Neurodevelopmental Therapy Concept & Principles Robyn Smith Department of Physiotherapy UFS 2012

What is NDT? NDT = Neurodevelopmental Therapy Also referred to as Bobath concept Approach to the management of children with pathology of the central nervous system

Background Developed in 1940’s United Kingdom Dr. Karel Bobath (neurologist) and his wife Berta (physiotherapist) “The aim of treatment for children with disabilities due to brain damage is to prepare them and guide them towards their greatest possible independence and to prepare them for as normal adolescence and adult lives as can be achieved” Bobath, 1984

Background “living concept” an approach that continues to evolve even today Based on current neuro- and movement sciences Evidence-based The most widely used form of neurodevelopmental therapy

Principles: What does NDT advocate: Problem solving Holistic → sensory –motor issues, also developmental, cognitive, perceptual, emotional and functional problems Interdisciplinary Interactive – parent and child involved Goal directed (Function and participation key) Early intervention recommended Advocates use ICF as tool

Basic departure point Understanding of : developmental process of motor control (sequencing) components of normal movement Components which constitute a functional task Good facilitation and handling skills

How does work? Neurological deficit or damage Disturbances in normal muscle tone → Disturbances in postural muscle tone (ability to develop antigravity control disturbed) Developmental problems – not attain milestones Abnormal sensory motor experience Persisting or worsening movement patterns

Systems involvement in case neurological damage: Neural elements: Muscles Nerves Non neural elements: Muscle contractility Biomechanical issues

How is it done? What does therapist aim to do during treatment? Trained therapist use specialised handling techniques to: Modify /influence patterns abnormal tone Preparation e.g. mobilisation Facilitate/ stimulate more normal movement patterns using key point control Automatic reactions (righting and equilibrium reactions- head and trunk control against gravity)

How is it done? What does therapist aim to do during treatment? Develop postural control/adjustments as background for voluntary movement Provide more normal sensory- motor experience Strengthen and open synaptic pathways and make use of neural plasticity Help the a child with neurological dysfunction to optimise their functional abilities

How is it done? What does therapist aim to do? Practice and repetition Carryover and parent participation Regular and quality physiotherapy intervention

NDT therefore provides the therapist with flexible treatment guidelines they can use to select individualised treatment strategies for their client “It is not a recipe” each child is different need to be able to use the principles in the context of each individual patient.

Facts on the evidence of effectiveness of NDT Are numerous s studies and evidence reviews but there is some difficulty in demonstrating the effectiveness of the approach Evidence of efficacy is relatively low to support use above other therapy modalities

Facts on the evidence of effectiveness of NDT Hard to compare outcomes as they depend on the type of cerebral palsy and the severity of the brain lesion Numerous problems with study methodology: few randomised controlled clinical trials, small sample size and variation of standardised outcome measures Poor description of the exact techniques and therapy intervention given and the duration thereof

Current opinion based on research then..... Studies on effectiveness of NDT have been inconclusive NDT has not been shown to be more effective than any other therapy approach

What to NDT therapists and parents say.... Based on the changes in the activity level and participation abilities of the child both parents and therapists feel that NDT is an effective approach Approach taught at most universities at a pre-at undergraduate level Most common meuropaediatric postgraduate course as well

What do the detractors of the approach say .... Therapy approach too “hands on” often not allowing the child to do things independantly Labour intensive Costly over time Lack of evidence to support its use

Should NDT be used in conjunction with other therapy approaches Based on the available research: YES

Physiotherapists toolbox: Rarely is NDT therapy used in isolation Most therapists use an eclectic approach to their therapy. NDT forms the core of their therapy but often used other approached or adjunct to make the therapy more child and family specific and effective

The physiotherapists toolbox The physiotherapists “toolbox” an eclectic approach (Mayston, M. 2007, p 69) Training functional Tasks for optimal Performance i.e. repetition & home activities Maintain muscle length Tone influencing, myofascial release, orthotics & stretching Specific training for neuroplasticity e.g. CIT Treadmill NDT Train postural reactions task specific goal directed The physiotherapists toolbox Child with Neurological impairment CVS & general Fitness activites Muscle strengthening Functional, resistance, weight bearing Sensory perception and cognitive function Social & behavioural aspects Encourage participation Hippotherapy Virtual reality &compression suit therapy

References Images courtesy of Google Brown, E. 20001. NDT course notes (unpublished) Brown, E. 2009. NDT early intervention course notes unpublished) Bobath Centre website www.bobath.org.uk Barber, C.E. 2008. A guide to physiotherapy in cerebral palsy. In Paediatrics and child Health. 18(9) September 2008 pp 410-413 Poutney, T. 2007. Cerebral Palsy in Physiotherapy for children pp 97-98 Ratliffe, K.T. 1998 Neurological and muscular disorders of childhood in Clinical Pediatric Physiotherapy. A guide for the Physical Therapy Team. pp 191-192

References Styer-Acevado, J. 2008. The infant with Cerebral Palsy in Pediatric Physical Therapy. Tecklin, J.S. (eds). 4th ed. pp 204-206 Sheperd, R.B. Cerebral Palsy in Physiotherapy in Paediatrics. 3rd ed. pp 124-125 Velikovi, T.D. Basic principles of neurodevelopmental treatment