NEURODEVELOPMENTAL TREATMENT (NDT) IN PAEDIATRICS VICTORIA PROODAY MANUELA OCRAINSCHI ALDA MELO OCT 1172Y April 05, 2005

Agenda Defining NDT Origins and key concepts of theoretical approach Assessment and intervention Evidence of efficacy Strengths and limitations Recommendations for clinical practice

NDT Advanced hands-on approach to the examination and treatment of individuals with disturbances of function, movement and postural control due to a lesion of the central nervous system (CNS) Used primarily with children who have cerebral palsy (CP) and adults with cerebral vascular accidents (CVA) Practiced by OT, PT, SLP who completed advanced training in NDT

Origins of Theoretical Approach NDT, first known as “The Bobath approach” was originated and developed by Berta Bobath, physiotherapist, and Dr. Karel Bobath in the late 1940s Name Bobath is still used in many countries, NDT is the name commonly used in North America Developed from observations, practical applications and desire to find better solutions for client’s problems NDT- name given by NDTA

Theoretical Approach (cont’d) In 1940s dominant therapeutic approach focused on changing function at the muscular level, but Bobath hypothesized that the disorder of coordination of posture and movement is what prevented functional performance Bobath introduced the revolutionary idea that a therapist could have an impact on client’s functional movement by influencing the CNS through carefully guiding the motor output through handling

Theoretical Approach (cont’d) NDT evolution Decreasing muscle tone through the use of reflex inhibiting postures Incorporation of hierarchical motor sequences into therapy, with one activity following another during facilitation (head control, rolling, sitting, quadruped, kneeling) Facilitation of automatic movement sequences as opposed to isolated developmental skills Currently, it is recognized the need to direct the treatment towards specific functional situations

Theoretical Approach (cont’d) “Living concept” Where Bobath Began Where NDT Is Now Problem-solving approach based on reflex/hierarchical models Problem-solving approach based on a system/selectionist model Hierarchical model of CNS structure and function Distributed model of CNS structure and function CNS viewed as the “controller”. Automatic postural control mechanism simplified the responsibility of the CNS in control of movement The CNS determines the pattern of neural activity based on input from multiple intrinsic systems and extrinsic variables that establish the context for movement initiation and execution Sensory feedback is important for the correction of movement errors Sensory feed-forward and feedback are equally important for different aspects of movement control “Positive signs” including spasticity and abnormal coordination of movement are the most important aspects of sensorimotor impairments The “negative signs’, including weakness, impaired postural control and paucity of movement are recognized as equally important as the “positive signs” in limitations of function limitations of function Muscle and postural tone determine the quality of the patterns of posture and movement used in functional activities Task goals, experience, individual learning strategies, movement synergies, energy and interests all affect the quality of the final action

Theoretical Approach (cont’d) The basic philosophy underlying all the NDT assumptions is that lesions in CNS produce problems in the coordination of posture and movement combined with atypical qualities of muscle tone that contribute directly to functional limitations These functional limitations are changeable when the intervention strategies target specific system impairments in activities and contexts that are meaningful in the life of the person.

NDT Assumptions Impaired patterns of postural control and movement coordination are the primary problems in clients with CP These system impairments are changeable and overall function improves when the problem 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 function and planning intervention. NDT clinicians focus on changing movement strategies as a means to achieve the best energy-efficient performance for the individual within the context of the age appropriate tasks and in anticipation of future functional tasks. Movement is linked to sensory processing Intervention strategies involve the individual’s active initiation and participation, often combined with therapist’s manual guidance and direct handling NDT intervention utilizes movement analyzes to identify missing or atypical elements that link functional limitation to system impairments Ongoing evaluation occurs throughout every treatment session The aim of NDT is to optimize function

Key Concepts I. Normal development Principles of normal development Cephalocaudal, proximal-distal, gross to fine Sensory-motor-sensory feedback system Components of normal development a. interplay between stability and mobility b. effects of postural reflex mechanism on movement postural tone muscle tone reciprocal innervation - interplay between agonist and antagonist muscles during coordinated muscle movement righting and equilibrium reactions Righting reactions - restore and maintain the vertical position of the head in space, the alignment of the head and trunk and trunk and limbs Equilibrium reaction - serve to maintain or regain balance during a shift in the center of gravity the ability dissociate movements development of postural control in the three planes of space Sequences of motor development II. Abnormal development III. Sensory input as a means of bringing about change  

The Assessment Process NDT focus: to identify the client’s abilities and limitations in order to tailor an individualized treatment plan and provide a basis for comparing the client’s abilities at a later point in time. Assessment consists of data collection, examination and evaluation. The examination and evaluation is done at the beginning of treatment, before and after each session, at the end of each block of intervention, and at the end of the entire treatment. This is the dynamic model of assessment and intervention. As you can see, all the elements build-up on the previous ones.

