Stroke: NDT FOR UPPER EXTREMITY FUNCTION 1

Reviewing the effectiveness of Neuro-Developmental Treatment on upper extremity functional

capacity in adults post-stroke.

Linda Ng and Emily Sosa

University of Utah
Stroke: NDT FOR UPPER EXTREMITY FUNCTION 2

Introduction

In the United States alone, stroke is the leading cause of long-term disability, costing

$38 billion per year (Dobkin & Dorsch, 2013). Impairments to the upper extremity (UE)—mainly

the arm or hand on one side of the body—are the most common disabling deficits after

stroke/cerebrovascular accident (CVA). Highly prevalent deficits can include: muscle weakness,

sensory loss and pain, which can contribute to limitations in carrying out meaningful activities

(Faria-Fortini, Michaelsen, Cassiano & Teixeira-Salmela, 2011).

Upper extremity functional capacity refers to the ability for a person to use his or her

upper limb in performing a task or activity that the individual views as necessary or desired in

his or her life. These tasks are activities of daily living (ADLs) that can include basic self-care

(bathing, grooming, dressing, eating, etc.). Functions that may require more independence can

include cooking, cleaning, laundry, shopping, driving, etc. and can be referred to as instrumental

activities of daily living or IADLs (“Functional Capacity,” 2002). People living with mobility and

functional use limitations in the upper extremity often have difficulty and restrictions in ADLs and

social participation (Kim, 2016). Upper extremity function in post-stroke rehabilitation can be

identified as a contributing factor for people to return to meaningful occupations, including ADLs

and IADLs.

The goal of post-stroke rehabilitation is to reduce impairments so that individuals can

return to the aforementioned aspects of life, as independently as possible. Neuro-

Developmental Treatment (NDT/Bobath) is a common approach used to address post-stroke

impairments. Neuro-Developmental Treatment was developed in the 1940s by Keral and Berta

Bobath for individuals with pathophysiology of their central nervous system, primarily children

with cerebral palsy and adults with CVA. This treatment attempts to integrate both sides of the

body—affected and unaffected during intervention. It incorporates therapeutic handling, which is

made up of interaction between the client and therapist, using two techniques: inhibition and

facilitation. Inhibition is used to treat and decrease hypertonicity, spasticity, and abnormal
Stroke: NDT FOR UPPER EXTREMITY FUNCTION 3

movements. Facilitation is used to help individuals learn or relearn normal movements (Semer,

2011). Ultimately, these techniques activate sensorimotor processing, task performance and

skill acquisition to facilitate participation in purposeful movements and activities (Instructors

group of NDTA, 2016).

The NDT approach is one of the most popular methods used across various countries in

treating individuals post-stroke (Tariah, Almalty, Sbeih & Oraibi, 2010). The Neuro-

Developmental Treatment Association (NDTA) offers certification and advanced courses geared

toward physical and occupational therapists and speech-language pathologists. The association

also offers conference and seminar opportunities intended for non-therapist audiences. All of

these courses can be rather costly. The purpose of this paper is to evaluate the available

evidence of the effects of using NDT to improve upper extremity functional capacity in adults

post-stroke, and to present whether the rationale exists to pay for the training to implement NDT

over other rehabilitation techniques.

Methods

This review of literature, published in English between 2005 to 2018, was conducted

using multiple databases (CINAHL, EBSCO, OTSeeker, PubMed, Scopus). Keywords used for

the search included: adults, stroke, post-stroke, CVA, Neuro-Developmental Treatment, NDT,

Bobath, upper extremity, upper limb. References of some identified articles were also reviewed

to find other relevant articles that may not have been included in the results of the database

searches.

One hundred and eleven articles were initially determined to have relevance to the

research question, but an inclusion criterion reduced the number of related articles to eight.

Only studies examining the effect of NDT or Bobath Concept on upper extremity function or

sensorimotor recovery in adults (18+ years of age), post-stroke, as part of one or multiple

outcomes, were included in this review. Studies reported in this review include: randomized

controlled trials (RCTs), two one-group pre- and post- test design, and a systematic review of
Stroke: NDT FOR UPPER EXTREMITY FUNCTION 4

RCTs. Quality of each article was based on whether they were peer-reviewed, the

Physiotherapy Evidence Database (PEDro) score in RCTs, and the level of evidence based on

a modified version of the levels of evidence that was developed by Sackett et al. (2000). Sample

sizes of all the studies reviewed herein ranged from 12 to 62.

