NDT (Neurodevelopmental
Therapy)/
BOBATH APPROACH
NDT/ Bobath approach is a “living concept”. It is a
problem solving approach that involves the treatment
and management of movement dysfunction in
individuals with CNS pathophysiology.
The person is addressed as a whole and the
intervention is individualized to meet his/her specific
goals
NDT is an interactive process among the individuals,
care givers and members of the interdisciplinary team
The overall goal of treatment and management is the
enhancement of the individual’s capacity to function
To achieve this goal, the practitioner addresses
quality of movement utilizing principles of movement
science
Treatment involves active participation of the
individual, direct handling to optimize function
with gradual withdrawal of direct input by the
therapist
The NDT approach contributes to a person’s
independence and quality of life
Bobath assumed that the abnormal patterns of
muscle tone and motor control were major
impairments interfering with normal motor
control of the trunk, arm and leg
Bobath found that when spasticity decreased,
her patients could acquire improved control of
posture and movement on their affected side
and could use these new patterns for function
Her approach involved the use of manual
techniques to eliminate abnormal tone and
movement and retrain normal patterns of
coordination in the affected trunk, arm and leg
Because her goal was to restore movement
and function, she rejected both traditional
compensatory approaches that neglected the
potential for function in the hemiplegic side
and other neurophysiological approaches that
encouraged abnormal movement and reflex
activity
Writings of K. Bobath rely on models of
nervous system function that are now out-of-
date, the Bobath approach has been the
target of criticism.
Since the deaths of Bobaths in 1990, the
Neurodevelopmental Treatment Association
in United States have been working to update
the theoretical basis of NDT/Bobath
treatment
Movement control problems
after stroke
Bobath described the loss of normal movement
responses as the first type of motor impairment
associated with hemiplegia
Patients with hemiplegia may demonstrate loss
of postural control or inability to activate muscles
automatically to maintain the body in balance at
rest and during movement
There is also loss of selective motor control of
the muscles controlling movement of the
hemiplegic arm and leg
Bobath identified abnormal tone as the second
motor problem interfering with the movement
control and function in hemiplegia
Patients may demonstrate flaccidity or spasticity
Bobaths believed that these two categories of
motor impairment results in stereotyped
nonfunctional movement patterns and functional
limitations associated with hemiplegia
They hypothesized that patients with hemiplegia
have forgotten how to move in normal patterns
of coordination
This sensorimotor disturbance results in loss of
normal movement responses, even when the
muscles are sufficiently strong enough to
support the movement
Neurodevelopmental treatment
of patients with stroke
DT/Bobath uses specific set of techniques to address
the problems of tone and movement control and to
provide sensory messages about how movement is
organized and executed
The techniques have the goals of preventing abnormal
patterns of coordination, retraining normal movement
responses and increasing functional use of the
hemiplegic side
[Link] used her hands on the patient’s body to
produce therapeutic changes in tone and movement.
She called this treatment “handling” to reflect the
manual hands-on quality of her treatment
Handling is a dynamic process and it activates
movement patterns in the patient that both decrease
abnormal tone and coordination and reeducate normal
movements.