Examination NDT Focus: to identify constrains that limit the client’s ability to perform functional activities. Components: Present and anticipated functional skills or limitation of skills Posture and movement components and compensatory strategies Anatomical and physiological status of those systems that contribute to functional limitations

Examination (cont’d) Functional Skills Gross and fine motor control, communication, and control of behavior and emotions Functional abilities and limitations Potential to change function Clusters of function and activity limitations Relationship between participation and activity level Assistive devices, splinting and orthothics

Examination (cont’d) Observation of posture, movement and compensatory strategies Spontaneous posture and movement Typical and atypical posture and movement Compensatory movement strategies Alignment, weight bearing, balance, coordination, muscle and postural tone, and movement components

Examination (cont’d) Individual systems related to function Neuromuscular system Musculoskeletal system Sensory, perceptual, cognitive systems Regulatory system (arousal, attention, emotional and behavioral responses) Limbic system (emotions, fear, pain) Respiratory, cardiovascular system Integumentary system (skin) As you can see, the NDT approach looks at the entire individual and his or her context

Examination (cont’d) Measurement Tools Norm-referenced tests (WeeFIM, AIMS, The School Functional Assessment) Criterion-referenced tests (COPM) Non-standardized tests (compare the performance at the beginning and at the end of the session)

Evaluation The therapist observes, describes and formulates hypothesis, linking treatment planning with outcomes. Client’s internal and external resources Functional limitations and participation restrictions The relationship between posture and movement components Hypotheses regarding impact of impairments on daily life function Potential to change Intervention plan developed 1,2,,5,6 corelate with stages in OPPM

NDT Intervention NDT Focus: what differentiates NDT intervention from other approaches is the precise therapeutic handling, including facilitation and inhibition, used to provide sensoriomotor cues that facilitates change in function ( Howle, 2004). “Handling is graded input provided by the therapist’s hands at key points of control on the child’s body…. and results in active control or movement” (Kramer, 1993, p. 78).

Principles of Intervention 1. Establish a treatment plan with anticipated outcomes that include specific, observable functions within a specific time frame under specific environmental conditions. 2. Therapy utilizes client’s strengths, recognizes 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. Treatment strategies often include preparation and simulation of critical foundational elements (task components) as well as practice of the whole task. 5. NDT intervention includes planning and solving motor problems. 6.    Repetition is an important component in motor learning. 7. Create an environment that is conducive to cooperative participation and support of the client’s efforts. 8.  Knowledge of the development of posture and movement components is use in designing treatment strategies. 9.  A single treatment session progresses from activities in which the client is most capable to activities that are more challenging. 10. NDT intervention methods include modifying the task, or the environment, and take into account the current level of the client’s performance and capacity for function. 11. Individual treatment sessions are designed to evaluate the effectiveness of treatment with the session. 12.  Families receive information regarding the client’s problems and management of those problems, as they are able to understand and assimilate the information. 13.  In an NDT approach, suggestions to the family are as practical as possible. 14.  NDT recommends an interdisciplinary model of service. 15. Coordinate with the goals and activities of all other medical, therapeutic, social, and educational disciplines to ensure a life-span approach to solving the client’s problems. Actually, handling is not done only with therapist’s hands, but with his/her entire body.

Intervention (cont’d) Sequence of Intervention Preparatory activities for passive movement or body alignment Selection of the key points for therapeutic handling according to the child’s postural tone Facilitation of active or automatic movement patterns by applying graded and varied therapeutic input

Intervention (cont’d) The key points (proximal or distal) are the places of physical contact between the therapist’s parts of the body or therapy equipment and client’s body. (Boehme, 1988)      Proximal key points: Located closer to the source of the problem, usually at the head, trunk, or large joints Used to influence posture and movement in all three planes (sagittal, frontal, and transverse), especially during difficult moments

Intervention (cont’d) Distal key points: Located away from the source of the problem, usually at the upper and lower extremities level Used to allow the client to engage in activities with minimal control of the therapist

Intervention (cont’d) “Facilitation is the process of intervention which uses the improved muscle tone in goal-directed activity. Facilitation techniques involve stimulation of the muscle activity to produce a desired motor response. It is related with the functional goal that needs to be achieved.” (Boehme, 1988, p. 3) Modifies postural control Guides the child’s posture or movement during the activity Techniques: tapping and intermittent compression to provide proprioceptive and tactile stimulation In practice, inhibition and facilitation techniques are used in combination. The therapist inhibits the dysfunctional component of the movement and facilitates the component that is missing from the functional pattern

