1. Neuro-Developmental Treatment & Stroke
Luke Adan
Lo Saechao
Lyle Silverthorn
Mikki Connor
Chris Lovelace
Michelle Smith

2. Learning Objectives
At the completion of this presentation, the learner will be able to:
Describe the main principles of NDT
Describe early NDT vs. recent NDT
Describe the effectiveness of WSTT vs. NDT for improving gait
Describe how NDT compares to other conventional therapy approaches.
List common problems with reviews of NDT

3. NDT Background
NDT approach began in the early 1940’s from the work of Mrs. Berta Bobath (Physical therapist) and pediatric neurologist Dr. Karel Bobath (Psychiatrist/Neurophysiologist).
Based on their experience of working with children with CP and adults with hemiplegia
Observations were based on the Reflex/Hierarchical model
Reflex Hierarchical model: Movement is determined by a rigid heirarchy of reflexes.
Abnormal movement is the result of de-inhibition of reflexes. Removal of CNS.

4. NDT and Adult Hemiplegia
Main problems in patients with UMN lesions:
Abnormal coordination
Abnormal postural tone
Thus, aims should be:
Introduction of more selective movement patterns in preparation for functional skills
Reduction of spasticity
Bobath, 1990

5. Early NDT
Bobath originally believed in reflex inhibiting postures (RIPs)
Placed and held patients in RIPs to break up the abnormal postural and movement patterns.
Believed this would change the activity of the whole body due to the “normalization” of postural tone.
No spontaneous carry over into movement and function occurred.
Treatment was too static and was not continued in this way
Bobath, 1990

6. Revised NDT
Theory: Dynamic “autoinhibition” by using reflex inhibiting movements
As patient moves, PT prevents the unwanted parts of the abnormal movement by using “key points of control”
Particularly proximal joints
PT should gradually withdraw control as the movement continues
Bobath, 1990

7. NDT Main Principles
It is impossible to superimpose normal movement patterns on abnormal ones, so abnormal patterns need to be inhibited
Movement is a sensory-motor experience: We do not learn a movement but the “sensation of a movement”
By moving the proximal part of the body it is possible to influence and change movements of the distal parts
“Shunting”: Position of the periphery sends sensory information to the CNS, causing the CNS to mirror the movement pattern in its output of excitatory signals to the periphery.
Magnus: Studies on cats
Bobath, 1990

8. Evolution of NDT Principles
NDT in North America is currently based on an interactive complex systems model
Problems in tone, posture, balance, and movement are equally important in producing atypical synergies that interfere with functional activities.
NDT recognizes that it is essential to evaluate measurable changes in functions as well as changes in motor and body systems that support those functions.
Neuro-Developmental Treatment Association, 2007

9. Evolution of NDT Principles
Original Core Concepts Still Applicable
Bobath’s therapeutic handling techniques make normal posture/movements more easy/likely to occur
Bobath’s focus on the interaction of impairments, function, and life participation (expanded to ICF)
Bobath’s focus on taking a “holistic” approach to treating patients
Neuro-Developmental Treatment Association, 2007

10. NDT in the Clinic Therapeutic handling allows the therapist to:
Feel the client’s response to changes in posture or movement
Fascilitate postural control and movement synergies that broaden the client’s options for selecting successful actions
Provide boundries for movements that distract from the goal
Inhibit or constrain those motor patterns that, if practiced, lead to secondary deformities, further disability, or decreased participation in society
Howle , 2002

11. Weight Supported Treadmill Training vs. NDT
Treadmill Training With Partial Body Weight Support
Compared With Physiotherapy in Nonambulatory
Hemiparetic Patients
Heese, S. et al.
Stroke. 1995;26:
Who here thinks NDT works better than Weight supported treadmill training?

