Neuro Developmental Treatment (NDT)

1. Neuro Developmental Treatment (NDT) کارگاه تخصصیبررسی مقایسه ای رویکردهای باتم آپ و تاپ دان در مداخلات کاردرمانی کودکان مبتلا به فلج مغزیبهار 1396 Tehran CP Workshop, May 2017

2. NDT Definition • NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. • The therapist uses the ICF model in a problem-solving approach to assess activity and participation, thereby to identify and prioritize relevant integrities and impairments as a basis for establishing achievable outcomes with clients and caregivers. Tehran CP Workshop, May 2017

3. NDT Subsystems • An in-depth knowledge of the human movementsystem, including the understanding of typical and atypical development, and expertise in analyzing postural control, movement, activity, and participation (ICF) throughout the life span, form the basis for examination, evaluation, and intervention. • Therapeutic handling, used during evaluation andintervention, consists of a dynamic reciprocal interaction between the client and therapist for activating optimal sensorimotor processing, task performance, and skill acquisition to enable participation in meaningful activities Tehran CP Workshop, May 2017

4. ICF model Tehran CP Workshop, May 2017

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7. Motor Control Approach • Neuromaturational Theories • Reflex/Hierarchical Theory • Generalized Motor Program Theory • Dynamic System Theory • Neuronal Group Selection Theory Tehran CP Workshop, May 2017

8. Reflex/Hierarchical Theory • This theory assumed that the structures of the brain were organized and developed in a hierarchy and that there was a fixed relationship between function and structure. • Each successively higher level of brain structures provided more precise movement integration. Therefore, as these structures developed, function changed accordingly. Tehran CP Workshop, May 2017

9. Reflex/Hierarchical Theory • The lowest level of fundamental movement patterns were sensory-elicited reflexes, which were then integrated into the automatic postural reflex mechanism as the higher brain levels developed. • These automatic movements, including righting and equilibrium reactions, were considered to be the basis for skilled voluntary movements. Tehran CP Workshop, May 2017

10. Reflex/Hierarchical Theory • The R/HTs helped to explain the stereotypic movements and postures seen in persons with neuropathology. • These were acceptable neural control models until the late 1960s and, although they did offer explanations for predictable movement seen in cerebral palsy (CP), their limitation was that they did not account for context-based movement, variability, individuality, novelty, and context-based behaviors. Tehran CP Workshop, May 2017

11. Generalized Motor Programs (GMPs) • Instruction are specified by the CNS • Control process is managed by a motor program • Motor program organizes, initiates, and carries out intended actions • Linear changes in movement behavior Tehran CP Workshop, May 2017

12. Generalized Motor Programs (GMPs) • Keele proposed the existence of a set of commands in the CNS named Generalized Motor Programs (GMPs) , which were assembled and initiated without sensory input and performed in the absence of peripheral feedback. • GMPs contain the abstract representation of movement, including the commands for movement, codes of action, and general features of movement sequences as well as the recruitment of appropriate agonists and synergists with adjustment of antagonists of peripheral feedback. Tehran CP Workshop, May 2017

13. Generalized Motor Programs (GMPs) • There could be basic motor plans for reaching and grasping and rhythmic movements for walking or speaking that are assembled prior to the need to move. • Simple sequences could then be linked together to produce complex actions, such as walking down a slope or singing. • The richness of the GMPs developed from both experience and learning. Tehran CP Workshop, May 2017

14. GMPs and CPGs • GMPs renewed the interest in the concept of Central Pattern Generators (CPGs) • Neural networks in the spinal cord capable of producing rhythmic movement even when isolated from the brain and sensory systems. • There was increasing evidence that specialized neural circuits do exist in the brain stem of vertebrates for breathing, chewing, and swallowing, and in the spinal cord for locomotive functions. Tehran CP Workshop, May 2017

15. Body Weight Support Treadmill Training • Partial body-weight-bearing (PBWB) gait training is one intervention that gains support from CPGs. Tehran CP Workshop, May 2017

16. Dynamic System Theory • Movement is produced from the interaction of multiple sub systems within the person, Task, and environment. • No sub system is most important • Dynamic system(DS) is complex • Development is in a non-linear rate, not steady • A movement pattern emerges (self-organizes) as a function of the ever-changing constraints placed upon it. Tehran CP Workshop, May 2017

17. Self organization • This theory deemphasizes instructions or neural selectivity to achieve coordinated actions and instead looks for explanations based on physical parameters. • Change occurs because one control parameter(Speed, Direction, force), or variable, reaches a critical value, which causes a change in the entire system. • For example, change in velocity regulates a change from walking to running. Change in the slope alters step frequency and step length in young children. Tehran CP Workshop, May 2017