Intervention (cont’d) “Inhibition is the process of intervention that reduces dysfunctional muscle tone.” (Boehme, 1988, p. 3) Reduces the intensity of spasticity Reduces the effect of fluctuating muscle tone Improves the range and variety of movements Not used with hypotonicity Techniques: traction and light joint compression It is used in combination with facilitation

Intervention (cont’d) Weight bearing and weight shifting promote: Postural alignment Child’s movements Proximal stability Adaptive equipment and orthothic devices Allows more independent movement Decreases the possibility of deformities and contractures Can be used by parents and other professionals to reinforce the therapy

Role of Play in NDT Intervention with Children Motivates and engages the child Provides appropriate stimuli for development of normal movement patterns Fulfills therapeutic goals Facilitates the handling techniques Facilitates the use of the gained movements in other activities Allows observation of child’s spontaneous and automatic postures and movements STRENGTHS; meaningful occupation

Evidence of Efficacy of NDT Intervention Overall research results regarding the efficacy of NDT are largely inconclusive Current research literature does not clearly demonstrate the efficacy or inefficacy of NDT as a treatment approach

Efficacy (cont’d) Children who received NDT performed slightly better than control or comparison groups (Ottenbacher, et al., 1986) Children with cerebral palsy 6 studies reported benefit vs. 4 studies reported no benefit (Brown & Burns, 2001) High-risk/low birth weight infants 1 study reported benefit vs. 5 reported no benefit (Brown & Burns, 2001) Only in 4 of the 7 studies was the benefit statistically significant

Efficacy (cont’d) From 101 studies identified 21 met inclusion criteria Overall results did not show an advantage for NDT intervention over the alternative to which it was compared No consistent evidence that NDT changed abnormal motor responses, slowed or prevented contractures, or that it facilitated more normal motor development or functional motor activities ( AACPDM, 2001) No consistent evidence that NDT changed abnormal motor responses, slowed or prevented contractures—Primary goal of NDT is to change neural-based motor responses of the CNS & major goal is to slow or prevent progressive deformity

Efficacy (cont’d) More intensive therapy did not confer a greater benefit 4 of the 21 studies were coded as Level I (definitive) evidence and 10 were Level II (tentative) evidence ( AACPDM, 2001)

Efficacy (cont’d) Factors that may account for research results Sample size Heterogeneous samples Participants not randomly selected Participants assigned to either a treatment group or a non-treatment groups without using an adequate blinding process 

Efficacy (cont’d) Different assessment tools used to collect the data in each study Whether many of the measures used are valid and/or sensitive enough to detect change Variation in outcomes being measured Variation in treatment therapy and duration of interventions

Efficacy (cont’d) Issues are methodological ones Absence of evidence of effectiveness should not be construed as proof that NDT treatment is not effective, may just reflect more meaningful research is needed “…a limited number of high quality NDT research efficacy studies have been published “ (Brown & Burns, 2001)

Strengths and Limitations Theoretical approach is compatible with OT principles, but in practice some Ots may be challenged to keep an occupational perspective Approach is supported in many paediatric practice settings Continuing education support for approach Requires investment of resources In practice is a lot of room for therapist interpretation/ “intuition” (Howle, 2004) Holistic Based on clinician feeling, intuition

Recommendations for Clinical Practice When evaluating research evidence may have to go beyond the systematic review Keep occupational perspective Doing NDT requires skill and practice----Engage in continuing professional education!! Difficult to evaluate its effectiveness because it is not a specific treatment that is delivered in a standardized manner (treatment setting could be standardized but child’s family, another condition of treatment, could never be) Continue ed- complex NDT, continue to change

References Boehme, R. (1988). Improving upper body control. An approach to assessment and treatment of tonal dysfunction. Tucson, AZ: Therapy Skill Builder. Brown, G. T., & Burns, S. A. (2001). The efficacy of neurodevelopmental treatment in paediatrics: A systematic Review. British Journal of Occupational Therapy, 64(5), 235- 244. Butler, C. & Darrah, J. (2001). Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence report. Developmental Medicine and Child Neurology, 43, 778-790. Howle, J.M. (2004). Neuro-develompmental treatment approach. Theoretical foundations and principles of clinical practice. Laguna Beach, CA: NDTA. Ottenbacher, K. J., Biocca, Z., DeCremer, G., Jedpvec. K. B., & Johnson, M. B. (1986). Quantitative analysis of the effectiveness of paediatric therapy: emphases on the neurodevelopmental treatment approach. Physical Therapy, 66, 1095-1101. Schoen, S. & Anderson, J. (1993). Neurodevelopmental treatment frame of reference (pp. 74- 86; pp. 49- 69). In P. Kramer & J. Hinojosa (Eds.) Frames of Reference for Pediatric Occupational Therapy. Baltimore, MD: Williams & Wilkins.