NEURODEVELOPMENTAL

TREATMENT (NDT)
IN PAEDIATRICS

VICTORIA PROODAY
MANUELA OCRAINSCHI
ALDA MELO

OCT 1172Y
April 05, 2005
 Agenda

• Defining NDT
• Origins and key concepts of theoretical
approach
• Assessment and intervention
• Evidence of efficacy
• Strengths and limitations
• Recommendations for clinical practice
 NDT
• Advanced hands-on approach to the examination
and treatment of individuals with disturbances of
function, movement and postural control due to a
lesion of the central nervous system (CNS)

• Used primarily with children who have cerebral

palsy (CP) and adults with cerebral vascular
accidents (CVA)

• Practiced by OT, PT, SLP who completed

advanced training in NDT
 Origins of Theoretical Approach

• NDT, first known as “The Bobath approach” was

originated and developed by Berta Bobath,
physiotherapist, and Dr. Karel Bobath in the late
1940s
• Name Bobath is still used in many countries, NDT
is the name commonly used in North America
• Developed from observations, practical
applications and desire to find better solutions for
client’s problems
 Theoretical Approach (cont’d)

• In 1940s dominant therapeutic approach focused

on changing function at the muscular level, but
Bobath hypothesized that the disorder of
coordination of posture and movement is what
prevented functional performance
• Bobath introduced the revolutionary idea that a
therapist could have an impact on client’s
functional movement by influencing the CNS
through carefully guiding the motor output
through handling
 Theoretical Approach (cont’d)
NDT evolution
1. Decreasing muscle tone through the use of reflex
inhibiting postures
2. Incorporation of hierarchical motor sequences into
therapy, with one activity following another during
facilitation (head control, rolling, sitting, quadruped,
kneeling)
3. Facilitation of automatic movement sequences as
opposed to isolated developmental skills
4. Currently, it is recognized the need to direct the
treatment towards specific functional situations
 Theoretical Approach (cont’d)
“Living concept”
Where Bobath Began
Problem-solving approach based on
reflex/hierarchical models
Hierarchical model of CNS structure and
function
CNS viewed as the “controller”. Automatic
postural control mechanism simplified the
responsibility of the CNS in control of
movement
Sensory feedback is important for the
correction of movement errors
“Positive signs” including spasticity and
abnormal coordination of movement are the
most important aspects of sensorimotor
impairments
Muscle and postural tone determine the quality
of the patterns of posture and movement used
in functional activities
Where NDT Is Now
Problem-solving approach based on a
system/selectionist model
Distributed model of CNS structure and function
The CNS determines the pattern of neural activity
based on input from multiple intrinsic systems and
extrinsic variables that establish the context for
movement initiation and execution
Sensory feed-forward and feedback are equally
important for different aspects of movement
control
The “negative signs’, including weakness,
impaired postural control and paucity of movement
are recognized as equally important as the
“positive signs” in limitations of function
limitations of function
Task goals, experience, individual learning
strategies, movement synergies, energy and
interests all affect the quality of the final action
 Theoretical Approach (cont’d)
The basic philosophy underlying all the NDT
assumptions is that lesions in CNS produce problems
in the coordination of posture and movement
combined with atypical qualities of muscle tone that
contribute directly to functional limitations
These functional limitations are changeable when
the intervention strategies target specific system
impairments in activities and contexts that are
meaningful in the life of the person.
 NDT Assumptions
1. Impaired patterns of postural control and movement coordination are the primary
problems in clients with CP
2. These system impairments are changeable and overall function improves when the
problem of motor coordination are treated by directly addressing neuromotor and
postural control abnormalities in a task specific context
3. Sensorimotor impairments affect the whole individual – the person’s function, place
in the family and community, independence and overall quality of life
4. A working knowledge of typical adaptive motor development and how it changes
across the life span provides the framework for assessing function and planning
intervention.
5. NDT clinicians focus on changing movement strategies as a means to achieve the
best energy-efficient performance for the individual within the context of the age
appropriate tasks and in anticipation of future functional tasks.
6. Movement is linked to sensory processing
7. Intervention strategies involve the individual’s active initiation and participation,
often combined with therapist’s manual guidance and direct handling
8. NDT intervention utilizes movement analyzes to identify missing or atypical
elements that link functional limitation to system impairments
9. Ongoing evaluation occurs throughout every treatment session
10.The aim of NDT is to optimize function
 Key Concepts
I. Normal development
• Principles of normal development
   Cephalocaudal, proximal-distal, gross to fine
• Sensory-motor-sensory feedback system
• Components of normal development
a. interplay between stability and mobility
b. effects of postural reflex mechanism on movement
 postural tone
 muscle tone
 reciprocal innervation - interplay between agonist and antagonist muscles during
coordinated muscle movement
 righting and equilibrium reactions
Righting reactions - restore and maintain the vertical position of the head in space, the
alignment of the head and trunk and trunk and limbs
Equilibrium reaction - serve to maintain or regain balance during a shift in the center
of gravity
 the ability dissociate movements
 development of postural control in the three planes of space
• Sequences of motor development
II. Abnormal development
III. Sensory input as a means of bringing about change
 The Assessment Process
NDT focus: to identify the client’s abilities and limitations in
order to tailor an individualized treatment plan and provide a
basis for comparing the client’s abilities at a later point in time.