18. What is a constraint? • They limit the Movement possibilities (degrees of freedom) of the individual • Biomechanical and anthropometric properties of the body system : body shape, weight, height, emotional, cognitive, etc. • Environmental: gravity, temperature, light, wind, etc • Task constraints: rules of the game, goal of the task, and the object or tools (i.e. size, shape, weight) manipulated. Tehran CP Workshop, May 2017

19. Attractor States • We prefer states to be stable. This state or stability is known as attractor state or what we presently prefer. • When a change in constraints occur, the stability of the system is endanger! • In time, the movement pattern will reorganize and the new one will begin to take over and stability is regained. Tehran CP Workshop, May 2017

20. Application in NDT • The clinicians can identify constraints that limit functional change and develop intervention strategies which directly target these constraints. • For example, in early infancy, the mass of the child’s head relative to the size of the rest of the body places constraints on, or limits, the rate at which head lifting and visual following can occur. • Delays in independent sitting constrain the foundations for manual development, mother–infant face to face interactions, and reaching behavior by 6-month-old infants. • In adults with CP, moderate weakness, increased muscle tone, bone and joint deformities, and progressive asymmetry in posture are independently responsible for limitations in independent ADL. Tehran CP Workshop, May 2017

21. Gravity as a major constraints in Motor Function • Introduction of BWST and Anti Gravity Treadmill • Reduce gravity’s impact by selecting any weight between 20% and 100% of your body weight Tehran CP Workshop, May 2017

22. Transitions or phase shift • Specific motor skills emerge from a series of states of stability, instability, and phase shifts in which new states become stable aspects of behavior. • During development, as the subsystems of developing systems change, motor behaviors can either become more stable or destabilize. These periods of destabilization are referred to as transition states. • During these times, new forms of movement are most likely to occur. These transitions are characterized either by an increased latency in time to return to a stable state after perturbation, or by increased variability in behavior. Tehran CP Workshop, May 2017

23. Problems of phase shift in CP • People with neuropathology with limited repertoires of movements may lack variability, and destabilizing these limited patterns is difficult. • The person continually tries to use the limited repertoires in all situations, and transitions from one state to another are increasingly difficult. The result is movement that is stereotyped and rigid Tehran CP Workshop, May 2017

24. Application in NDT • The intervention is most effective during periods characterized by high degrees of variability. These are often the periods during new experiences (and new environments) • NDT recognizes that these periods of transition are the times that intervention can promote and direct efficient motor patterns as the client is working out new functional movements in increasingly complex contexts. Tehran CP Workshop, May 2017

25. Application in NDT • As a child with hemiplegia experiences a normal growth spurt at age 2, he may appear clumsy, fall more frequently, stand with more of his weight on the less involved side, or even walk without placing the heel (on the more involved side) on the ground during the stance phase. • This is a time to increase the intensity of intervention to take advantage of the variability in gait and balance Tehran CP Workshop, May 2017

26. Neuronal Group Selection Theory • When hundreds of thousands of strongly interconnected neuronal circuits act as structural/ functional units, called neuronal groups, they increase their effectiveness. • Neural structures are determined by the competition among neural elements to assure variation(Diversity) in neuroanatomical structures. • Primary motor repertoires are movements characterized by variability and are not connected to either sensory inputs(feedback) or function. • These connected neuronal groups initially develop by genetic encoding (Evolution). Tehran CP Workshop, May 2017

27. Primary Neuronal Repertoires • Orienting the head and eyes to light and sound. • Orienting the head to clear the airway when prone. • Coordinating suck and swallow. • Bringing the mouth to the hand. • Following moving objects with the eyes. • Projecting the arm toward objects. • Reciprocal kicking. • Sensory elicited reactions and responses (sometimes referred to as primitive reflexes, such as head and body righting, palmar grasp, rooting reaction, Moro reflex). • General motility. • Attachment to the human face Tehran CP Workshop, May 2017

28. PNR and NDT • NDT therapists use a problem-solving approach to plan intervention strategies that are flexible enough to accommodate the differences of each individual client. • Selective competition supports the hypothesis that variability of movement. • Primary Variability is part of a primary repertoire, and it is important to allow clients to select their own way to organize motor responses. • Intervention includes assisting the client to organize movementrepertoires in relevant contextes Tehran CP Workshop, May 2017

29. Secondary Neuronal Repertoires • If PNR are reinforced by a supportive environment, people in it, and the infant’s success in fulfilling his or her needs, they lead to an even richer, purposeful secondary repertoire of responses. • The brain instantaneously “selects” the response that adapts to external conditions and that is the most fit for each individual person. • SNR is developed based on experience-dependent selection of the most effective neuronal networks. • The infant organizes postural control as an essential element of all movement repertoires. • Secondary repertoires link sensory features to specific motor behaviors. • Children with mild to moderate forms of CP develop SNR, but at a slower pace and in a reduced form Tehran CP Workshop, May 2017