Results

Of the 111 articles found to be relevant to the research question, eight fit the inclusion

criteria for this review. Five of the eight studies are RCTs, are considered to be at evidence level

one, and have a PEDro score of at least five. These studies include measures at multiple points

in time for at least two different intervention groups (Huseyinsinoglu, Ozdincler & Krespi, 2012;

Langhammer & Stanghelle, 2011; Pelocini et al., 2016; Platz, Eickhof, van Kaick, Engel, &

Pinkowski, 2005; Tariah, Almalty, Sbeih & Al-Oraibi, 2010). A level one, systematic review of

randomized controlled trials, intended to evaluate evidence of the effectiveness of NDT in stroke

rehabilitation is included. Seven of the sixteen studies in the systematic review investigated the

use of NDT to regain sensorimotor control of an affected upper limb following a stroke (Kollen et

al., 2009). Two studies of the eight included articles, at evidence level three, are one-group, pre-

and post-test designs that aimed to find the results of using NDT for the rehabilitation of UE

function in adults post-stroke (Mikolajewska, 2011; Mikolajewska 2014). Table 1 contains an

overview of the studies included in this review.

Five studies were conducted in an outpatient setting (Huseyinsinoglu et al., 2012;

Langhammer & Stanghelle, 2011; Mikolajewska, 2011; Mikolajewska 2014; Pelocini et al.,

2016), another study was conducted in multiple inpatient settings (Platz et al., 2005), and the

last two studies were a combination of inpatient and outpatient treatment and assessments

(Kollen et al., 2009; Tariah et al., 2016).

Three RCTs and the systematic review showed significant differences in outcome

measures, in favor of other approaches over NDT. Huseyinsinoglu et al. (2012) found

significantly better Amount of Use Scale and Quality of Movement Scale scores (P = 0.003, P =
Stroke: NDT FOR UPPER EXTREMITY FUNCTION 5

0.01) at the end of treatment in the Constraint-Induced Movement Therapy (CIMT) group over

the NDT group. Langhammer and Stanghelle (2011) found that the items from the Sodring

Motor Evaluation Scale (SMES): arm (p = 0.02-0.04) and hand (p = 0.01-0.03), were

significantly better in the Motor Relearning Program group than the NDT group. Platz et al.

(2005) showed significant gains in motor outcomes of augmented exercise therapy time (AETT)

BASIS group over AETT Bobath group (p = 0.0432) and significantly less deterioration of

passive joint motion in BASIS group (p = 0.0090). In the 2009 systematic review of RCTs done

by Kollen et al., there were significant improvements in outcomes in favor of other approaches

over NDT in three of the seven relevant studies. The remaining four studies showed no

significant differences between groups.

In relation to motor outcome, Tariah et al. (2016) found significant differences between

the CIMT group and the NDT group, in favor of CIMT. Only the initial post-treatment

measurement in the Wolf Motor Function Test (WMFT) functional ability score (P = 0.003) was

significant. While there were significant improvements found in the Pelocini et al. (2016) study in

all outcomes for both the Functional (NDT) group and Non-Functional group, no significant

differences in UE sensorimotor, function and independence were found between groups. The

2011 Mikolajewska (2011) article was one of the evidence level three studies that found

significant improvements using NDT in hand functions using the Bobath Scale. Recovery

occurred in 55 participants (91.66%), relapse was not stated, and there were no measurable

changes in 2 participants (3.33%). Mikolajewska (2014) also showed significant improvements

in and NDT group, pre-to-post, in upper limb muscle tone, hand function and selected ADLs (P

= .003, P = .000 and P = .000).

Discussion

In examining NDT interventions in patients after stroke, eight studies were identified to fit

the inclusion criteria for this review. Overall, there were six, evidence level one studies (RCTs

and a systematic review of RCTs), that showed a statistically significant improvement in the
Stroke: NDT FOR UPPER EXTREMITY FUNCTION 6

NDT groups; however, no statistically significant differences between results of the NDT method

and other therapy methods. Two studies at evidence level three, indicated statistically significant

differences between pre- and post-test results of a single treatment group.

The reviewed literature can be placed at level A, class I on the American Heart

Association evidence-based scoring system. Justification for this score is based on the

evaluation of the eight studies. Many were RCTs conducted across multiple populations and

found similar results. In all of the studies examined in this review, NDT groups showed

statistically significant improvement from baseline in the upper extremity functional measures;

however, NDT results did not show statistically significant improvement over other therapies.

Neuro-Developmental Treatment can be an effective therapy in occupational therapy for

rehabilitation of adults living after a stroke to improve upper extremity functional capacity and

individuals’ ability to perform meaningful ADLs and IADLs. However, there are other factors to

consider. The long-term effects of NDT post-stroke is not well established in these studies. Also,

the difference in treatment settings could be a confounding factor that elicits need for further

investigation. Because NDT groups did not show statistically significant differences in

comparison to other treatment groups, there is left more area for inquiry. Additional studies with

more specific objectives that investigate setting and long-term effects are needed to help

determine the value of using NDT over other treatments.

