Brief introduction to NDT

By Kinjal Shah (intern from SGMPC)

AIM OF TREATMENT

• Aim of the treatment for cerebral palsy/with disabilities due to brain damage is to prepare and guide them towards their greatest possible independence and to prepare them for as a a normal adolescences and adult lives as can be achieved by Bobath in 1984.

• The concept of neuro-developmental treatment (NDT) has been evolved empirically by Mrs. Bertha Bobath from 1942 onwards.

• By careful clinical observation of adult hemiplegia and of children with cerebral palsy, she studied their reactions to being handled.

• Dr.Karel Bobath, her husband & a neurologist, tried to find the theoretical explanations. By Kong 1991.

• NDT is a holistic approach dealing with the quality of patterns of coordination & not only the problems of individual muscle function.

• It involves the whole person, not only sensory-motor problems but also problems of development ,perceptual-cognitive impairment, emotional, social & functional problems of daily living (Bobath 1990).

A Brain lesion interferes with the development of normal postural

control in relation to gravity.

1. Instead of normal postural tone, we find abnormal tone: too high (spsticity), too low (hypotonicity) or fluctuating (athetosis).

2. Instead of normal reciprocal interaction, we find excessive co-ordination, or sudden inhibition of antagonists resulting in the lack of ability to make a graduated movement.

3. Instead of normal automatic movement patterns of righting, equilibrium,& protective reactions, we find a few static and stereotyped postural patterns of tonic reflexes.

• The abnormal sensory-motor development interferes with child’s whole development i.e. sensory, perceptual, cognitive, psychological.

• Associated sensory &/or perceptual deficits can be primary due to brain lesion but frequently they are secondary to the physical disability, which prevents child

• Associated sensory &/or perceptual deficits can be primary due to brain lesion but frequently they are secondary to the physical disability, which prevents child

from exploring himself the environment.

• He does not develop the same concept of his body. as does a normal child.

• Abnormal sensorymotor experiences will result in an abnormal body awareness & abnormal body image (Bobath 1984; Kong 1986; Quinton 1986).

• It is impossible to superimposed normal movement patterns on abnormal ones, the abnormal patterns need to be suppressed (inhibited).

• The importance of sensory motor experience- we do not learn a movement but a “sensation of movement”.

• By moving the proximal part of body it is possible to influence and to change the movement s of distal parts (Bobath 1942).

Parents participation is important

• Guiding & training the parents in home management is of the greatest importance.( finnie 1986, bobath 1997).

Inhibition combined with stimulation & facilitation

• After preparing & obtaining a more normal postural tone the patient needs to learn move in many different combinations of more normal movement patterns.

• Mrs. Bobath looked for possibilities of a how to transmit to the patient in order to enable them to experience normal sensation of functional movements they had either lost or never developed.

• Only by feeling a near normal movements with minimal effort can the patient learn how to perform it.

• The therapist’s task is to make this possible.

• Bobath recognized that during normal development, in the beginning there is influence of tonic reflexes which later disappear & are supported by the development of righting reactions.

• These are later overlapped & integrated into balance reactions & voluntary movements (Kong 1991).

Reflex inhibitory control

• Inhibition is the process of intervention that reduces dysfuntinal muscle tone. It breaks up the abnormal excessive flexion or extension(Bobath 1984; Quinton 1986;Boehme 1988).

Inhibition combined with stimulation & facilitation

• After preparing & obtaining a more normal postural tone the patient needs to learn move in many different combinations of more normal movement patterns.

• Mrs. Bobath looked for possibilities of a how to transmit to the patient in order to enable them to experience normal sensation of functional movements they had either lost or never developed.

• Only by feeling a near normal movements with minimal effort can the patient learn how to perform it.

• The therapist’s task is to make this possible.

• Bobath recognized that during normal development, in the beginning there is influence of tonic reflexes which later disappear & are supported by the development of righting reactions.

• These are later overlapped & integrated into balance reactions & voluntary movements (Kong 1991).

SUPINE

• Baby’s position: the baby lies in supine on the floor.

• Therapist position: Long sitting on the floor with baby between her legs.

GOALS

• Activation of eye muscles.

• Visual tracking.

• Activation of head turning with rotation.

• Activation of head, trunk & neck flexors.

• Elongation of spinal extensors.

• UE reaching.

• In supine we can also give,

• Hands to arms.

• Hands o mouth & face.

• Hand to hand.

• Hands to head.

• Tactile exploration with hands.

• Visual body exploration with eyes.

SUPINE ROLLING

HANDS TO FEET ROLLING.

• Baby’s position: the baby lies on the mat.

• Therapist position: heel sit in front of baby in a position to move with baby.

GOALS

• Elongation of spinal extensors.

• Activation of trunk flexors.

• Hip flexion with knee extension.

• Sensory feedback of side lying to facilitate lateral righting reactions.

Supine to sit

• Baby’s position: lies on the floor.

• Therapist position: heel sit on the floor in front of baby.

GOALS

• Rotation of trunk & pelvis over hip.

• UE weight bearing.

• Lateral righting reactions.

• Oblique abdominal activation.