12. Purpose
Compare the efficiency of PT based on NDT vs. WSTT in gait training for post stroke chronic hemi paretic patients.
- Compare the efficiency of PT based on NDT vs. WSTT in gait training for post stroke chronic hemi paretic patients.
Heese et al. 1995

13. Participants 7 nonambulatory hemiparetic patients 52 to 72 years old
The study had 7 nonambulatory hemiparetic patients (52 to 72 years old). They had a very small sample group, but lets see what happens.
Heese et al. 1995

14. Methods A-B-A single case study design
3 phases were administered to the participants
1st phase= WSTT
2nd phase= NDT
3rd phase= WSTT
- The pts were treated with an A – B – A single case study design. Which means they are given treatment A 1st, then treatment B, and then treatment A again.
The 1st phase was WSTT, 2rd phase was NDT, and the 3rd phase was again WSTT “follow the pattern?” =)
Heese et al. 1995

15. Results-Functional Ambulation Category
- One of the measurements they used for results was the Functional Ambulation Category.
- As you can see FAC levels only improved during the TM phases
* Treadmill training was superior to NDT with regard to improvement of gait ability tested by the FAC (P < .05)
Heese et al. 1995

16. Results-Rivermead Motor Assessment
- Another measurement they used was the Rivermead Motor Assessment
- According to the study no therapy proved to be superior because there was not a significant difference between the two.
Heese et al. 1995

17. Results-gait velocity
The last measurement they used was Gait Velocity
Treadmill training was more effective than NDT (P<.05)
A phase – patients increased their gait velocity with a mean of 150.4%
B phase – walking speed did not change consistently
A phase – patients increase their gait velocity with a mean of 43.5%
Heese et al. 1995

18. Conclusion (Big Picture)
WSTT is superior to NDT because WSTT is…
Task oriented exercise
More independent
Higher dosage
WSTT is a better approach to gait training because according to this study it is a task oriented exercise,
it teaches independency from the PT, and has better dosage ( more reps ). (MIKE)
Heese et al. 1995

19. Thaut, Leins et al. Rhythmic Auditory Stimulation Improves Gait More Than NDT/Bobath Training in Near-Ambulatory Patients Early Poststroke: A single-Blind, Randomized Trial. Neurorehabil Neural Repair 2007;21:455
Purpose: to examine the clinical efficacy of RAS for post stroke gait training by comparing it to NDT.

20. Subjects
155 hemiparetic patients were randomly selected to (RAS group or NDT group).
Age: 69 ± 11
155 hemiparetic patients were randomly selected and randomly assigned to experimental group (RAS group) or the control group (NDT group).
the ave. age for both groups was around 69 plus or minus 11
Thaut et al. 2007

21. Methods RAS - metronome and music tapes NDT – Bobath principles
Major gait parameters measured: velocity, stride length, cadence, and swing symmetry.
The RAS group followed established protocols using a metronome and specifically prepared music tapes.
The NDT group practiced similar instructions about gait parameters.
The major gait parameters measured were 1. velocity 2. stride length 3. cadence 4. swing symmetry
Heese et al. 1995

22. Results
Both groups improved in all gait parameters , but more significant differences were found in favor of the RAS in all 4 gait parameters.
as you can see the SL and cadence in the RAS group similarly increased the same amount. This is important because these parameters when coupled suggests a more functional recovery of gait mechanics.
Heese et al. 1995

23. Conclusion (Big Picture)
According to this study RAS is superior to NDT because…
RAS gives the pt. an external cue to regulate parameters of gait.
It only works when its on. When off only a few minutes will transfer.
It only works when its on. When its turned off only a few minutes will transfer because of the high dosage given. This is what Mike and I discussed.
Heese et al. 1995

24. Paci, M. PHYSIOTHERAPY BASED ON THE BOBATH CONCEPT FOR ADULTS WITH POST-STROKE HEMIPLEGIA: A REVIEW OF EFFECTIVENESS STUDIES. J Rehabil Med 2003; 35: 2–7
Systematic Review of 15 trials out of 726
6 RCTs, 6 CTs, 3 Case Series
No level 1 studies due to small sample size or weak evidence from P-value
Age range years
“NDT is the most widely used approach in the rehabilitation of hemiparetic subjects in Europe, and it is well known and frequently used in many countries, including the USA, Canada, Japan, Australia and Israel”
Purpose:
Is there evidence that NDT is effective?
Is NDT more effective than other treatments for adults with hemiplegia?