Assessment consists of data collection, examination and

evaluation.

The examination and evaluation is done at the beginning of

treatment, before and after each session, at the end of each block
of intervention, and at the end of the entire treatment.

Re-
Initial Data Evaluation Plan of care Intervention examination
contact collection Analysis (goals, plan and
objectives) evaluation
 Examination
NDT Focus: to identify constrains that limit the
client’s ability to perform functional activities.

Components:
• Present and anticipated functional skills or
limitation of skills
• Posture and movement components and
compensatory strategies
• Anatomical and physiological status of those
systems that contribute to functional limitations
 Examination (cont’d)

Functional Skills
Gross and fine motor control, communication, and control
of behavior and emotions
•Functional abilities and limitations
•Potential to change function
•Clusters of function and activity limitations
•Relationship between participation and activity level
•Assistive devices, splinting and orthothics
 Examination (cont’d)

Observation of posture, movement and

compensatory strategies
• Spontaneous posture and movement
• Typical and atypical posture and movement
• Compensatory movement strategies
• Alignment, weight bearing, balance, coordination,
muscle and postural tone, and movement components
 Examination (cont’d)

Individual systems related to function

• Neuromuscular system
• Musculoskeletal system
• Sensory, perceptual, cognitive systems
• Regulatory system (arousal, attention, emotional and
behavioral responses)
• Limbic system (emotions, fear, pain)
• Respiratory, cardiovascular system
• Integumentary system (skin)
 Examination (cont’d)

Measurement Tools
• Norm-referenced tests (WeeFIM, AIMS, The School
Functional Assessment)
• Criterion-referenced tests (COPM)
• Non-standardized tests (compare the performance at the
beginning and at the end of the session)
 Evaluation
The therapist observes, describes and formulates
hypothesis, linking treatment planning with outcomes.

• Client’s internal and external resources

• Functional limitations and participation restrictions
• The relationship between posture and movement
components
• Hypotheses regarding impact of impairments on daily
life function
• Potential to change
• Intervention plan developed
 NDT Intervention

NDT Focus: what differentiates NDT

intervention from other approaches is the precise
therapeutic handling, including facilitation and
inhibition, used to provide sensoriomotor cues that
facilitates change in function ( Howle, 2004).

“Handling is graded input provided by the

therapist’s hands at key points of control on the
child’s body…. and results in active control or
movement” (Kramer, 1993, p. 78).
 Principles of Intervention
1. Establish a treatment plan with anticipated outcomes that include specific, observable functions within
a specific time frame under specific environmental conditions.
2. Therapy utilizes client’s strengths, recognizes that each individual has competencies and disabilities.
3. Set anticipated outcomes and impairment goals in partnership with the family, the client, and the
interdisciplinary team.
4. Treatment strategies often include preparation and simulation of critical foundational elements (task
components) as well as practice of the whole task.
5. NDT intervention includes planning and solving motor problems.
6.    Repetition is an important component in motor learning.
7. Create an environment that is conducive to cooperative participation and support of the client’s efforts.
8.  Knowledge of the development of posture and movement components is use in designing treatment
strategies.
9.  A single treatment session progresses from activities in which the client is most capable to activities
that are more challenging.
10. NDT intervention methods include modifying the task, or the environment, and take into account the
current level of the client’s performance and capacity for function.
11. Individual treatment sessions are designed to evaluate the effectiveness of treatment with the session.
12.  Families receive information regarding the client’s problems and management of those problems, as
they are able to understand and assimilate the information.
13.  In an NDT approach, suggestions to the family are as practical as possible.
14.  NDT recommends an interdisciplinary model of service.
15. Coordinate with the goals and activities of all other medical, therapeutic, social, and educational
disciplines to ensure a life-span approach to solving the client’s problems.
 Intervention (cont’d)

Sequence of Intervention
• Preparatory activities for passive movement or body
alignment
• Selection of the key points for therapeutic handling
according to the child’s postural tone
• Facilitation of active or automatic movement patterns
by applying graded and varied therapeutic input
 Intervention (cont’d)
The key points (proximal or distal) are the places of physical
contact between the therapist’s parts of the body or therapy
equipment and client’s body. (Boehme, 1988)     

Proximal key points:

• Located closer to the source of
the problem, usually at the
head, trunk, or large joints
• Used to influence posture and
movement in all three planes
(sagittal, frontal, and
transverse), especially during
difficult moments
 Intervention (cont’d)

Distal key points:

• Located away from the
source of the problem,
usually at the upper and
lower extremities level
• Used to allow the client
to engage in activities
with minimal control of
the therapist
 Intervention (cont’d)   
“Facilitation is the process of intervention which uses
the improved muscle tone in goal-directed activity.
Facilitation techniques involve stimulation of the muscle
activity to produce a desired motor response. It is related
with the functional goal that needs to be achieved.”
(Boehme, 1988, p. 3)

