2.

Enumerate the principles and practices of Neuro Developmental Therapy

INTRODUCTION:

Neuro Developmental Therapy (NDT) / Bobath concept is a problem-solving

approach used in the evaluation and treatment of individuals with movement and
postural control disturbances due to a lesion of the central nervous system (CNS).  It is
named after Berta Bobath, a physiotherapist, and her husband Karel, a psychiatrist /
neuropsychiatrist, who proposed the approach for treating patients affected with CNS
disorders. They developed this approach for effective management of neuro-motor
dysfunctions manifested by children with cerebral palsy (CP). Earlier, braces, passive
stretching, and surgery were the most common forms of interventions.

According to Bobath, the motor problems of CP arise fundamentally from CNS

dysfunction, which interferes with the development of normal postural control against
gravity and impedes normal motor development. Their goal was the establishment of
normal motor development and function and/or the prevention of contractures and
deformities. Their neurodevelopmental approach focused on sensorimotor components
of muscle tone, reflexes and abnormal movement patterns, postural control, sensation,
perception, and memory (i.e. components thought most likely to be impaired as a result
of CNS damage). Handling techniques that controlled various sensory stimuli were used
to inhibit spasticity, abnormal reflexes, and abnormal movement patterns, and were also
used to facilitate normal muscle tone, equilibrium responses, and movement patterns.
The child was a relatively passive recipient of NDT treatment. The normal
developmental sequence was advocated as a framework for treatment.

BASIC PRINCIPLES OF BOBATH CONCEPT:

The following points are what Berta Bobath identified as unique assumptions
about atypical movement, which outlined the basic principles of the Bobath Concept:

1. Muscle weakness or tightness in hemiplegia and cerebral palsy was a direct result of
lesions or damage to the central nervous system (CNS).
2. Individuals with cerebral palsy and hemiplegia had a disorder of posture AND
movement
3 Atypical movement as a result of damage to the CNS had the potential to recover.

PRINCIPLE OF NDT:

NDT is based on the premise that the presence of normal postural reflex
mechanisms is fundamental to a motor skill's performance. The normal postural reflex
mechanisms consist of righting and equilibrium reactions, reciprocal innervation, and
 coordination patterns. The release of abnormal tone and tonic reflexes seen in CP
interfered with the development of righting and equilibrium reactions. It is an interactive
problem-solving approach that focuses on continuing reassessment with attention to
individual goals, developing working hypotheses, treatment plans, and relevant objective
measures to evaluate interventions.

 Regardless of severity, individuals of any age with damage to their CNS can be
handled with this approach.
 It lays emphasis on following interdependent aspects important for optimizing
motor recovery:

1. Integration of postural control and task performance.

2. Selective movement control for the production of coordinated sequences
of movements.
3. Contribution of sensory inputs to motor control and motor learning.

SHAPING CLINICAL PRACTICE THROUGH HYPOTHESIS GENERATION,

THEORIES, ASSUMPTIONS, AND PRINCIPLES:

HYPOTHESIS:
The therapist needs to develop a set of clinical hypotheses to guide the intervention
process. A hypothesis is “a tentative explanation for an observation, phenomenon, or
scientific problem that can be tested by further investigation.” Hypotheses can help to direct
both assessment and intervention.
The therapist who uses the NDT Practice Model to develop a plan of care (POC) could
hypothesize that one person’s inability to stoop down to pick up a box is primarily due to
musculoskeletal impairments like decreased Range of Movements (ROM) and weakness. In
another case the same activity limitation may be due to decreased somatosensory awareness
on the right side. Testing the hypotheses determines the effective POC as well as the choice
of intervention strategies for each patient. The ongoing formulation and testing of hypotheses
are key elements in NDT practice that are uniquely applied in the individual patient’s
evaluation and intervention process.
THEORY:
A theory is a collection of hypotheses that have stood the test of time. A theory emerges
when the same predictions of phenomena are consistently observed across time. Theories can
inform a planner’s thinking during all stages and offer insights to translate into better
intervention. A theory can be explanatory, describing why a problem exists, or it can be
a change theory, guiding the development of health interventions.
ASSUMPTION:
Within broad theories the therapist makes assumptions that guide or frame the entire
evaluation, intervention planning, and implementation process. Assumptions can be explicit
and clearly articulated by the practitioner, or they can be implicit and not even consciously
acknowledged by the therapist. Explicit assumptions can be made specific enough to be
clinically tested, and, based on the findings, the overall theory can be modified.
 For example a clinician may begin every assessment by asking the family about the
activity limitations that most restrict the individual’s participation. Hidden in this practice is
the assumption that intervention is most effective when focused on a functional outcome that
the patient values. If the clinician holds these assumptions as valid, sessions would be
organized around the valued functional outcomes rather than being focused solely on
increasing range of motion, strengthening a muscle, or striving to improve a posture, such as
developing head control.
PRINCIPLE:
The therapist then generates principles to guide the intervention process and aid in
forming a practice model. A principle is “an accepted or professed rule of action or conduct.”
Principles can be general; for example, effective treatment should include active work by the
patient, to far more specific; for example, during intervention for a client with neuromuscular
impairment, the clinician should address the patient’s inability to recruit specific postural
motor units by facilitating sustained isometric contractions of the desired postural muscles in
the shortened range of those. The NDT Practice Model then is framed by our assumptions
and guided by our practice theory, and reflects the collective body of principles.