25. NDT Vs. EMG Feedback No difference found in all outcome measures
Upper Limb
EMG activity
Upper Extremity Function Test
Finger Oscillation Test
Health Belief Survey
Mood and Affect Tests
Basmajian et al, 2003
Lower Limb
ROM
Gait analysis
Mulder et al., 1986

26. NDT Vs. Traditional Functional Retraining General Rx
NDT group improved more on Barthel Index than TFR
No significant difference in all measures
Functional Independence Measure (FIM)
Box & Block Test
Nine-hole Peg Test
Salter et al., Gelber et al., Lewis, 2003

27. NDT vs. Brunnstrom General Rx
No significant difference in all outcome measures
Action Reach Arm Test
Barthel Index
Gait speed
Wagenaar et al., 2003

28. NDT Vs. Motor Relearning Programme General Rx
MRP group improved more in:
Barthel Index
Motor Assessment Scale
Sodring Motor Evaluation Scale
No difference found in
Nottingham Health Profile
Langhammer et al., 2003

29. NDT Vs. Forced Use Upper Limb
Forced Use group had more improvements than NDT in Action Reach Arm Test (dexterity)
No difference in all other outcome measures
Rehabilitation Activities Profile
Fugl-Meyer
Motor Activity Log
Van der Lee et al., 2003

30. Conclusion
No evidence supporting NDT as the optimal type of treatment.
Important to note:
So even though NDT may NOT be superior, it does positively effect recovery
There was a significant improvement in most of the measured parameters for the NDT groups, but the improvements weren’t significantly different than other treatments
Paci, 2003

31. Hiraoka, K. Rehabilitation Effort to Improve Upper Extremity Function in Post-Stroke Patients: A Meta-Analysis. J Phys Ther Sci (13), 5-9.
Studies ranged between
14 trials reviewed
All RCTs
Interval Since Stroke
0 days to 8 years
Length of Treatment
2 to 50 weeks
Sample Size
20 to 282 people

32. Methods Interventions Assessed NDT vs. Conventional PT
Conventional PT vs. No Rx
EMG biofeedback vs. Conventional PT
EMG biofeedback vs. No Rx
Upper extremity function assessed by:
Rivermead Motor Assessment Arm Scale,
Action Reach Arm Test,
Fugl-Meyer Assessment,
Upper Extremity Functional Test,
Frenchay Arm Test.
Hiraoka, 2001

33. Results Used Cohen’s criteria to determine effect size
- Large effect (significant difference) = ≥0.8
- Medium effect (difference) = 0.5 – 0.8
- Small effect (no difference) = 0.2 – 0.5
Interventions Assessed
NDT vs. Conventional PT: effect size = (0.01)
Conventional PT vs. No Rx: effect size = 0.51
EMG biofeedback vs. Conventional PT = 0.75
EMG biofeedback vs. No Rx = 0.85

34. Conclusion
The effects of NDT and conventional treatment are almost identical
EMG Feedback had a larger effect on improving UE function in post stroke patients than NDT or conventional PT
Hiraoka, 2001

35. Yelnik, A. et al. Rehabilitation of Balance After Stroke With Multisensorial Training: A Single-Blind Randomized Controlled Study. Neurorehabil Neural Repair 2008; 22: 468
Objective:
Compare 2 physical rehabilitation approaches to restore balance after recent stroke: NDT vs Multisensorial Training
Methods:
68 patients who were able to walk without human assistance
3 to 15 months post first stroke
Received NDT or Mulitisensorial Rx for 20 sessions in 4 weeks
Sample Size
NDT = 35 patients
Multisensorial = 33 patients

36. Outcome Measures Standing balance Berg Balance Scale Dynamic balance
Assessed during walking by percentage of double-limb stance time
Daily Independence
Functional Independence Measurement (FIM)
Quality of Life
Nottingham Health Profile
Yelnik et al., 2008

37. Assessment Differences between groups on Day 30
No difference between groups
Differences between groups on Day 90
Both the NDT and Multisensorial approach showed significant improvements in all outcome measures compared to baseline measures, but the Multisensorial approach showed more improvement.
However, the differences between-groups were of no statistical significance
Yelnik et al., 2008

