Neuro-Developmental Treatment: Definitions and Philosophical Foundations

1 Neuro-Developmental Treatment: Definitions and Philosophical Foundations

Judith C. Bierman

This chapter provides a contemporary conceptual/theoretical definition of Neuro-Developmental Treatment (NDT). It then outlines 10 key philosophical tenets that form the foundation of the more specific theoretical assumptions and the practice model that emerged since NDT’s origination with the Bobaths in the 1940s. Clinical application examples of each tenet are provided. The chapter concludes with a summary table listing the 10 tenets with associated classical references from the Bobaths or early supportive works by other authors compared with contemporary references from more recently active clinicians or scientific researchers.

Learning Objectives

Upon completing this chapter, the reader will be able to do the following:

• Define NDT.

• Explain the philosophical tenets of NDT.

• Outline the consistencies of NDT since its origin and contrast them with philosophical and theoretical aspects that demonstrate NDT’s growth and maturation.

1.1 Introduction

NDT originated with work by Bobath and Bobath 1,2,3,4,5,6,7,8 in the 1940s for the treatment of individuals with neurological disorders of posture and movement. The Bobaths developed the approach specifically to guide therapists who manage and treat individuals diagnosed with stroke or cerebral palsy (CP). This chapter presents a definition of NDT and discusses its basic philosophical tenets. The key components that have remained constant across the years are discussed and the philosophical foundations that have remained constant are presented. The Bobaths, however, viewed their work as a “living concept”⁹ that would change across time based on changes in the populations served, the health care system, new clinical experiences, and scientific research.^9,10,11 Therefore, the practice of NDT as well as portions of the philosophy and theory of NDT have changed across time. These changes have been reported in both the literature focusing on pediatric practice as well as that focusing on adult-onset neuromuscular disorders. The summary of changes in NDT practice and the rationale for these changes have been presented by Bly,¹² Graham et al,¹³ and Mayston¹⁴ and are included in this chapter.

1.2 NDT Defined

Definition of Neuro-Developmental Treatment

NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. The therapist uses the International Classification of Functioning, Disability and Health (ICF) model in a problem-solving approach to assess activity and participation, thereby to identify and prioritize relevant integrities and impairments as a basis for establishing achievable outcomes with clients and care-givers. An in-depth knowledge of the human movement system, including the understanding of typical and atypical development, and expertise in analyzing postural control, movement, activity, and participation throughout the life span, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activating optimal sensorimotor processing, task performance, and skill acquisition to enable participation in meaningful activities.15

1.3 Philosophical Tenets of NDT

The basic philosophical statements or tenets of NDT are general or global beliefs or assumptions that are too broad to test via research studies, but serve as a foundation of the entire practice model. In the 1940s and 1950s, the Bobaths 1,2,3,4,5,6,7,8,10 developed a new approach to the treatment of individuals with central nervous system (CNS) disorders of posture and movement. Berta Bobath, a physical therapist, found clinically that it was possible for her to change the muscle tone in individuals who had suffered a stroke or who had CP.^1,3,4,7,8 This finding was contrary to the medical understanding of the time.10 The understanding of motor control at that time was based on Sherrington’s^16,17,18 theories of a reflexive hierarchy.

Based on his wife’s findings and his own research, Karel Bobath,^6,19 a physician, wrote theoretical explanations for his wife’s clinical findings, and he made recommendations based on his readings and understanding of how she could improve her clinical practice. The revised clinical practice led to more questions and additional exploration of the literature that again modified the treatment approach. The discoveries the Bobaths made were formalized in their writings, and the underpinnings of the approach were outlined in descriptions of an overall philosophy, theoretical assumptions, and specific recommendations for the practice of NDT.

The following philosophical tenets are central to NDT and have been consistent across the years, yet these tenets have also grown and developed as Howle described in 2002.²⁰ These philosophical tenets lay a foundation and provide a framework for the theoretical assumptions and for the practice model of NDT.

1.3.1 Summary of Philosophical Tenets

Therapy Works

Therapists today assume that therapeutic rehabilitation is an effective intervention for individuals with neuromuscular disorders. Therapists routinely develop plans of care that include outcomes of projected changes in participation, functional activities, and body structure and function for the client. There may be disagreements about the best avenue to reach the desired outcomes, but it is routine for physicians to refer patients with stroke or CP to therapists for evaluation and intervention.