Stroke: NDT FOR UPPER EXTREMITY FUNCTION 7

References

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Faria-Fortini, I., Michaelson, S.M., Cassiano, J.G., & Teixeira-Salmela, L.F. (2011). Upper

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Stroke: NDT FOR UPPER EXTREMITY FUNCTION 9

Table 1.

Study Participants Therapy Outcome Measures Results

Characteristics of Interest

Huseyinsinoglu et al. N=24 Time: NDT received 1 MAL-28 AOU Significant

(2012) 18-80 years of age hr of training, CIMT MAL-28 QOM improvements seen in
Level 1 3-24 months post received 3 hrs of WMFT MAL-28 (subjective) in
RCT N(NDT)=11 training for 10 MESUPES CIMT over NDT
PEDro=7 N=(CIMT)=13 consecutive weekdays FIM
2 dropped out Place: Outpatient No significant
11 analyzed physiotherapy dept of differences in motor
stroke unit scores between groups

Kollen et al. (2009) 7 of 16 studies Not specified for all FMA 3 of 7 studies showed
Level 1 (sensorimotor control of studies SMES significant between
Systematic Review of UE) RMA group improvement in
RCTs favor of other
PEDro>6 approaches

4 of 7 showed no
significant differences
between approaches

Langhammer, B. & N=61 Time: 5 days per week, MAS Statistically significant
Stanghelle, J.K. (2011) 4 dropped out from 40 min sessions for SMES difference in favor of
Level 1 each group length of stay MRP over NDT
RCT N(NDT)=29 intervention
PEDro=5 N(MRP)=24

Mikolajewska (2011) N(NDT)=60 Time: 30 min sessions Bobath Scale Recovery in 55 cases,
Level 3 42-86 years of age for 5 days per week for Relapse not stated; No
One-group pre-post 6 weeks-3 years post two weeks, a total of 10 measurable changes in
design sessions 2 cases
Place: Outpatient
rehabilitation Significant and favorable
changes in health status
described by Bobath
Scale

Mikolajewska (2014) n=35 Time: 5 days of Ashworth Scale for 23 showed no

Level 3 65+ years of age treatment for two Grading Spasticity improvement from the
One-group pre-post 1 month - 3 years weeks (10 sessions Bobath Scale Ashworth Scale; 32
design post-stroke total) Barthel Index indicated recovery in the
MD interpretation Bobath Scale, while 16
had no recovery

Statistically significant
difference in pre- and
post- tests results

Pelocini et al. (2016) N=12 Time: 30, 90 minute FMA Participants improved
Level 1 38-71 years of age sessions, five times per ARAT significantly in Fugl-
RCT 1-10 years post week for 6 weeks MBI Meyer immediately after
PEDro=7 N(FS/NDT)=7 Place: not specified treatment in both groups.
1 dropped out
N(NFS)=6 No significant difference
in outcomes was
observed between
groups at any point of
evaluation

Platz et al. (2005) N=62 Time: over 4 weeks, all FMA (arm motor) Significant gains in
Level 1 3 weeks - 6 months participants received FMA (arm sensation) motor outcome in BASIS
RCT post “usual treatment”, FMA (joint) group
PEDro=8 N(no AETT)=20 AETT groups received ARAT over Bobath group
N(AETT as Bobath)=21 20 extra arm training Ashworth Scale (p=0.0432)
Stroke: NDT FOR UPPER EXTREMITY FUNCTION 10

1 did not complete sessions, 45 min each MBI

N(AETT as BASIS)=21 Place: 3 inpatient Passive joint motion
1 did not complete neurorehabilitation deteriorated less in
centers BASIS group (p=0.0090)

Tariah et al. (2010) N=18 Time: CIMT 2 hrs per WMFT Initial post-treatment
Level 1 >40 and < 75 yrs of day, 7 days per week MAL WMFT significant
RCT age for 2 mos; NDT 2 hrs FMA improvement in CIMT
PEDro=7 2 months post per day during over NDT
N(control/NDT)=10 weekdays, home
2 dropped out program 2 hrs per day Initial post-treatment
N(CIMT)=10 during weekend for 2 MAL significant
months improvement within NDT
Place: CIMT home-
based; NDT Outpatient CIMT showed no other
rehabilitation and home significant improvement
in any other arm motor
function outcomes over
NDT

Note: ARAT=Action Research Arm Test; Bobath Scale; FIM=Functional Independence; FMA=Fugl-Meyer

Assessment; MAL=Motor Activity Log; MAL-28 AOU=Motor Activity Log-28 Amount of use; MAL-28

QOM=Motor Activity Log-28 Quality of movement; MAS=Motor Assessment Scale; MESUPES=Motor

Evaluation Scale for Upper Extremity in Stroke Patients; MBI=Modified Barthel Index; RMA=Rivermead

Motor Assessment; SMES=Sodring Motor Evaluation Scale; WMFT=Wolf Motor Function Test