Evolution of Neurodevelopmental

Therapy ( NDT)

RAGUL . M
MOT-2ND YEAR
Introduction

• There are a number of neurological approaches used in

the management of the patient following a neurological
deficit.

• The Bobath Concept is one of the most commonly

used of these approaches and it offers therapists working
in the field of neurological rehabilitation a framework for
their clinical interventions.

• The Neuro-Developmental Treatment (NDT)

frame of reference is a dynamic hands-on treatment
approach guiding occupational therapists globally in their
assessment and intervention of pediatric clients who
experience posture and movement impairments.
• This client-centered perspective provides an
individualized, problem-solving framework for
managing the motor skill challenges that limit the child’s
participation in life roles.

• Sensorimotor techniques are the fundamental

applications of this frame of reference, focusing on
prevention, remediation, and reeducation of movement
within a functional context.
History :
• Berta Bobath, physiotherapist and her husband, Dr.
Karel Bobath first developed the ‘‘Bobath approach’’
in the 1940s. This approach was later identified in the
scientific literature as the NDT approach for children
with cerebral palsy .

• Mrs. Bobath proposed that with guided movement

experiences, children with cerebral palsy could change
their muscle strength and length leading to changes in
functional performance (Bobath, 1948).

• Through NDT intervention, Mrs. Bobath detected

observable and palpable changes in the neuromotor
systems of her patients with cerebral palsy.
• The Bobaths themselves have said: “Since we began
our treatment in 1943 we have been learning constantly,
and experience has taught us to change our approach
and our emphasis on certain aspects of our treatment.”

• Nonetheless the basic concept has stayed the same

with the emphasis being on the neurological aspect of
the movement disorder and the therapist’s ability to
observe and analyse this disordered movement.

• The Bobaths emphasised that NDT was not a

“method of treatment” as this would imply something
rigid and standardised; rather it was a flexible
approach to management which would accommodate
the tremendous variations seen in cerebral palsy.
• As newer understandings of movement and
movement control have evolved so has the approach
grown and developed.

• The Bobath Concept was not exclusive but could be

applied to all patients with a disorder of motor control,
regardless of how severe their cognitive or physical
deficits might be.

• The Bobath Concept continued to develop throughout

Dr and Mrs Bobath’s life time. In 1984 the Bobaths
founded the International Bobath Instructors Training
Association (IBITA) , an organisation that maintains the
standards of teaching and developments of the Bobath
Concept worldwide.
• In the late 1990s the Neuro-Developmental
Treatment Association (NDTA) adopted a model of
practice entitled the ‘‘NDTA Enablement Model of
Health and Disability’’ guided by the World Health
Organization’s International Classification of
Functioning, Disability and Health Model.

• The Enablement/Disablement model of NDT considers

the ‘‘whole’’ person, recognizing both competencies and
limitations in a wide variety of domains.

• NDT Enablement/Disablement model is the focus upon

the domain of motor function as the key contribution of
the NDT frame of reference to the occupational
performance of the client
NDTA Enablement Model of Health and Disability
• Mrs Bobath stated that each therapist works
differently according to their experiences and
personality, but all can build treatment upon the same
Concept (Schleichkorn 1992).

• Dr Bobath stated ‘the Bobath Concept is unfinished,

we hope it will continue to grow and develop in years to
come’
Concepts of NDT :

 Motor control:
• The mechanism for motor control is described in
more functional terms by the “normal postural reflex
mechanism” .

• These include the three components necessary for

performance of skilled movement.
1) normal postural tone
2) reciprocal innervation
3) normal pattern of coordination
1) Postural tone:
It is consider to be a dynamic phenomenon
constantly changing to provide the adequate amount of
fixation to the body to support itself against gravity and
to perform skilled movement.

2) Reciprocal innervation:
• It is related to the concept of Postural tone.
• It is referred to as reciprocal inhibition when there is a
controlled inhibition of antagonist with contraction of
the agonist.
• The antagonists are inhibited in a finely graded
manner, not only to permit the movement of the agonist,
but also to modify and guide the movement.
example:
Co contraction , which is the controlled simultaneous
activation of both agonist and antagonist . This form of
reciprocal innervation is important for postural control
such as standing on one leg.

3) Coordinated patterns of posture and movement:

It includes the patterns of posture and movement
common to all of us that we need to perform activities of
daily life.
 Kinesiological and Biomechanical concepts:

NDT draws upon kinesiological and biomechanical

concepts as a theoretical foundation for analysis and
treatment of posture and movement
impairments.