This practice, based on the perceived effectiveness of therapy, is contrary to the generally held beliefs of the 1940s and 1950s when the Bobaths began their approach.10 At that time, it was commonly believed that patients who had suffered a neurological insult could only expect to learn to compensate for their deficits or to seek orthopaedic surgeries for the subsequent contractures or deformities. The historical basis for therapeutic exercise and the dilemmas present in the middle of the 1900s were outlined and addressed in a month-long conference sponsored by the American Physical Therapy Association (APTA). The Northwestern University Therapeutic Exercise Project was held in Chicago and both the conference and the published proceedings came to be known as NUSTEP.^21,22

Like the Bobaths, clinicians practicing within the NDT framework today believe that the participation restrictions, functional limitations, atypical posture and movements, and impairments associated with CNS disorders can be changed through therapy. Now, however, we have a growing body of evidence to support that belief. Franki et al,^23,24 in 2012, reviewed evidence for basic physical therapy techniques focusing on lower limb function and found positive results. In an additional review, they found that interventions based on a conceptual framework were effective in improving lower limb function. Specifically, they found evidence that NDT was effective in making positive changes in all domains described in the International Classification of Functioning, Disability and Health (ICF)²⁵ developed by the World Health Organization (WHO).

Evidence is also accumulating that supports NDT’s effectiveness regardless of age or diagnosis. Arndt et al²⁶ focused on intervention with infants, whereas Adams et al²⁷ and Slusarski²⁸ reported on the effectiveness in improving gait in children with CP, and Mikotajewska²⁹ reported the positive results in gait with adults post-stroke with therapeutic intervention.

Therapists who use the NDT Practice Model also believe that therapy works through prevention. Although stroke, CP, and brain injury are defined as disorders of posture and movement caused by nonprogressive lesions to the CNS,^{30,31,32,33,34} the literature provides evidence that, although the lesion may not be changing, the expression of the disorder in terms of the presenting impairments frequently does change over time. Therapists using an NDT problem-solving model look for somewhat predictable patterns in the emergence of secondary impairments and related changes in the individual’s functional activity. They believe that it is feasible to avoid or minimize the development of some of the secondary impairments by monitoring and altering the individual’s posture, movement, and functional activity across time. Therefore, it is important that they understand the expressions of anticipated impairments from specific pathologies and recognize their occurrence across patient populations and ages. This concept is presented in greater detail in Chapters 10 and 11 on CP and stroke, respectively.

The assumption that NDT intervention is effective is further bolstered by the increasing evidence of plasticity of all the body systems across the lifespan.^35,36,37 A hallmark of human function is the adaptability of all body systems, which can be either positive, leading to increased function or participation, or maladaptive, leading to greater functional limitation and additional impairments. This process is evident in everyone, including those who have had a CNS insult. The basic concepts of recovery, plasticity, and compensation across the life span are foundational tenets of NDT; and are discussed in Chapter 15. Thus, NDT practice is applicable whether one is managing a baby in a neonatal intensive care unit (NICU), a child at a school or outpatient clinic, a teen with a traumatic brain injury being followed in a rehabilitation facility, or an elderly individual at home who had a stroke later in life.

Treat the Individual as a Whole

Since the development and inception of NDT, the clinician has been encouraged to evaluate and treat the client as a whole person.²⁰ Therapists view an individual who has had a stroke or who has been diagnosed with CP as a unique individual, not as someone with a spastic arm or a hypotonic leg. This philosophy may best be illustrated by sharing one individual’s story.

Mike was 21 years old when his parents brought him for therapy. They were interested in obtaining a wheelchair for their son. Mike had been diagnosed in infancy as having severe CP, and his parents had not been given much hope for managing his condition, or even for his survival. It became clear that he had a mixed form of CP with elements of spasticity and athetosis that were evident in all four limbs. Mike was the first child of his parents and lived in a rural setting. He had never attended public school and, in fact, had not been out of his mother’s sight since his birth. He slept in the same room with his parents due to their persistent fear that he might die in his sleep.

Mike demonstrated multiple and severe functional activity limitations. He could not roll over in bed, he could not sit without support, and he could not walk, even with an assistive device. He had to be carried everywhere. He was dependent for all activities of daily living (ADLs) and, in fact, was still fed pureed foods from a baby bottle with the nipple cut open. He could not speak, but he could communicate using a tapping system with one arm to spell out words. Four taps for a d, 15 for an o, and 6 for a g. He also knew Morse code and could communicate via a shortwave or ham radio.

A team of practitioners evaluated Mike, covering various systems and facets of the condition. The team included an occupational therapist (OT), a physical therapist (PT), a physician, a psychologist, and a speech-language pathologist (SLP). In the initial team meeting, Mike’s evaluations determined that he was healthy. He had not experienced the anticipated respiratory ailments suggested in his infancy, and his cardiac assessment showed normal function. He did not demonstrate any of the frequently associated disorders, such as seizures. He did not have primary sensory impairments, such as poor vision or hearing. Additionally, the psychologist reported that, although standardized testing was difficult to administer, testing could estimate that his IQ was above 130.