• Modifies postural control

• Guides the child’s posture or movement during the activity
• Techniques: tapping and intermittent compression to provide
proprioceptive and tactile stimulation
 Intervention (cont’d)   

“Inhibition is the process of intervention that reduces

dysfunctional muscle tone.”
(Boehme, 1988, p. 3)

• Reduces the intensity of spasticity

• Reduces the effect of fluctuating muscle tone
• Improves the range and variety of movements
• Not used with hypotonicity
• Techniques: traction and light joint compression
It is used in combination with facilitation
 Intervention (cont’d)   
Weight bearing and weight shifting promote:
• Postural alignment
• Child’s movements
• Proximal stability

Adaptive equipment and orthothic devices

• Allows more independent movement
• Decreases the possibility of deformities and contractures
• Can be used by parents and other professionals to
reinforce the therapy
Role of Play in NDT Intervention with
Children
• Motivates and engages the child
• Provides appropriate stimuli for development of
normal movement patterns
• Fulfills therapeutic goals
• Facilitates the handling techniques
• Facilitates the use of the gained movements in
other activities
• Allows observation of child’s spontaneous and
automatic postures and movements
 Evidence of Efficacy of NDT
Intervention

• Overall research results regarding the efficacy of

NDT are largely inconclusive
• Current research literature does not clearly
demonstrate the efficacy or inefficacy of NDT as a
treatment approach
 Efficacy (cont’d)
• Children who received NDT performed slightly
better than control or comparison groups
(Ottenbacher, et al., 1986)

• Children with cerebral palsy

 6 studies reported benefit vs. 4 studies reported no
benefit (Brown & Burns, 2001)
• High-risk/low birth weight infants
 1 study reported benefit vs. 5 reported no benefit
(Brown & Burns, 2001)

• Only in 4 of the 7 studies was the benefit

statistically significant
 Efficacy (cont’d)

• From 101 studies identified 21 met inclusion criteria

• Overall results did not show an advantage for NDT
intervention over the alternative to which it was
compared
• No consistent evidence that NDT changed abnormal
motor responses, slowed or prevented contractures, or
that it facilitated more normal motor development or
functional motor activities
( AACPDM, 2001)
 Efficacy (cont’d)

• More intensive therapy did not confer a greater

benefit
• 4 of the 21 studies were coded as Level I
(definitive) evidence and 10 were Level II
(tentative) evidence
( AACPDM, 2001)
 Efficacy (cont’d)

Factors that may account for research results

1. Sample size
2. Heterogeneous samples
3. Participants not randomly selected
4. Participants assigned to either a treatment group or a non-
treatment groups without using an adequate blinding
process 
 Efficacy (cont’d)

5. Different assessment tools used to collect the data in each

study
6. Whether many of the measures used are valid and/or
sensitive enough to detect change
7. Variation in outcomes being measured
8. Variation in treatment therapy and duration of
interventions
 Efficacy (cont’d)

• Issues are methodological ones

• Absence of evidence of effectiveness should not
be construed as proof that NDT treatment is not
effective, may just reflect more meaningful
research is needed
• “…a limited number of high quality NDT research
efficacy studies have been published “ (Brown &
Burns, 2001)
 Strengths and Limitations

• Theoretical approach is compatible with OT

principles, but in practice some Ots may be
challenged to keep an occupational perspective
• Approach is supported in many paediatric practice
settings
• Continuing education support for approach
• Requires investment of resources
• In practice is a lot of room for therapist interpretation/
“intuition” (Howle, 2004)
 Recommendations for Clinical
Practice

• When evaluating research evidence may have to go

beyond the systematic review
• Keep occupational perspective
• Doing NDT requires skill and practice----Engage in
continuing professional education!!
 References
Boehme, R. (1988). Improving upper body control. An approach to assessment and
treatment of tonal dysfunction. Tucson, AZ: Therapy Skill Builder.
Brown, G. T., & Burns, S. A. (2001). The efficacy of neurodevelopmental treatment in
paediatrics: A systematic Review. British Journal of Occupational Therapy, 64(5),
235- 244.
Butler, C. & Darrah, J. (2001). Effects of neurodevelopmental treatment (NDT) for
cerebral palsy: an AACPDM evidence report. Developmental Medicine and Child
Neurology, 43, 778-790.
Howle, J.M. (2004). Neuro-develompmental treatment approach. Theoretical
foundations and principles of clinical practice. Laguna Beach, CA: NDTA.
Ottenbacher, K. J., Biocca, Z., DeCremer, G., Jedpvec. K. B., & Johnson, M. B. (1986).
Quantitative analysis of the effectiveness of paediatric therapy: emphases on the
neurodevelopmental treatment approach. Physical Therapy, 66, 1095-1101.
Schoen, S. & Anderson, J. (1993). Neurodevelopmental treatment frame of reference
(pp. 74- 86; pp. 49- 69). In P. Kramer & J. Hinojosa (Eds.) Frames of Reference for
Pediatric Occupational Therapy. Baltimore, MD: Williams & Wilkins.