30. Change the PNR to SNR • Transition occurs at function-specific ages • All changes are not just changes in synaptic formation and neural circuitry. • The development of secondary repertoires also depends on changes in the musculoskeletal system, perception, experience, and a gradual change in agility, adaptability, and the ability to make complex movement sequences. • The development of successful reaching and grasping emerges during the first 4 months, changing from movements that are variable in path, speed, and accuracy, to reaching movements with mature kinematics involving fewer movement units Tehran CP Workshop, May 2017

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32. NDT and SNR • NDT intervention strategies provide very specific sensory input that grades the intensity, rhythm, and duration of somatosensory, visual, and auditory inputs while allowing the client to attend to specific aspects of the task. • NDT intervention recognizes that repetition is an important component in motor learning. Motor activities that are task specific and repeated throughout a session with variability and are included in a home program have a better chance of becoming part of the client’s favored functional repertoire. Tehran CP Workshop, May 2017

33. Forming and Connecting Global Maps • The continual selection of neuronal groups during development and through repeated selection binds neuronal groups together to form neuronal maps. • When maps are repeatedly selected to produce meaningful behavior, they form global maps. • Essential to the development of global maps is sufficient experience with slightly different tasks to permit the neuronal maps to respond differently to various objects and events in the environment.( secondary variability) Tehran CP Workshop, May 2017

34. DS versus NGS • Like the theory of NGS, the theory of DS maintains that interactions among the elements of a system give rise to patterns without instructions or without a controller. • Both theories propose that individuals who explore a variety of possible solutions to motor problems will increase their movement repertoires, have greater success, and have an easier time meeting the demands of tasks in their daily lives. Tehran CP Workshop, May 2017

35. DS versus NGS • In DS the neural substrate plays a subordinate role than environment whereas in NGS, development is the result of a complex intertwining of information from genes and environment. • A central issue for DS is that, although movement possibilities (or degrees of freedom) may be constrained by any of the body systems, they are primarily constrained by the biomechanical and anthropometric properties of the musculoskeletal system. • The variation in NGS is not random, but determined by criteria set by genetic information Tehran CP Workshop, May 2017

36. NDT effectiveness • Evans-Rogers et al reported on outcomes of short-term intensive NDT intervention based on parental perspectives and functional outcomes • Girolami and Campbell reported on the efficacy of NDT treatment for infants born prematurely and found improved motor control • Arndt et al report on the effectiveness in an NDT based trunk protocol in infants. • Tsorlakis et al showed the effectiveness of NDT and underline the need for intensive application of the treatment. Tehran CP Workshop, May 2017

37. COPCA (Coping with and Caring for infants with special needs - a family centered program) • COPCA has educational and motor goals. • Learn 2 move 0-2 and learn 2 move 2-3 • Components: • A family involvement and educational component as coaching • A NDT based on the principles of the Neuronal Group Selection Theory • Its effectiveness has been showed (Hielkema et al 2010, Ketelaar et al 2010) Tehran CP Workshop, May 2017

38. NDT Critics • Butler et al(2001) • More intensive therapy did not seem to confer a greater benefit • There was also no clear evidence that NDTproduced other potential benefits such as enhancement ofsocial–emotional, language, or cognitive domains of development, better home environments, improved parent–childinteractions, or greater parent satisfaction • There was notconsistent evidence that NDT changed abnormal motoricresponses, slowed or prevented contractures, or that it facilitated more normal motor development or functional motoractivities Tehran CP Workshop, May 2017

39. NDT Critics • Diane L. Damiano(2009) • Therapies that involve multiple types of exercises, such as NDT are an issue from a scientific standpoint because they each have multiple components that are likely to have varying degrees of evidence. These programs should be dissected so that the active ingredients can be identified and retained ifsuperior to other alternatives and ineffective ones discarded. • The fact that NDT has failed to demonstrate superiority over any alternative treatments to which they have been compared is also a concern Tehran CP Workshop, May 2017

40. NDT Critics • Novak et al(2013) • regarding contracture, high-quality RCTs showedthat casting was a superior treatment to NDT • regarding tone reduction, the highest quality evidence suggested that NDT was ineffective for this indication and other evidence shows BTX exists as a highly effective alternative • NDT is time-consuming and expensive for families, and, what is more, a high-quality RCT shows that substantially better functional motor gains are achieved from motor learning than from NDT at equal doses Tehran CP Workshop, May 2017

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43. با سپاس www.farvardin-group.com @farvardin_group_channel @neuroscience4family @farvardin_group96 Tehran CP Workshop, May 2017