Here was a young man who had a single system (neuromuscular) with impairments, yet this one system negatively influenced his overall quality of life, limited many of his activities, and restricted his participation. The complexity of his situation became clearer when he was asked what he would like to work on in therapy. He replied that he would need time to think about it. The next week he returned and delivered a goal statement, which he had dictated to his mother, stating, “I would like to be able to go to McDonald’s by myself, order a Big Mac, French fries, and a chocolate shake, pay for it with my own money, go to the table, eat it, and then leave.” He wanted independent mobility in the community (does that mean drive there?) and within a relatively crowded restaurant. He wanted to communicate with staff at McDonald’s. He wanted to pay for it with his own money, reflecting a work ethic and interest in employment that was consistent across time. He wanted to feed himself the approximately eight different textures in the Big Mac and to consume the age-appropriate diet. He wanted to be by himself instead of with his mother.

He did not say that he wanted head control or that he wanted better strength or more normal tone. He wanted to be able to participate fully in life, just as any another 21-year-old would report. Mike demanded that we evaluate and treat him as a whole person. We, as therapists, should not look at him as someone with stiff and poorly controlled legs and arms or someone who gags on pureed foods. We must look at him and his desired participations, his functional activities and limitations, and all of his system integrities and impairments within the scope of all of his contextual factors.

Due to this vision, of full participation, OTs cannot exclusively work with the arms and hands, PTs the legs, or SLPs the mouth to achieve the optimal discipline-specific outcomes. For example, for an OT to work with a client to develop a reach overhead, she might be required to work with the client to develop a more stable base from the individual’s trunk and lower body. Or in a different case, in order for a client to speak loudly enough to be heard by peers in a crowded cafeteria, the SLP may be required to address thoracic mobility, abdominal strength, and pelvic stability to forcefully control the air flow during phonation. In addition, therapists representing different disciplines cannot hold sole responsibility for addressing a specific system impairment, such as OTs only addressing the sensory impairments or PTs only working on strengthening. The clinician must treat the person as a whole being. The NDT clinician works with the person who has had a stroke or who has CP. The therapist is not just intervening with the neuromuscular impairment nor the ineffective posture and movement. The therapist is not developing a specific functional activity from a menu of generally recognized or developmentally important functions or even encouraging the generalized development of participation. The NDT clinician works with a person and perhaps that person’s family, friends, and colleagues. A key philosophical tenet of NDT is to focus on the whole person in intervention planning and implementation. The NDT Practice Model includes this key element at every stage of evaluation and intervention.

The Purpose of Therapy Is to Increase the Individual’s Participation and Activity

Clinicians using the NDT Practice Model view the desired outcomes of intervention to be improved functional activities and increased participation that are valued by the individual. Therapists know that they must simultaneously minimize impairments and work to avoid potential future disabilities that might develop based on ineffective posture and movements.

From the beginning of their work in this field, the Bobaths identified a relationship between an individual’s functional activities and participation in societal roles and underlying issues of posture and movement based on the interactions of all of the body systems. Initially, they described a focus in therapy on developing more typical postures and movement to permit greater skill or functional ability.7,38,39,40 Clinicians now focus on increasing functional activities or participation through addressing specific impairments in the person’s posture and movement and individual body system impairments.^15,20 Across time, the Bobaths’ work encouraged therapists to focus on function. As early as the 1970s, their work and research encouraged therapists to work in functional contexts.^9,10 In work with a 2-year-old with CP, for example, therapists could position the child on a potty seat rather than a piece of therapeutic equipment, such as a ball or bench, to help the child develop sitting balance.

Understanding the interaction of functional activities or limitations with related single- and multisystem integrities and/or impairments through careful and ongoing analysis is foundational within the practice of NDT. There is current support for this concept by Saether et al,41 who reviewed the relationship of trunk control for sitting and gait in children and adolescents with CP. In addition, Curtis et al⁴² performed a retrospective study relating trunk control to multiple activities or functional outcomes.

It is also important to consider the influence of multiple contextual facilitators and barriers on those activities and/or limitations. This analysis or problem solving is imbedded throughout examination, intervention planning, and intervention implementation.¹⁵ It is included in home programming with recommendations of how to integrate therapeutic activities into daily life rather than by providing a separate list of exercises to be completed by either the individual or caregivers.

