Neuro-Developmental Treatment (NDT) Foundations

• Neuro-Developmental Treatment (NDT) is being approached for adult neurorehabilitation, focusing on foundations.

Objectives

• Understand foundational principles of NDT for adult neurorehabilitation.
• Discuss NDT principles in the context of occupational therapy evaluation and treatment.
• Learn NDT handling techniques for adults with neurological impairment.
• Observe current evidence-based practice for NDT.

Foundational Principles

History

• The NDT approach is referred to as the "Bobath" approach.
• It was developed in the 1940s by Dr. Karel Bobath, a neurologist, and his wife Berta, a physiotherapist, in the United Kingdom.
• The approach is based on Berta's gymnastics background, emphasizing alignment, posture, and movement analysis.
• NDT was initially used with children with cerebral palsy and adults with hemiplegia, aiming to regulate abnormal tone and retain normal movement patterns.
• Described as a "living concept," NDT recognizes the need for ongoing adaptation as new information on CNS dysfunction treatment emerges.

Theory Constructs

• Abnormal coordination and functional limitations in hemiplegia post-CVA are associated with:
  • Loss of normal movement responses involving postural and selective movement control.
  • Development of abnormal tone and movement, including flaccidity, spasticity, and associated reactions.
• Addressing these problems improves movement and control of the hemiparetic side, enhancing occupational performance.

Overview

• NDT is a dynamic, problem-solving, sensorimotor approach for restoring movement and functional performance.
• It identifies and corrects underlying impairments affecting functional movement and daily activities.
• Emphasis is placed on unique client needs, posture and movement analysis, facilitation of normal movement, inhibition of abnormal tone, proximal and distal points of control, movement quality, affected side incorporation, active participation, therapeutic handling, and reflex-inhibiting positioning.

Evaluation through NDT

• Uses a top-down approach, starting by establishing an occupational profile and understanding functional goals.
• Focuses on observing the client's performance within the context of various occupations.
• Assessment includes posture and alignment, normal motor skills, alignment and movement during basic motor tasks, and underlying impairments like changes in muscle strength, tone, activation, and sensory processing.
• Encourages a collaborative approach with overlaps between evaluation and intervention.

NDT Intervention

• Principles of NDT intervention include:
  • Achieving and maintaining postural alignment that is neutral and symmetrical
  • Inhibition of abnormal tone, compensatory movements, and abnormal/repetitive movement patterns.
  • Facilitation of normal motor performance skills.
  • Incorporation of hemiparetic side
  • Therapeutic handling during task/occupation practice
  • Application and meaningful contexts
• Interventions typically follow the sequence:

Postural Alignment

• NDT emphasizes proper postural alignment and proximal control for functional movement return.
• Normal movement cannot be achieved on misaligned joints.
• Achieving neutral posture involves the head, neck, shoulders, chest, trunk, and hips
• Utilizes handling techniques and external aids like positioning wedges, bolsters, and mirrors.

Inhibition Techniques

• Reflex-inhibiting patterns (RIPs) are used.
• Patients typically begin with UE flexor spasticity.
• Therapeutic handling facilitates movement into a RIP of shoulder depression with external rotation, elbow and wrist extension, and an open hand position.
• Spastic muscles require slow, gradual handling to achieve RIP- avoid working distal to proximal

Inhibition Techinques - Positioning

• Proper positioning is crucial to inhibit flexor synergistic patterns, ensuring proper alignment and stretch.

Inhibition Techniques - Mobilizations

• Scapular mobilizations are used ti reduce tone, prevent adhesion or contracture, and maintain passive/active range of motion.
• Trunk rotation inhibits trunk flexors
• Weight-bearing modulates hypertonicity ideally utilized in RIP positions.

Facilitation Techniques

• Weight-bearing is used as a facilitator.
• Closed-chain movement maintains muscle length, reduces hypotonicity, and increases muscle activation
• Trunk/proximal muscles shift body weight over the affected extremity, creating demand for muscles
• Weight-bearing causes forced lengthening, shortening, and contraction of the affected extremity muscles
• Occurs more naturally with the LEs than the UEs during standing and transferring
• Begin UE weight-bearing in more accepting positions, then progress to weight-bearing on the extended arm in sitting/standing.

Facilitation Techniques - Guided Assistance

• Guided movement/active assistance is provided through normal patterns of movement and open-chain exercises.
• Therapists supports at proximal and distal key points for quality of movement.
• Therapists corrects and maintains normal joint alignment during movement at the trunk, hips, and hemiparetic shoulder
• Guidance and support are reduced as participation and movement capabilities increase
• Sensory input is given for normal patterns of movement.

Facilitation Techniques - Place-and-hold

• Therapists places body parts into the desired position and prompts the patient to "hold."
• This technique allows for active muscle engagement to maintain position and bodily alignment,
• Provides proprioceptive sensory input
• Place-and-hold avoids compensatory patterns
• Gradual progression by decreasing support as movement comes back

Use of Affected Side

• Uses the affected side/extremity during movements to increase active engagement and sensory input
• Increases stability during dynamic tasks
• Uses the affected to decrease/normalize tone and prevents non-use, to encourage neuroplasticity and promote independence
• Functional training improves occupation-as-means and occupation-as-ends

Current Evidence

• The NDT approach has evolved since the 1940s with advancements in motor learning, control, development, and neuroplasticity.
• There is no evidence of NDT approach superiority in treating UMN injuries, extremity recovery, pain, tone, or activity participation
• NDT relies on clinical expertise and experience, as well as limited clinical trials and systematic reviews, to support its efficacy.
• Despite a lack of strong evidentiary support, it is a commonly used neurorehabilitative treatment.

Application to Practice

• NDT focuses on neurological recovery, with an establishment of postural control and alignment to inhibit abnormal patterns and facilitate normal patterns.
• Encourages active participation within functional situations
• NDT principles can/should be implemented in conjunction with other neurorehabilitation approaches.