Luke AdanLo Saechao

Lyle SilverthornMikki Connor

Chris LovelaceMichelle Smith

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

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

NDT and Adult Hemiplegia

Main problems in patients with UMN lesions: Abnormal coordination Abnormal postural toneThus, aims should be: Introduction of more selective movement

patterns in preparation for functional skills Reduction of spasticity

Bobath, 1990

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 way Bobath, 1990

Revised NDTTheory: 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

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

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

Evolution of NDT PrinciplesOriginal 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

NDT in the ClinicTherapeutic 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

Treadmill Training With Partial Body Weight Support Compared With Physiotherapy in Nonambulatory Hemiparetic Patients

Heese, S. et al.Stroke. 1995;26:976-981

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

Participants

7 nonambulatory hemiparetic patients 52 to 72 years old

Heese et al. 1995

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

Results-Functional Ambulation Category

Heese et al. 1995

Results-Rivermead Motor Assessment

Heese et al. 1995

Results-gait velocity

Heese et al. 1995

Conclusion (Big Picture)

WSTT is superior to NDT because WSTT is…Task oriented exercise More independentHigher dosage

Heese et al. 1995

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

Subjects 155 hemiparetic patients were randomly

selected to (RAS group or NDT group). Age: 69 ± 11

Thaut et al. 2007

Methods

RAS - metronome and music tapesNDT – Bobath principlesMajor gait parameters measured: velocity,

stride length, cadence, and swing symmetry.

Heese et al. 1995

Results

Heese et al. 1995

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

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 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?

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

NDT Vs. Traditional Functional RetrainingGeneral Rx

NDT group improved more on Barthel Index than TFR

No significant difference in all measuresFunctional Independence Measure (FIM)Box & Block TestNine-hole Peg Test

Salter et al., Gelber et al., Lewis, 2003

NDT vs. BrunnstromGeneral Rx

No significant difference in all outcome measuresAction Reach Arm TestBarthel IndexGait speed

Wagenaar et al., 2003

NDT Vs. Motor Relearning ProgrammeGeneral Rx

MRP group improved more in:Barthel IndexMotor Assessment ScaleSodring Motor Evaluation Scale

No difference found inNottingham Health Profile

Langhammer et al., 2003

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 measuresRehabilitation Activities ProfileFugl-MeyerMotor Activity Log

Van der Lee et al., 2003

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 recoveryThere 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

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

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

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 AssessedNDT vs. Conventional PT: effect size = (0.01)Conventional PT vs. No Rx: effect size = 0.51EMG biofeedback vs. Conventional PT = 0.75 EMG biofeedback vs. No Rx = 0.85

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

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

Outcome MeasuresStanding 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

AssessmentDifferences 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

Conclusion

No significant differences between NDT and Multisensorial Training

No evidence that one approach is superior to the other

Yelnik, A. et al

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 (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.

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

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

Common Problems with reviews of NDT

Little homogeneity between studiesStage of stroke recovery Treatment intervalAge of patientsOutcome measuresTreatment comparison

Failure to clarify exact methods used

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

HOWEVER, today there is good evidence to support other interventions: CIMTBWSTTTask-Specific TrainingMental Imagery

WE NEED TO BE EDUCATORS IN THE CLINIC!

Learning ObjectivesAt 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

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; 1-109.Hesse, S. et. al. (1995). Treadmill Training with Partial Body Weight Support

Compraed With Physiotherapy in Nonambulatory Hemiparetic Patients. Stroke. 26:976-981.

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);40:e89-e97.

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): 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: 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: 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