The ICF²⁵ model clearly defines and outlines different domains of human health and/or disability. This model, developed by the WHO, organizes, labels, or categorizes concepts of health and disability worldwide. It provides the terminology for describing how a practitioner using the NDT Practice Model addresses activity limitations in relationship to body system impairments within specific contextual factors and will be described in greater detail in Chapter 3. Ultimately, the person’s function is explored at a body system level, an individual level, and the level of societal roles. Each domain is also viewed within contexts of the individual and the environment. In the NDT approach, the relationship and interactions of these domains are critical. The ongoing relationships of these in evaluation, intervention planning, and intervention are presented in NDT Practice Model.¹⁵

Build on the Individual’s Strengths while Addressing Impairments

The medical rehabilitation model has a history of being a problem-oriented model for care. Individuals with health care needs seek treatment from health care providers who develop interventions to minimize or manage the impairment. The ICF model reflects a change in the approach to care.²⁵ The ICF model has now moved from identifying a separate health or wellness domain and a separate one of disability to viewing each domain as a continuum from health to disability. Every person is viewed as having aspects of health and disability.²⁵ The NDT clinician, building on this perspective, expects strengths in every individual and builds an intervention plan based on those strengths. The therapist identifies the strengths in every domain (participations, activities, and system integrities) within the ICF model as well as the participation restrictions, activity limitations, or body structure or function impairments. These strengths are then foundational in planning intervention and in the implementation of the plan on a moment-to-moment basis. The NDT plan of care builds on those strengths rather than only addressing the problems.¹⁵

Mike, presented earlier in this chapter, was engaged in initial problem solving based on the strength of his intellect. He could use his ability as a good problem solver to aid in solving motor problems encountered in daily life. He also, however, had integrities in several of the body systems where he also had identified impairments. For example, Mike had impairments of the neuromuscular system that contributed to limited motor control in his trunk and all four limbs. However, he demonstrated enough motor control of his upper extremity to communicate via his tapping or use of a radio device for Morse code. During intervention, this effective posture and movement control was built upon and modified to help him develop the skill to control a joystick on a powered wheelchair and to access a more widely acceptable augmentative communication device. Another example is that Mike had nearly full range of motion, so it was possible to work in supported postures with better alignment to develop the graded control in the lower extremities for transfers. The therapist and Mike not only focused on the abnormal control and coordination of the neuromuscular system but worked to build better control and coordination based on the integrities of the musculoskeletal and sensory systems as well as those in the neuromuscular system.

Individualize Intervention

The previous philosophical tenets demonstrate that intervention must be individualized.¹⁵ Using a prescribed set of exercises or implementing a specific, rigid treatment protocol is not a part of NDT. A hallmark of NDT is that it is a problem-solving process that requires ongoing evaluation and modification of the intervention during the entire process.^9,10,20,43 The decision-making process for therapists planning intervention for complex individuals is difficult. Rothstein and Echternach⁴⁴ developed the Hypothesis-Oriented Algorithm for Clinicians (HOAC) in 1986 to provide a systematic method for clinical decision making in physical therapy that is independent of the overall treatment philosophy. Included in the eight-step method is the formulation of hypotheses or clinical impressions or predictions at several points of the intervention process.

The evaluation process within the NDT Practice Model begins with information gathering and examination of the individual across all domains of the ICF model. The problem solving starts with the analysis of the relationship of the critical activity limitations and participation restrictions with the underlying body structure and functional impairments. A specific clinical hypothesis of which impairments should be addressed first and in what functional contexts is formulated in an intervention plan. The resulting individualized plan is implemented by the clinician.

However, when implementing the proposed intervention plan, practitioners also include ongoing evaluation. The clinician observes and consistently analyzes the session to determine if the desired outcomes are emerging. Were the initial hypotheses accurate? or do they need modification? In principle, the clinician works in the microseconds and millimeters of examination, evaluation, and intervention suggested by Quinton, in her writings, in her teachings, and in personal communications with other authors and practitioners such as Nelson and Howle.^20,45,46 The therapist does not plan a series of intervention sessions and then reevaluate at the end of the session, the end of the week, or the end of the month or year. Instead, the therapist observes, monitors, palpates, and evaluates every microsecond. The NDT clinician is constantly asking, Is this better or not? Is this the most efficient avenue to success? Should we modify the session and use a different strategy? This problem solving is the hallmark of NDT. NDT is not the regimented use of a specific handling strategy.15

Additionally, the therapist also works in millimeters.^45,46,47,48 As an individual moves from prone to sitting, for example, the therapist evaluates the transition being performed during every millimeter of the transition. It is not sufficient to examine the entire transition to determine the level of success. It is necessary to observe where in the transition change occurs. The clinician asks, Where in the transition does the individual have more or less control? Where is it necessary for the therapist to add or lessen the assistance that is given?

The evaluation, plan, and intervention are individually tailored. The intervention is based on the interaction of all the person’s body systems, on the mix of effective and ineffective posture and movement, on the functional activities and activity limitations, on the participation and participation restrictions, and on all of the contextual factors that significantly influence and challenge the person.

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