The NDT therapist uses handling to provide specific
tactile, proprioceptive and kinesthetic messages that
help organize the quality of patient’s movement and
influence the status of relative impairments, such as,
spasticity and flaccidity
B. Bobath found that certain hand placements, which
she called “Key points of control” are most effective
for controlling the patient’s movement. During the
treatment the therapist selects the key points that give
maximal control over the patient’s problems and the
movement pattern the therapist wishes to influence
Proximal key points are used to influence posture and
movement of the trunk, shoulder girdle and hip
Distal key points are used to control the position of
the distal extremities
Handling is used for two types of techniques:
Inhibition
Facilitation
Inhibition techniques are used to address problems of
abnormal tone and abnormal coordination. Inhibition
techniques often use “Reflex-Inhibiting Patterns (RIPs)”, a
term of patterns that counteract the pull of tight or spastic
muscles
The NDT therapist uses RIPs to establish a normal tonal
state prior to teaching normal movements. Bobath
believed that therapists should not attempt to retrain
normal movement responses until the spasticity was
minimized, because spasticity prevents normal movement
patterns of reciprocal muscle activation
When the tone is normalized through inhibition,
the NDT therapist uses facilitation techniques to
train movement patterns
Facilitation techniques are used to activate
automatic postural responses and trunk control,
and to train weight-bearing and non-weight
bearing movements in the arm and leg
INHIBITION TECHNIQUES
Inhibition techniques unique to NDT are:
Passive elongation
Proximal dissociation
Reflex Inhibiting Patterns (RIPs)\
Inhibitory positioning devices and orthotics
Weight shifting
Normal limb movements
Passive elongation
Shortened muscles lose strength because
they are contracting at the end of the joint
range, where muscles are weak
Slow, even pressure is applied to gradually
elongate a shotened muscle
Proximal dissociation
It consists of separate movements of
adjacent proximal body parts
In brain damaged patients, these isolated
movements are often lost and the patient
moves head and shoulder movements en
bloc, as a solid unit
Reflex inhibiting patterns
RIPs can be facilitated using proximal or
distal key points of control
Proximal key points include the head, trunk,
pelvis, shoulder, elbow and lower trunk
Distal key points include the forearm, hand,
knee and foot
Inhibitory positioning and
orthotics
Passive elongation and RIPs are
supplemented by positioning devices that
maintain the elongation of the shortened
muscles
Orthotics can also supplement passive
elongation and RIPs. The spasticity reduction
splint, finger abduction splint, inflatable splint,
serial casting, dynamic sling are few
examples of orthotics that can inhibit the
flexion synergy of the arm
Active movement
Weight shifting in miniature ranges is another
inhibition technique that inhibits rigid fixing.
Weight shifting includes both axial weight
shifts and limb weight shifts
Maximum physical support, minimum
resistance, and miniature speed are the keys
to using these inhibition techniques
effectively
NDT evaluation/ treatment
Identify abilities and functional capabilities
Identify functional limitations
Determine what problems interfere with movement
control and functional performance, such as:
Abnormal tone
Abnormal coordination
Loss of postural control
Loss of selective movement control
sensation
Establish functional goals and treatment goals:
The NDT therapist gathers assessment information
through a variety of procedures
The therapist observes the patient’s behavior to
gather information about typical posture, preferred
movement patterns and spontaneous use of the
hemiplegic side
The therapist notes whether the patient
spontaneously uses the affected side or relies on
compensations that reflects asymmetry and neglect
It is essential to evaluate motor patterns and the
patient’s response to being moved
The NDT therapist uses handling to identify the
normal movement patterns that are contributing to
the patient’s movement problems and functional
limitations
To assess movement control, the therapist moves
the patient into postures and movement sequences
example checking postural and equilibrium reactions
by facilitating trunk movements
Te therapist uses the information gained in the
observational stage to select movement
patterns to be assessed by handling
Handling provides the therapist with specific
sensory information about the quality and the
strength of the patient’s movements
When the movement control is present on the
hemiplegic side, the patient actively assists
with the movement. If the therapist stops the
movement briefly and lightens manual support,
the patient will briefly hold the position. Bobath
referred to this as “placing response”. Placing
is possible only when muscle tone is in the
normal range and muscle strength is available
to support the movement
Treatment goals for stages of
recovery
NDT therapist establishes goals to be
achieved through practice
NDT therapist establishes goals that relate to
motor problems such as spasticity, that will
be inhibited and movement on the hemiplegic
side to be facilitated
The exact goal depends upon the patient’s
problems, level of functional independence,
movement control and reasons for seeking
treatment
In acute stage, the NDT goals focus on
increasing independence in life tasks,
preventing the development of abnormal tone
and abnormal movements and increasing
movement control on the hemiplegic side
To accomplish this functional goal the NDT
therapist introduces and practices adapted
techniques for ADL, bed mobility, transfers
and wheel chair management, positioning,
ROM exercises, inhibitory treatment
techniques
NDT treatment goals for the patient with
spasticity include inhibiting abnormal tone
and movement, increasing normal movement
responses, and improving the occupational
performance by incorporating the hemiplegic
side into task performance
Treatment of Hemiplegic arm
The Bobath approach to treatment of
hemiplegic arm is designed to address
impairments such as abnormal tone, pain,
subluxation, and loss of movement control
Specific impairments are treated using
inhibition techniques such as RIPs, scapula
mobilization, trunk rotation and weight
bearing
Bobath’s Approach vs. NDT
Bobath NDT
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