Presentation on theme: "Neuro-Developmental Treatment & Stroke"— Presentation transcript:
1 Neuro-Developmental Treatment & Stroke Luke AdanLo SaechaoLyle SilverthornMikki ConnorChris LovelaceMichelle Smith
2 Learning ObjectivesAt the completion of this presentation, the learner will be able to:Describe the main principles of NDTDescribe early NDT vs. recent NDTDescribe the effectiveness of WSTT vs. NDT for improving gaitDescribe how NDT compares to other conventional therapy approaches.List common problems with reviews of NDT
3 NDT BackgroundNDT 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 hemiplegiaObservations were based on the Reflex/Hierarchical modelReflex 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 coordinationAbnormal postural toneThus, aims should be:Introduction of more selective movement patterns in preparation for functional skillsReduction of spasticityBobath, 1990
5 Early NDTBobath 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 wayBobath, 1990
6 Revised NDTTheory: Dynamic “autoinhibition” by using reflex inhibiting movementsAs patient moves, PT prevents the unwanted parts of the abnormal movement by using “key points of control”Particularly proximal jointsPT should gradually withdraw control as the movement continuesBobath, 1990
7 NDT Main PrinciplesIt is impossible to superimpose normal movement patterns on abnormal ones, so abnormal patterns need to be inhibitedMovement 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 catsBobath, 1990
8 Evolution of NDT Principles NDT in North America is currently based on an interactive complex systems modelProblems 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 ApplicableBobath’s therapeutic handling techniques make normal posture/movements more easy/likely to occurBobath’s focus on the interaction of impairments, function, and life participation (expanded to ICF)Bobath’s focus on taking a “holistic” approach to treating patientsNeuro-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 movementFascilitate postural control and movement synergies that broaden the client’s options for selecting successful actionsProvide boundries for movements that distract from the goalInhibit or constrain those motor patterns that, if practiced, lead to secondary deformities, further disability, or decreased participation in societyHowle , 2002
11 Weight Supported Treadmill Training vs. NDT Treadmill Training With Partial Body Weight SupportCompared With Physiotherapy in NonambulatoryHemiparetic PatientsHeese, S. et al.Stroke. 1995;26:Who here thinks NDT works better than Weight supported treadmill training?
12 PurposeCompare 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 participants1st phase= WSTT2nd phase= NDT3rd 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 VelocityTreadmill 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 consistentlyA 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 exerciseMore independentHigher dosageWSTT 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;21:455Purpose: to examine the clinical efficacy of RAS for post stroke gait training by comparing it to NDT.
20 Subjects155 hemiparetic patients were randomly selected to (RAS group or NDT group).Age: 69 ± 11155 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 11Thaut 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 symmetryHeese et al. 1995
22 ResultsBoth 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: 2–7Systematic Review of 15 trials out of 7266 RCTs, 6 CTs, 3 Case SeriesNo level 1 studies due to small sample size or weak evidence from P-valueAge 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 LimbEMG activityUpper Extremity Function TestFinger Oscillation TestHealth Belief SurveyMood and Affect TestsBasmajian et al, 2003Lower LimbROMGait analysisMulder et al., 1986
26 NDT Vs. Traditional Functional Retraining General Rx NDT group improved more on Barthel Index than TFRNo significant difference in all measuresFunctional Independence Measure (FIM)Box & Block TestNine-hole Peg TestSalter et al., Gelber et al., Lewis, 2003
27 NDT vs. Brunnstrom General Rx No significant difference in all outcome measuresAction Reach Arm TestBarthel IndexGait speedWagenaar et al., 2003
28 NDT Vs. Motor Relearning Programme General Rx MRP group improved more in:Barthel IndexMotor Assessment ScaleSodring Motor Evaluation ScaleNo difference found inNottingham Health ProfileLanghammer 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 measuresRehabilitation Activities ProfileFugl-MeyerMotor Activity LogVan der Lee et al., 2003
30 ConclusionNo evidence supporting NDT as the optimal type of treatment.Important to note:So even though NDT may NOT be superior, it does positively effect recoveryThere was a significant improvement in most of the measured parameters for the NDT groups, but the improvements weren’t significantly different than other treatmentsPaci, 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 between14 trials reviewedAll RCTsInterval Since Stroke0 days to 8 yearsLength of Treatment2 to 50 weeksSample Size20 to 282 people
32 Methods Interventions Assessed NDT vs. Conventional PT Conventional PT vs. No RxEMG biofeedback vs. Conventional PTEMG biofeedback vs. No RxUpper 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 – 0.5Interventions AssessedNDT vs. Conventional PT: effect size = (0.01)Conventional PT vs. No Rx: effect size = 0.51EMG biofeedback vs. Conventional PT = 0.75EMG biofeedback vs. No Rx = 0.85
34 ConclusionThe effects of NDT and conventional treatment are almost identicalEMG Feedback had a larger effect on improving UE function in post stroke patients than NDT or conventional PTHiraoka, 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: 468Objective:Compare 2 physical rehabilitation approaches to restore balance after recent stroke: NDT vs Multisensorial TrainingMethods:68 patients who were able to walk without human assistance3 to 15 months post first strokeReceived NDT or Mulitisensorial Rx for 20 sessions in 4 weeksSample SizeNDT = 35 patientsMultisensorial = 33 patients
36 Outcome Measures Standing balance Berg Balance Scale Dynamic balance Assessed during walking by percentage of double-limb stance timeDaily IndependenceFunctional Independence Measurement (FIM)Quality of LifeNottingham Health ProfileYelnik et al., 2008
37 Assessment Differences between groups on Day 30 No difference between groupsDifferences between groups on Day 90Both 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 significanceYelnik et al., 2008
38 ConclusionNo significant differences between NDT and Multisensorial TrainingNo evidence that one approach is superior to the otherYelnik, 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 reviewedSample size: 813 patients total ( in individual studies)Inclusion criteria:Involvement of adult patients with a cerebrovascular accidentThe effects of the Bobath Concept were compared with those of an alternative methodRandomized, 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 extremityBalance controlMobility (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 effectivenessBoudewijn et al. 2009
41 ResultsThere was no evidence of the superiority of NDT for sensorimotor control of the upper and lower limb, dexterity, mobility, ADLs, HRQOL, and cost-effectivenessOnly limited evidence was found to support the superiority of NDT for balanceBoudewijn et al. 2009
42 Common Problems with reviews of NDT Little homogeneity between studiesStage of stroke recoveryTreatment intervalAge of patientsOutcome measuresTreatment comparisonFailure to clarify exact methods used
43 Why Do We Use NDT? Personal Experience of the Therapist Authority Evidence Based PracticeNDT works, but not better or worse than other methodsIf 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: CIMTBWSTTTask-Specific TrainingMental Imagery WE NEED TO BE EDUCATORS IN THE CLINIC!
45 Learning ObjectivesAt the completion of this presentation, the learner will be able to:Describe the main principles of NDTDescribe early NDT vs. recent NDTDescribe the effectiveness of WSTT vs. NDT for improving gaitDescribe how NDT compares to other conventional therapy approaches.List common problems with reviews of NDT
46 Works CitedBobath, 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 CitedLennon, 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