NDT PRACTICE THEORY:

There are three major categories of questions addressed by NDT assumptions that are
foundational in the NDT Practice Model:
1. How do people function? How are the body systems organized, controlled, or
coordinated in individuals without impairments? How do people typically learn to
participate in or perform activities? How are functions learned at different ages,
physical characteristics, in different contexts, and with different experiences?
2. What goes wrong in the control and coordination of the systems in individuals with
neuromuscular disorders, such as CP, or in cases of stroke or traumatic brain injury
(TBI)?
3. What is the most effective intervention for individuals with disorders of posture and
movement?

THEORETICAL FRAMEWORK:

NDT as a neuromuscular and functional reeducation technique now includes

neuroplasticity as a basis how the brain can change and reorganize itself and its processes
based on practice and experience.

 Facilitation of normal postural alignment and movement patterns.

 Demand should be placed on the involved side during developmental and functional
activities.
 Sensory feedback (manual contact, visual integration, somatosensory reinforcement)
is essential to recovering function.
 Treatment includes looking at the whole person and specific functional needs;
recovery vs compensation.
  Focus on interaction of impairment functions and life participation
 Movement is a sensory motor experience or integration
 By moving proximal parts of the body it is possible to influence change of posture
and movement in distal part
 It is impossible to superimpose normal movement pattern on abnormal ones its
important to inhibit abnormal movements primarily.

AIM OF BOBATH TECHNIQUE:

 Change atypical tone
 Mobilise tight structures
 Activate appropriate muscle groups
 Strengthen weak muscles
 Improve quality of posture and movement with hands-on.
 Take hands off to increase child’s own activity
 Encourage child’s problem-solving skills to improve independence
 Work within appropriate context to improve functional skills

INTERVENTION STRATEGIES:
Intervention consists of therapeutic handling, facilitation, and activation of key points of
control.
Therapeutic handling is used in order to influence the quality of the patients' movements
and incorporates both facilitation and inhibition.
Facilitation is a key technique used by Bobath practitioners to promote motor learning. It
is the use of sensory information (tactile cue through manual contacts, verbal directions) to
reinforce weak movement patterns and to discourage overactive ones. The appropriate
provision of facilitation during the motor task is regulated in time, modality, intensity and
withdrawal, all of which affects the outcome of motor learning.
Inhibition can be described as reducing parts of movement/posture that are abnormal and
interfere with normal performance.
Key points of control generally refers to parts of the body that are advantageous when
facilitating or inhibiting movement/posture.

NDT HANDLING TECHNIQUES:

Inhibition techniques are used to:
• Decrease abnormal muscle tone that interferes with passive and active movement.
• Restore normal alignment in the trunk and extremities by lengthening spastic muscles.
• Stop unwanted movements and associated reactions from occurring.
• Teach methods for decreasing the abnormal posturing of the arm and leg during task
performance.
 Facilitation techniques are used to:
• Provide the sensation of normal movement on the hemiplegic side.
• Provide a system for relearning normal movements of the trunk, arm, and leg.
• Stimulate muscles directly to contract isometrically, eccentrically, or isotonically.
• Allow practicing movements while the therapist maintains some constraints.
• Teach ways to incorporate the involved side into functional tasks and occupations.

