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
• In 1940sdominant 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.

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 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

Where Bobath Began Where NDT Is Now

Problem-solving approach based on Problem-solving approach based on a system/selectionist

reflex/hierarchical models model

Hierarchical model of CNS structure and Distributed model of CNS structure and function
function

CNS viewed as the “controller”. Automatic The CNS determines the pattern of neural activity based on
postural control mechanism simplified the input from multiple intrinsic systems and extrinsic variables
responsibility of the CNS in control of that establish the context for movement initiation and
movement execution

Sensory feedback is important for the Sensory feed-forward and feedback are equally important for
correction of movement errors different aspects of movement control

“Positive signs” including spasticity and The “negative signs’, including weakness, impaired postural
abnormal coordination of movement are the control and paucity of movement are recognized as equally
most important aspects of sensorimotor important as the “positive signs” in limitations of function
impairments limitations of function

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Muscle and postural tone determine the Task goals, experience, individual learning strategies,
quality of the patterns of posture and movement synergies, energy and interests all affect the quality
movement used in functional activities of the final action

4. Currently, it is recognized the need to direct the treatment towards

specific functional situations.

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

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 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
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

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  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

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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
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
• contribute to functional limitations

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
Individual systems related to function
• Neuromuscular system
• Musculoskeletal system

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 • Sensory, perceptual, cognitive systems
• Regulatory system (arousal, attention, emotional and
behavioral responses)
• Limbic system (emotions, fear, pain)
• Respiratory, cardiovascular system
• Integumentary system (skin)
• postural tone, and movement components
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

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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.

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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.

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.

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

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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

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“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
“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
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 • Techniques: traction and light joint compression
It is used in combination with facilitation
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
• Children who received NDT performed slightly better than control or
comparison groups (Ottenbacher, et al.,1986)

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 • 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
• 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)
• 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)
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
groupsDifferent assessment tools used to collect the data in each
study
5. Whether many of the measures used are valid and/or sensitive
enough to detect change
6. Variation in outcomes being measured
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7. Variation in treatment therapy and duration of interventions
8. without using an adequate blinding process
9. Issues are methodological ones
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!!

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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 & Wilkin….

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