Brief introduction to NDT

By Kinjal Shah (intern from SGMPC)

AIM OF TREATMENT
• Aim of the treatment for cerebral palsy/with disabilities due to brain damage is to prepare and guide them towards their greatest possible independence and to prepare them for as a a normal adolescences and adult lives as can be achieved by Bobath in 1984.

• The concept of neuro-developmental treatment (NDT) has been evolved empirically by Mrs. Bertha Bobath from 1942 onwards. • By careful clinical observation of adult hemiplegia and of children with cerebral palsy, she studied their reactions to being handled. • Dr.Karel Bobath, her husband & a neurologist, tried to find the theoretical explanations. By Kong 1991.

• NDT is a holistic approach dealing with the quality of patterns of coordination & not only the problems of individual muscle function. • It involves the whole person, not only sensorymotor problems but also problems of development ,perceptual-cognitive impairment, emotional, social & functional problems of daily living (Bobath 1990).

A Brain lesion interferes with the development of normal postural control in relation to gravity.

1. Instead of normal postural tone, we find abnormal tone: too high (spsticity), too low (hypotonicity) or fluctuating (athetosis). 2. Instead of normal reciprocal interaction, we find excessive co-ordination, or sudden inhibition of antagonists resulting in the lack of ability to make a graduated movement.

3. Instead of normal automatic movement patterns of righting, equilibrium,& protective reactions, we find a few static and stereotyped postural patterns of tonic reflexes.

• The abnormal sensory-motor development interferes with child’s whole development i.e. sensory, perceptual, cognitive, psychological. • Associated sensory &/or perceptual deficits can be primary due to brain lesion but frequently they are secondary to the physical disability, which prevents child

• Associated sensory &/or perceptual deficits can be primary due to brain lesion but frequently they are secondary to the physical disability, which prevents child from exploring himself the environment. • He does not develop the same concept of his body. as does a normal child.

• Abnormal sensorymotor experiences will result in an abnormal body awareness & abnormal body image (Bobath 1984; Kong 1986; Quinton 1986).

• It is impossible to superimposed normal movement patterns on abnormal ones, the abnormal patterns need to be suppressed (inhibited).

The importance of sensory motor experience- we do not learn a movement but a “sensation of movement”.

• By moving the proximal part of body it is possible to influence and to change the movement s of distal parts (Bobath 1942).

Parents participation is important
• Guiding & training the parents in home management is of the greatest importance.( finnie 1986, bobath 1997).

Inhibition combined with stimulation & facilitation
• After preparing & obtaining a more normal postural tone the patient needs to learn move in many different combinations of more normal movement patterns. • Mrs. Bobath looked for possibilities of a how to transmit to the patient in order to enable them to experience normal sensation of functional movements they had either lost or never developed.

• Only by feeling a near normal movements with minimal effort can the patient learn how to perform it. • The therapist’s task is to make this possible. • Bobath recognized that during normal development, in the beginning there is influence of tonic reflexes which later disappear & are supported by the development of righting reactions.

• These are later overlapped & integrated into balance reactions & voluntary movements (Kong 1991).

Reflex inhibitory control
• Inhibition is the process of intervention that reduces dysfuntinal muscle tone. It breaks up the abnormal excessive flexion or extension(Bobath 1984; Quinton 1986;Boehme 1988).

Inhibition combined with stimulation & facilitation
• After preparing & obtaining a more normal postural tone the patient needs to learn move in many different combinations of more normal movement patterns. • Mrs. Bobath looked for possibilities of a how to transmit to the patient in order to enable them to experience normal sensation of functional movements they had either lost or never developed.

• Only by feeling a near normal movements with minimal effort can the patient learn how to perform it. • The therapist’s task is to make this possible. • Bobath recognized that during normal development, in the beginning there is influence of tonic reflexes which later disappear & are supported by the development of righting reactions.

• These are later overlapped & integrated into balance reactions & voluntary movements (Kong 1991).

SUPINE
• Baby’s position: the baby lies in supine on the floor. • Therapist position: Long sitting on the floor with baby between her legs.

GOALS
• • • • • • Activation of eye muscles. Visual tracking. Activation of head turning with rotation. Activation of head, trunk & neck flexors. Elongation of spinal extensors. UE reaching.

• • • • • • •

In supine we can also give, Hands to arms. Hands o mouth & face. Hand to hand. Hands to head. Tactile exploration with hands. Visual body exploration with eyes.

SUPINE ROLLING
HANDS TO FEET ROLLING. • Baby’s position: the baby lies on the mat. • Therapist position: heel sit in front of baby in a position to move with baby.

GOALS
• • • • Elongation of spinal extensors. Activation of trunk flexors. Hip flexion with knee extension. Sensory feedback of side lying to facilitate lateral righting reactions.

Supine to sit
• Baby’s position: lies on the floor. • Therapist position: heel sit on the floor in front of baby.

GOALS
• • • • Rotation of trunk & pelvis over hip. UE weight bearing. Lateral righting reactions. Oblique abdominal activation.