OUTLINE OF NDT APPROACH

Patient: Life Role, Supports Systems, Home Environment, Patient's
Individualized Goals
Functional Outcomes
Pathologies, Abilities, Limitations

Optimize use of systems (sensory, musculoskeletal) and available

Motor Control
movement patterns/ synergies

Target the Involved

Progressive, increased demand and functional use
Side

Closed vs. open environment, simple vs. complex, part vs. whole,
Motor Learning
practice and feedback/ knowledge of results 

Coordination with rehab team, parents/ caregivers, and support staff to

Team-Approach
allow for continual practice and consistent use of facilitation strategies

 ESSENTIALS FOR TREATMENT EFFECTIVENESS:

 Therapists must be able to observe and distinguish normal from abnormal alignment
and movement patterns.
 Therapists must be able to make the functional retraining activities meaningful to the
patient; task specific.
 Therapists must be able to select the optimal practice method, feedback, and
environment for maximum function and independence.
 Therapists must have stable footwear, good flexibility in lumbar spine and lower
extremities for optimal body mechanics during mat activities.

KEY ELEMENTS TO APPLYING NDT

Alignment  Cannot impose normal movement on malaligned joints 

Handling  Inhibition, Facilitation, Key points 

Placing  Assisting patients in achieving the appropriate 

CLINICAL APPLICATION OF BOBATH CONCEPT:

MOTOR CONTROL:
. Bobath Concept concerns sensory, perception and adaptive behaviour along with the
motor problem that involves the whole patient. It is a goal-orientated and task-specific
approach, aiming to organise the internal (proprioceptive) and external (exteroceptive)
environment of the nervous system for efficient functioning of the individual. It is an
interactive process between patients and therapists.

Therapy focuses on the following:

• Neuro-muscular system, spinal cord and higher centres to change motor performance,
• Neuroplasticity, an interactive nervous system, and individual expression of
movement.
• Overcoming weakness of neural drive after a UMN lesion through selective activation
of cutaneous and muscle receptors.

It is aimed at preventing development of spasticity and improving residual function.

Therapists can influence hypertonia at a non-neural level by influencing muscle length and
range.

Therapists work on tone to improve movement, not to normalise tone. Tone can be reduced
by:

1. Mobilisation of muscles and stiff joints,

2. Muscle stretch,
3. Practice of more normal movement patterns,
4. Through a more efficient, less effortful performance of functional tasks
5. Weight-bearing.

MUSCULOSKELETAL SYSTEM :

The Bobath approach addresses the problems that occur as a result of impairment of the
developing CNS that affect the individual's sensory - motor, cognitive, perceptual, social and
emotional development

• It recognises the need for thorough analysis of each patient's functional skills and
need for the person's own activity
• It is an important approach to the rehabilitation of patients with neurological injuries.
• It is based on the brain's ability to reorganise (neuroplasticity).
• It is a multidisciplinary approach, involving physiotherapists, occupational therapists
and speech and language therapists.
• Individuals with CNS pathophysiology have dysfunction in posture and movement
and subsequent functional activity limitations.
• This therapy uses guided or facilitated movements as a treatment strategy to ensure
correlation of input from tactile, vestibular, and somatosensory receptors within the body.

NDT AS A STAND-ALONE INTERVENTION :

NDT-based therapy programs will address functional movements that revolve around
postural control and alignment: without it, unsupported movement does not work. This
automatically includes any of the following functional movements and transfers:

1. Head control;
2. Rolling (supine<->sidelying<-> prone);
3. Crawling;
4. Sitting unsupported;
5. Functional reaching of the arm;
6. Quadruped positioning;
7. Kneeling;
8. Standing unsupported;
9. Side-lying to sitting;
10. Sit-to-stand transfers;
11. Stand pivot transfers;
12. Ambulating;
13. Jumping;
14. Running.
NDT has been proven effective for cerebral palsy and hemiplegia. Nowadays NDT has
been tried in various conditions like
- Traumatic Brain Injury
- Spinal cord injury (SCI)
- Brain tumor
- Dementia
- Multiple sclerosis (MS)
- Parkinson’s disease (PD)
- Amyotrophic lateral sclerosis (ALS)
- Infection-related encephalitis

CONCLUSION:
Cerebral palsy is long-life, but improves with adequate intervention. NDT is in practice a
successful approach but we should not think that we can cure a brain lesion or cerebral
palsy, or that we can change all cases to only “minimal”cerebral palsy. If the treatment is
started before abnormal patterns of movement have become established, we can help the
child to organise his potential abilities in what for him is the most normal way.