38. Conclusion
No significant differences between NDT and Multisensorial Training
No evidence that one approach is superior to the other
Yelnik, A. et al

39. Kollen, B.J. et al. The Effectiveness of the Bobath Concept in Stroke Rehabilibation: What is the Evidence? Stroke (Journal of the American Heart Association). 2009(40), e89-e97.
16 trials reviewed
Sample size: 813 patients total ( in individual studies)
Inclusion criteria:
Involvement of adult patients with a cerebrovascular accident
The effects of the Bobath Concept were compared with those of an alternative method
Randomized, controlled clinical trial (RCT)
Only English or Dutch publications were considered for inclusion.

40. Inclusion Criteria (Cont.)
Rehab outcomes were measured in one or more of the following:
Sensorimotor function of the upper and/or lower extremity
Balance control
Mobility (The ability to (re)position the body by transfer or gait)
Dexterity (Reaching, grasping, fine hand use)
Activities of Daily living (ADLs)
Health-Related Quality of Life (HRQOL)
Cost effectiveness
Boudewijn et al. 2009

41. Results
There was no evidence of the superiority of NDT for sensorimotor control of the upper and lower limb, dexterity, mobility, ADLs, HRQOL, and cost-effectiveness
Only limited evidence was found to support the superiority of NDT for balance
Boudewijn et al. 2009

42. Common Problems with reviews of NDT
Little homogeneity between studies
Stage of stroke recovery
Treatment interval
Age of patients
Outcome measures
Treatment comparison
Failure to clarify exact methods used

43. Why Do We Use NDT? Personal Experience of the Therapist Authority
Evidence Based Practice
NDT works, but not better or worse than other methods
If you are going to put your hands on a patient NDT is a good intervention to use

44. HOWEVER, today there is good evidence to support other interventions:
CIMT
BWSTT
Task-Specific Training
Mental Imagery
 WE NEED TO BE EDUCATORS IN THE CLINIC!

45. Learning Objectives
At the completion of this presentation, the learner will be able to:
Describe the main principles of NDT
Describe early NDT vs. recent NDT
Describe the effectiveness of WSTT vs. NDT for improving gait
Describe how NDT compares to other conventional therapy approaches.
List common problems with reviews of NDT

46. Works Cited
Bobath, B. (1990). Adult Hemiplegia: Evaluation and Treatment, 3rd Edition. Oxford: Heinemann Medical Books. Foley, N. et Al. Upper Extremity Interventions. Evidence-Based Review of Stroke Rehabilitation. 2009; Hesse, S. et. al. (1995). Treadmill Training with Partial Body Weight Support Compraed With Physiotherapy in Nonambulatory Hemiparetic Patients. Stroke. 26: Hiraoka, K. Rehabilitation Effort to Improve Upper Extremity Function in Post-Stroke Patients: A Meta-Analysis. J Phys Ther Sci. 2001(13), 5-9. Howle, J.M. (2007). NDT in the United States: Changes in Theory Advance Clinical Practice. Retrieved April 2009 from Howle, J.M. (2002). Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice. Neuro-Developmental Treatment Association. Kollen, B.J. et al. (2009). The Effectiveness of the Bobath Concept in Stroke Rehabilibation: What is the Evidence? Stroke (Journal of the American Heart Association);40:e89-e97.

47. Works Cited
Lennon, S. & Ashburn, A. (2000). The Bobath concept in stroke rehabilitation: a focus group study of the experienced physiotherapists’ perspective. Disability and Rehabilitation, 22 (5):
Paci, M. Physiotherapy based on the bobath concept for adults with post-stroke hemiplegia: a review of effectiveness studies. J Rehabil Med 2003; 35: 2–7.
Thaut, M.H. et al, (2007). Rhythmic Auditory Stimulation Improved Gait More that NDT/Bobath Training in Near-Ambulatory Patients Early Poststroke: A Single-Blind, Randomized Trial. MeurorehabilNeuralRepair; 21:
Yelnik, A. et al, (2008). Rehabilitation of Balance After Stroke With Multisensorial Training: A Single-Blind Randomized Controlled Study. Neurorehabil Neural Repair; 22: 468