Important concepts are planes of movement,

alignment, range of motion (ROM), base of support,
muscle strength, postural control, weight shifts, and
mobility.
Planes of movements:
 Sagittal plane - motor control begins in sagittal
plane with babies rehearsing flexion and extension
movements of their bodies against gravity.
 Frontal plane - Movements in the frontal plane begin
to integrate with sagittal plane movements as the baby’s
torso muscles become active and biomechanically
competent in producing forces against gravity.
 Transverse plane - Transverse plane movements are
the most sophisticated motor patterns of typical
development requiring interplay of the musculature
developed in the sagittal and frontal plane. Movement in
the transverse plane enables rotation around the body
axis necessary for developing balance and posture in
space.
• Alignment of the body:
It refers to the arrangement of these bodily segments
relative to each other with reference to the force of
gravity, the base of support, and the nature of the task.

• Range of motion:
It is the joint flexibility allowed at a joint. Normal
voluntary, active joint ROM is also required for
movement production.

• Base of support
It is the area of the body that is in contact with the
support surface
• Weight shifts and mobility off the center of mass is
required for a person to be able to meet varying demands
of task performance. Movement of the body in space
requires a shift of weight off the center of mass in one of
the various planes of movement.
 Sensory and Musculoskeletal system:

Our exteroceptors, especially the eyes and ears, are the

initiators of our motor responses which are subsequently
guided and controlled throughout their courses by the
feedback from muscles, tendons and joints , that is from
our proprioceptors .
 Theories
1) Hierrachial theory:

• The first NDT interventions were based on the

scientific understanding that prevailed in the 1940s and
1950s.

• At that time, the investigators thought that the central

nervous system was 'hard‐wired', which meant that
voluntary movement was controlled by a higher
level cortical centre, while lower centres controlled
more primitive reflexes. This was known as a
'hierarchical/reflex model'.
• Motor control is hierarchically arranged: HIGHER,
MIDDLE, and LOWER levels of CNS.
• Higher centers regulate and control the middle and
lower centers.
• Damage to the CNS results to disruption of the
normal coordinated function of these level.
Current theoretical foundation:

• As a ‘‘living concept,’’ NDT draws upon the

knowledge of evolving contemporary science.

• Movement analysis, problem solving, and handling

intervention prevail as primary constructs aimed at the
influence of posture and movement skills in pediatric
clients.

• Primary concepts of therapeutic exercise,

biomechanics, and kinesiology contribute to core NDT
theoretical foundations.
2) Dynamic Systems Theory:

• Movement is an interactive process between

multiple systems.

• Typical control of posture and movement relies upon

interplay between elements of the various neural and
body systems, the task, the individual, and the context of
the task.

• The Dynamic Systems perspective rejects the

hierarchical ‘‘top-down’’ perception of the nervous
system operating as a control center over the production
of motor skills.
Dynamic system theory:
• The nervous system codes and learns movements
related to task and environmental conditions.
Movements having functional relevance to a person are
stored as a ‘‘dynamic system’’ of information processing.

• When one element in the movement system is altered,

change is observed in the entire movement system.
3) The Neuronal Group Selection Theory:

• This theory provides the occupational therapist with

an understanding of the neuronal interactions inside the
CNS contributing to movement production.

• According to Neuronal Group Selection Theory, the

brain is dynamically organized into neural networks or
neuronal groups that share connections related to their
function.

• Engagement with the environment and tasks shape

these neuronal groups, creating networks of hardwired
neurons engrammed through repeated experience.
• In each individual’s nervous system is shaped by the
distinct and unique experiences of that individual,
accomplished by a selective neurobiological process
known as ‘‘pruning.’’ The nervous system selectively
cuts back on neural connections that are unnecessary
while trimming and organizing the connections of value.

• NDT uses handling as its ‘‘key’’ treatment strategy

correlating enhanced somatosensory input with
movement, loading the nervous system with additional
neurochemical information to reinforce the neural
mapping process.
4) Sensory contributions:

• NDT recognizes two distinct types of complementary

sensory systems contributing to the production of well-
coordinated movement.
1) Feedforward sensory system
2) Feedback sensory system

• The feedforward sensory system is a proactive sensory

system that anticipates and initiates movements
intrinsic to the person, while the complementary
feedback sensory system reacts to the environment,
regulating and adapting motor execution.
• Together these sensory systems interact within the CNS
fueling the motor system with information about the
movement, the task, and the environment.

• Sensory processing is the ability to receive, register,

and organize sensory input for use, facilitating creative
and adaptive responses to the surrounding environment.

• The acquisition of complex, intentional, and accurate

coordinated movements requires precise registration
and interpretation of sensory feedback received from the
movement and the environment.
• Registration of this sensory information within the
nervous system serves as an internal mechanism for,
1) Detection of movement errors
2) the learning of new movements,
3) motor planning, and skilled motor execution.

