Neurodevelopmental Therapy Concept & Principles

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

2. What is NDT? • NDT = Neurodevelopmental Therapy • Also referred to as Bobathconcept • Approach to the management of children with pathology of the central nervous system

3. Background • Developed in 1940’s • United Kingdom • Dr. KarelBobath (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

4. 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

5. 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 Principles: What does NDT advocate:

6. 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

7. 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

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

9. 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)

10. 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

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

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. 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

20. 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

21. References • Images courtesy of Google • Brown, E. 20001. NDT course notes (unpublished) • Brown, E. 2009. NDT early intervention course notes unpublished) • Bobath Centre websitewww.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

22. 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