Prone on lap
• • • • • • • Baby’s position: baby lies on lap in prone. Therapist position: long sitting on floor. GOALS Elongation of rectus abdominus muscle. Elongation of hip flexors. Neck, trunk, and hip extension. Head lifting..sensory stimulation.

Prone lateral weight shifts
• Baby’s position: lies in prone on your lap,with both arms flexed over your legs. • Therapist position: long sit on the floor.

goals
• • • • Elongation of rectus abdominus. Elongation of hip flexors. Head lifting & turning from side to side. Sensory stimulation through the visual, tactile, proprioceptive and vestibular system. • Lateral righting reaction. • Lower extremities dissociation.

Prone on ball
• Baby’s position: lies prone on ball with the ribs and pelvis well supported by ball. Baby’s arms are in shoulder flexion over ball. • Therapist position: place your self behind the baby in a position to move forward with baby.

GOALS
• Head & trunk extension. • Symmetrical hip & knee extension. • Forward protective extension of upper extremities. • UE weight bearing. • Vestibular & proprioceptive stimulation.

On ball we can give weight bearing on forearm also weight bearing on extended arms.

Lateral righting reaction
• Baby’s position: baby lies in prone over the ribs and pelvis well supported. Arms in shoulder flexion over the ball. • Therapist position: kneel beside ball.

GOALS
• Lateral righting reaction of head & trunk. • Elongation of the weight bearing side. • Abduction & protective extension of the free extremities.

Prone to sitting on floor
• Baby’s position: the baby lies in prone or in fore arm weight bearing. • Therapist position: kneel beside the baby.

GOALS
• • • • • Movement around the body axis. Trunk rotation. UE weight bearing & weight shifting. Pelvic femoral mobility. Somatosensory input into the base of support for subsequent postural preparation & reaction in sitting.

PRONE TO RUNNER’S STRETCH POSITION • Baby’s position: baby lies prone or in weight bearing on the mat with the hips extended. • Therapist position: kneel beside the baby.

GOALS
• Head lifting & righting on the saggital plane. • UE, extended arm weight bearing. • Elongation of the trunk muscles on the weight bearing side. • Lateral flexion of spine & lateral righting of head, trunk, & pelvis on the unweighted side.

• Lower extremity dissociation, including increased range of motion at the hips & knees. • Marked dissociation of LE dissociation prevents the pelvis from moving on saggital plane thus preventing it from moving into an anterior or posterior pelvic tilt. Therfore movements around the pelvis & LS occur on the frontal & transverse plane.

• Marked dissociation of LE dissociation prevents the pelvis from moving on saggital plane thus preventing it from moving into an anterior or posterior pelvic tilt. Therefore movements around the pelvis & LS occur on the frontal & transverse plane.

Sitting to quadruped to kneeling
• Baby’s position: the baby is in long sitting on floor. • Therapist position: sit behind or beside the baby.

GOALS
• • • • Trunk rotation. UE sideward protective extension. UE weight bearing & weight shifting. Hip & knee flexion followed by hip extension with knee flexion. • Elongation of quadriceps. • Activation of gluteus maximus.

• Activation of gluteus maximus. • Trunk extension on extended hips.

Prone to standing
• Baby’s position: the baby lies in prone or in forearm weight bearing on the floor with hips extended. • Therapist position: kneel beside the baby.

GOALS
• Lateral weight shifts with elongation of the weight bearing side in prone to sidelying & kneeling to half kneeling. • Lateral righting of the unweighted side in prone to side lying & kneeling to half kneeling. • UE weight bearing & weight shifting.

• Lower extremity dissociation with hip & knee flexion on one side, & with hip & knee extension on the other side. • Hip extension with knee flexion. • Elongation of quadriceps & hip flexors. • Activation of the hip extensor & hip abductors.

• Trunk extension on extended hips. • Dissociation of lower extremities under the trunk. • Transitions between ankle planter flexion & dorsi flexion. • Elongation of the ankle dorsiflexor muscle.

Prone on bolster
• Baby’s position: baby sit beside the bolster. • Therapist position: kneel or heel sit behind the baby.

GOALS
• Trunk rotation with symmetrical shoulder flexion. • Hip extension with activation of gluteus maximus. • Symmetrical trunk extension. • UE weight bearing & weight shifting for increased proprioception & stability.

• Active shoulder flexion with elbow, wrist & finger extension. • Elongation of wrist & finger flexors.

Symmetrical stance: weight shifts to the lateral borders of the feet.
• Baby’s position: the baby stands in front of you. • Therapist position: sit or kneel behind the baby with your hands on the baby’s femur.

• Baby’s position: the baby stands side ways to you. The baby’s hands are free at sides. • Therapist position: sitting on a mobile stool.

Thank you……
Thank you……

references
• Baby treatment based on NDT principles. By Lois bly. • www. Google.com.

Symmetrical stance: weight shifts to the lateral borders of the feet.
• Baby’s position: the baby stands in front of you. • Therapist position: sit or kneel behind the baby with your hands on the baby’s femur.

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