• Movements created by an individual’s motor system in

the absence of sensory feedback from the body or the
environment are derived from the feedforward sensory
system, preparing the motor system with appropriate
sensory information in advance of muscle recruitment.
• NDT provides the child with enriched motor
experience and opportunity to practice movements
emphasizing sensorimotor feedback and providing
possibilities for problemsolving movement strategies.

5)Motor learning:

• NDT also assimilates principles of motor learning

theory into its primary theoretical foundations.

• Motor learning theory is a set of processes that directly

relate to practice or experience leading to relatively
permanent changes in the capability for movement.
• NDT intervention structures motor learning experiences
eliciting active movement participation from the client.

• Physical and cognitive, verbal and nonverbal

guidance as well as verbal and nonverbal
feedback in relationship to performance are shared
elements of motor learning theory and NDT
intervention.

• Transfer of newly learned skills into daily life settings is

an inherent feature of the NDT approach.
• There are numerous variables that are considered to
be important determinants in motor learning,
1) practice (amount, variability, contextual
interference [order of repetitions such as blocked or
random]
2) part or whole task
3) augmented feedback (frequency, timing)
4) mental practice
5) modelling
6) guidance
7) attentional focus (goal attainment)
8) contextual variety.
Evolution:
Inhibiting techniques
• Inhibition techniques are meant to suppress abnormal patterns
of movement. The techniques for inhibition have changed over
the years.

• In the 1950s, Reflex inhibiting postures were used during

treatment to inhibit abnormal pattern of movement.

• The patient was held in postures that reversed the abnormal

patterns interfering with movement.

• Although the `postures' inhibited spasticity by modifying its

patterns, they were seen to be too passive and prevented
movement. This did not allow for any carry-over into
movement and function.
• She clearly states that using static postures is ineffective
in the long term in inhibiting spasticity.

Handling
and KPC
Reflex
Inhibiting
patterns
Reflex
Inhibiting
Postures
Reflex Inhibiting patterns:
• The reflex inhibiting patterns allowed the control of
movement from key-points of control where
techniques of inhibition, stimulation and facilitation
could be applied.

• In this way, the child could be more active, the

pattern and quality of movements could be guided and
controlled and whole sequences of movement could be
facilitated without the influence of hypertonus.
• As a result of reflex inhibiting pattern, the child
can feel more normal tone and freedom from the
abnormal reflex activity allows the child to perform the
normal movements facilitated by the therapists.

• The bobaths stated that the child needs a great deal of

active movement, with the use of key points or
appropriate points of contact, to provide inhibition
and , at the same time, guide patients through active
movement.

• Bobath clearly states that using static postures is

ineffective in the long term in inhibiting spasticity; the
patient must be active while the therapist assists the
patient to move using keypoints of control and reflex
inhibiting patterns
Handling and Key Points of Control:

• Therapeutic handling is the primary intervention

technique of NDT. When handling, the therapist places
his or her hands purposefully and precisely upon the
child’s body to specifically influence posture and
movement.

• Handling directs, regulates and organizes tactile,

vestibular, and proprioceptive contributions of
movement production thereby it controls various
sensory stimulus.
• Through handling, the child is guided to decrease the
amount of excessive muscle force used to stabilize the
body segments.

• As the child develops independent motor control, the

therapist diminishes handling support as the child
assumes greater internal control of his or her movement
strategies.

• Handling is based upon principles of

biomechanics, laws of physics, and knowledge of
anatomy and kinesiology.
 Handling progresses from
passive elongation and alignment

active assisted movement

resistive activities, which ensures desired muscle

synergy during task performance.

 The placement of the therapist’s hands needs to be

preplanned and monitored ensuring against
unnecessary and potentially confusing sensory
information.
• Light pressure touch may leave the child feeling
insecure or confused about the movement expectations.
If the pressure is too heavy, however, movement may
be ‘‘blocked’’ or minimized by the therapist’s excessive
sensory information.

• The therapist’s hands serve to guide rather than control

movements.

• Initially, hands-on placement may be necessary for the

execution of all of the child’s movements. In time as the
child develops greater internal motor control, the
therapist reduces the pressure and handling intensity
promoting increasingly independent problem
solving and motor execution.
Mrs. Bobath called the hand
placement as ‘‘key points of
control.

CKP (Central Key Point)

🠶 Ant (sternum)

🠶 Post (spine
PKP (Proximal Key Point):

 Shoulder/scapula, pelvis/hip
 Located closer to the source of the problem.
 Used to influence posture and movement in all three
planes(sagittal, frontal, and transverse).

DKP (Distal Key Point):

 Located away from the source of the problem, usually at

the upper and lower extremities level.

