & Hesse, S. 2004
Using NDT to reestablish walking movement patterns helps clients ambulate more effectively. When functionality and purposeful movement, such as actually walking on a treadmill, is added, the effect observed is even more significant. This is another example of not only the effectiveness of NDT, but how embedding occupation into the intervention improves functional performance.

Additional Research
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