Neuro-Developmental Treatment

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 1940s 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

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
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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

Bobath, 1990
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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
• Bobaths therapeutic handling techniques make
  normal posture/movements more easy/likely to
  occur
• Bobaths focus on the interaction of impairments,
  function, and life participation (expanded to
  ICF)
• Bobaths 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 clients response to changes in posture
  or movement
• Fascilitate postural control and movement
  synergies that broaden the clients 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
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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. 199526976-981

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Purpose

• Compare the efficiency of PT based on NDT vs.
  WSTT in gait training for post stroke chronic
  hemi paretic patients.

Heese et al. 1995
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Participants

• 7 nonambulatory hemiparetic patients
• 52 to 72 years old

Heese et al. 1995
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Methods

• A-B-A single case study design
• 3 phases were administered to the participants
• 1st phase WSTT
• 2nd phase NDT
• 3rd phase WSTT

Heese et al. 1995
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Results-Functional Ambulation Category
Heese et al. 1995
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Results-Rivermead Motor Assessment
Heese et al. 1995
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Results-gait velocity
Heese et al. 1995
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Conclusion (Big Picture)

• WSTT is superior to NDT because WSTT is
• Task oriented exercise
• More independent
• Higher dosage

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 200721455
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Subjects

• 155 hemiparetic patients were randomly selected
  to (RAS group or NDT group).
• Age 69 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.

Heese et al. 1995
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Results
Heese et al. 1995
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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.

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 27

• 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 15-95 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?

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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
• EMG activity
• ROM
• Gait analysis
• Mulder et al., 1986

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NDT Vs. Traditional Functional RetrainingGeneral
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

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NDT vs. BrunnstromGeneral Rx

• No significant difference in all outcome measures
• Action Reach Arm Test
• Barthel Index
• Gait speed
• Wagenaar et al., 2003

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NDT Vs. Motor Relearning ProgrammeGeneral 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

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NDT Vs. Forced UseUpper 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

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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 werent 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. 2001(13), 5-9.

• Studies ranged between 1966 - 1999
• 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

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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

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Results

• Used Cohens 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

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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

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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

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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

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Conclusion

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

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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 (21-120 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.

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• 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

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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

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• 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!

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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 1-109.
• Hesse, S. et. al. (1995). Treadmill Training
  with Partial Body Weight Support Compraed With
  Physiotherapy in Nonambulatory Hemiparetic
  Patients. Stroke. 26976-981.
• 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 www.ndta.org
• 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)40e89-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) 665-674.
• Paci, M. Physiotherapy based on the bobath
  concept for adults with post-stroke hemiplegia a
  review of effectiveness studies. J Rehabil Med
  2003 35 27.
• 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 21 455-459
• Yelnik, A. et al, (2008). Rehabilitation of
  Balance After Stroke With Multisensorial
  Training A Single-Blind Randomized Controlled
  Study. Neurorehabil Neural Repair 22 468