 Jaw, wrist, base of the thumb, ankle, big toe,

elbow, knee.
 Used to allow the client to engage in activities with
minimal control of the therapist.

 Head may be a proximal or distal KPC.

 Distal key points of control are only effective when the

child possesses sufficient proximal control.

 Therapists must be very conscientious not to pull on

an extremity that is subluxed, flaccid, or out of
alignment when facilitating movement with a distal hand
placement.
Whether NDT should follow the treatment in
Developmental sequence........?

• As the normal development of an infant was thought to

follow a predictable sequence based on the hierarchical
development of the levels of the nervous system.

• Consequently early NDT treatment of the cerebral

palsy child followed the normal sequence of development
and therapy was progressed according to that sequence.

• However the Bobaths themselves had already

abandoned this aspect of treatment, noting that even
normal children do not adhere to such a strict
developmental sequence.
• Treatment should not attempt to follow the
sequence of development , Rather it should be
decided what each child needs most urgently at any one
stage or age and what is absolutely necessary for him in
preparation for future functional skills or for improving
the skills he has, but performs abnormally.

• There is no time to waste on unspecified

developmental treatment, for we cannot expect that
such treatment will automatically carry over into
functional skills later on.
• The Bobaths discussed their realization that their
treatment had not automatically carried over
into activities of daily life, as they had expected it
would.

• Consequently, systematic preparation for specific

functional tasks was instituted with an aim of treating
the children in actual settings where they live,
play, and learn.
The Bobath Concept in Present and Future.....!!!!

• We are still working to achieve a more functional

application of the concept, through systematic
preparation for skills, thorough parent training and
liaison with other professionals involved in the
management of each child.

• Treatment of children in functional situation is

encourage.

• The important role of NDT in preventing contracture

and deformity is stressed.
OLD THEORY NEW THEORY

Hierarchical brain organization Systems Model

Static postures and positions used Client is an active participant in

for treatment the session
Progressing the client through Developmental milestones serve as
normal developmental milestones guidelines but should not be
strictly adhered to .

Development of control proceeds Control of movement develops in

in a cephalocaudal direction proximal to distal or distal to
proximal directions
Work on components of Client must work on functional
motions which the child will then tasks to learn the skill
apply to function

CNS viewed as the “controller”. 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.
Muscle & postural tone Task goals, experience,
determine the quality of the individual learning strategies,
patterns of posture & movement movement synergies, energy and
used in functional activities. interests all affect the quality of
the final action .
Assessment.
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

Inhibition of spasticity, abnormal reflex and movement

pattern
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 .

Role of Play and functional activities in NDT Intervention

with Children.
Conclusion:

 The Bobath concept will not change although the

application of it will continue to develop over time as we
learn more both clinically and theoretically.

 . The essence of the concept will always be:

 The emphasis on quality of movement.

 Geared towards function with regard to quality.
 Forward looking: consideration of long-term
outcome especially regarding orthopaedic intervention.
 Individual treatment/programme planning.
 Non-selective: able to treat any disorder of motor
control.
 The client is seen as a whole.
 Parent (helper) training is essential.
 Multidisciplinary approach with an emphasis on
teamwork.

 Every client, whether a child or an adult, has the

potential for more normal activity and function. Our
responsibility as therapists is to discover the best way for
our clients to achieve their best potential.
Dr Bobath
stated ‘the
Bobath
Concept is
unfinished,
we hope it
will
continue to
grow and
develop in
years to
come’
Reference:
1) Forssberg H, Hirschfeld H , The Bobath Concept — Evolution
and Application, Movement Disorders in Children. Med Sport
Sci. Basel, Karger, 1992, vol 36, pp 1-6 .
2) Sue Rain, Bobath Concept; Theory and Clinical Practice in
Neurological Rehabilitation. 2009
3) Joanne v, Toby L; Neurodevelopmental treatment: A review of the
writings of the Bobaths, Paediatric Physical Therapy, 1991; 125-
129.
4) Charlene B, Johanna D; Effects of neurodevelopmental treatment
(NDT) for cerebral palsy: an AACPDM evidence report,
Developmental Medicine & Child Neurology 2001, 43: 778–
790.
5) Louise F, The Efficacy of the Neurodevelopmental Therapy
treatment approach in 4-7 year old children with cerebral palsy,
THE UNIVERSITY OF STELLENBOSCH, 2001, 1-148.
6) Dina M , Motor-Learning Theory and the Neurodevelopmental
Treatment Approach: A Comparative Analysis, Occupational
Therapy in Health Care, 1996: 10, 25-39.

7) Paula Kramer, Paediatric Occupational Therapy, 3rd edition.