Prone on lap

• Baby’s position: baby lies on lap in prone.

• Therapist position: long sitting on floor.

• GOALS

• Elongation of rectus abdominus muscle.

• Elongation of hip flexors.

• Neck, trunk, and hip extension.

• Head lifting..sensory stimulation.

Prone lateral weight shifts

• Baby’s position: lies in prone on your lap,with both arms flexed over your legs.

• Therapist position: long sit on the floor.

goals

• Elongation of rectus abdominus.• Elongation of hip flexors.• Head lifting & turning from side to side.• Sensory stimulation through the visual,

tactile, proprioceptive and vestibular system.

• Lateral righting reaction.• Lower extremities dissociation.

Prone on ball

• Baby’s position: lies prone on ball with the ribs and pelvis well supported by ball. Baby’s arms are in shoulder flexion over ball.

• Therapist position: place your self behind the baby in a position to move forward with baby.

GOALS

• Head & trunk extension.

• Symmetrical hip & knee extension.

• Forward protective extension of upper extremities.

• UE weight bearing.

• Vestibular & proprioceptive stimulation.

On ball we can give weight bearing on forearm also weight bearing on extended arms.

Lateral righting reaction

• Baby’s position: baby lies in prone over the ribs and pelvis well supported. Arms in shoulder flexion over the ball.

• Therapist position: kneel beside ball.

GOALS

• Lateral righting reaction of head & trunk.

• Elongation of the weight bearing side.

• Abduction & protective extension of the free extremities.

Prone to sitting on floor

• Baby’s position: the baby lies in prone or in fore arm weight bearing.

• Therapist position: kneel beside the baby.

GOALS

• Movement around the body axis.

• Trunk rotation.

• UE weight bearing & weight shifting.

• Pelvic femoral mobility.

• Somatosensory input into the base of support for subsequent postural preparation & reaction in sitting.

PRONE TO RUNNER’S STRETCH POSITION

• Baby’s position: baby lies prone or in weight bearing on the mat with the hips extended.

• Therapist position: kneel beside the baby.

GOALS

• Head lifting & righting on the saggital plane.

• UE, extended arm weight bearing.• Elongation of the trunk muscles on the

weight bearing side.• Lateral flexion of spine & lateral righting of

head, trunk, & pelvis on the unweighted side.

• Lower extremity dissociation, including increased range of motion at the hips & knees.

• Marked dissociation of LE dissociation prevents the pelvis from moving on saggital plane thus preventing it from moving into an anterior or posterior pelvic tilt. Therfore movements around the pelvis & LS occur on the frontal & transverse plane.

• Marked dissociation of LE dissociation prevents the pelvis from moving on saggital plane thus preventing it from moving into an anterior or posterior pelvic tilt. Therefore movements around the pelvis & LS occur on the frontal & transverse plane.

Sitting to quadruped to kneeling

• Baby’s position: the baby is in long sitting on floor.

• Therapist position: sit behind or beside the baby.

GOALS

• Trunk rotation.

• UE sideward protective extension.

• UE weight bearing & weight shifting.

• Hip & knee flexion followed by hip extension with knee flexion.

• Elongation of quadriceps.

• Activation of gluteus maximus.

• Activation of gluteus maximus.

• Trunk extension on extended hips.

Prone to standing

• Baby’s position: the baby lies in prone or in forearm weight bearing on the floor with hips extended.

• Therapist position: kneel beside the baby.

GOALS

• Lateral weight shifts with elongation of the weight bearing side in prone to sidelying & kneeling to half kneeling.

• Lateral righting of the unweighted side in prone to side lying & kneeling to half kneeling.

• UE weight bearing & weight shifting.

• Lower extremity dissociation with hip & knee flexion on one side, & with hip & knee extension on the other side.

• Hip extension with knee flexion.

• Elongation of quadriceps & hip flexors.

• Activation of the hip extensor & hip abductors.

• Trunk extension on extended hips.

• Dissociation of lower extremities under the trunk.

• Transitions between ankle planter flexion & dorsi flexion.

• Elongation of the ankle dorsiflexor muscle.

Prone on bolster

• Baby’s position: baby sit beside the bolster.

• Therapist position: kneel or heel sit behind the baby.

GOALS

• Trunk rotation with symmetrical shoulder flexion.

• Hip extension with activation of gluteus maximus.

• Symmetrical trunk extension.

• UE weight bearing & weight shifting for increased proprioception & stability.

• Active shoulder flexion with elbow, wrist & finger extension.

• Elongation of wrist & finger flexors.

Symmetrical stance: weight shifts to the lateral borders of the feet.

• Baby’s position: the baby stands in front of you.

• Therapist position: sit or kneel behind the baby with your hands on the baby’s femur.

• Baby’s position: the baby stands side ways to you. The baby’s hands are free at sides.

• Therapist position: sitting on a mobile stool.

Thank you……

Thank you……

references

• Baby treatment based on NDT principles. By Lois bly.

• www. Google.com.

Symmetrical stance: weight shifts to the lateral borders of the feet.

• Baby’s position: the baby stands in front of you.

• Therapist position: sit or kneel behind the baby with your hands on the baby’s femur.