NDT by Dr. Rati.

NEURODEVELOPMENTAL TREATMENT APPROACHNEURODEVELOPMENTAL TREATMENT APPROACHNEURODEVELOPMENTAL TREATMENT APPROACHNEURODEVELOPMENTAL TREATMENT APPROACH

IN 1940s Bertha Bobath and Karl Bobath started a new treatment approach for children

with Cerebral Palsy or those with Developmental delay. It was developed due to the clinical

experience of Bertha Bobath; as she found that handling patient’s body made a difference

in the distribution of stiffness and control of movement.

The main purpose of this approach was:-

1. To develop more effective treatment for Children with Cerebral Palsy

2. The Focus of the theory is to address & to inhibit abnormal motor pattern & facilitate

more functional patterns.

3. Its aim is to inhibit spasticity and synergies.

Principles of NDT:-

- To facilitate normal autonomic responses that are involved in voluntary movement, it

uses inhibitory postures and movements

- It uses understanding of Normal movement to analyze atypical of abnormal

movement.

- It breaks movement into its component parts before whole movement can be

practiced Eg- Sit to Stand ( Components: forward weight shift, weight bearing on

feet , trunk and head extension , transfer of weight on the new base of support)

- It emphasizes influence of Biomechanical & Environmental constraints on movement

Eg- Use of stool for lateral wt shift compared to use of Vestibular ball for lat. Wt

shift.

- It uses manual handling techniques for giving inputs. Inputs can be in the form of

negative input ( Inhibition ) or positive input (Facilitation)

- Hands are placed as a Key point to encourage movement control.

- NDT is primarily a Hands-On approach.

The purpose of having the hands-on is:-

1) to align the body segments Eg- correction of rib cage alignment over pelvis in sitting.

2) To stabilize the body segments

3) To initiate movement of a body segment

4) To prevent movement of a body segment

- The hands should contour to the shape of the part.

- They should never cause discomfort.

- Never push, pull or lift the client

- If the hands are well placed then they give information of the Muscle tension or

relaxation of the muscle

- Hands could also serve the purpose of a ‘Guiding Hand’ (G- Hand)‘– which always

leads the movement & an ‘Assisting Hand’ (A- Hand)– which either completes the

movement or provides necessary stability

- Hands can be placed:-

1) Across the joint to facilitate wt. shift E.g.- Sit to stand by facilitation through lower

extremity (LE), hands across hip joint.

2) Over muscle Eg All fours to Quadruped hands over gluteus maximus

3) Over Proximal joint for stability Eg – sit to stand by facilitation through Pelvis

4) Over Distal joint if some component of stability exists proximally E.g.- sit to stand

by facilitation through UE.

- Body Mechanics: -Always position yourself so that you can also move along with the

client.

- Base of Support: - if rotation of extremity occurs before a wt shift is attempted most

commonly there is a blocking of the wt shift referred to as the ‘Buttress Effect’. Eg- In

sitting on a bench, if lat. Wt. shift is attempted with the LE in Abduction and

internal rotation at hip, there will a blocking of wt shift, thereby causing early

instability in lat. wt shift and thus reducing the range of wt. shift.

- Movement should be practiced in all three planes i.e. Antero-posterior, Lateral &

Diagonal.

- Alignment of the client is the most essential feature for the effectiveness of the each

technique based on NDT principles. Always align the body segments such that wt

transfer is smooth and does not aggravate any abnormal mobility between two or

more segments. Eg:- Alignment of the rib cage over the pelvis in CP child is of

utmost importance as delayed or no development of abdominal muscles leaves the

rib cage in a hanging and hyper mobile state w.r.t trunk. Therefore it is important in

all Ant-Post wt shifts that the trunk remains straight, rib cage in straight line with

the pelvis. Also LE should be in 90-90 position i.e hips make an angle of 90o w.r.t

trunk. Similarly knees & ankle should make 90o, pelvis in neutral alignment, and

head in straight line over the trunk.

- Choice of tool: - for dynamic tasks like sit to stand, or lat. Wt. shift, a vestibular ball

would give more range and mobility. Similarly the therapist should choose their own

position or tool according to that of the client. Eg- if the client is doing lateral wt.

shift on a Vestibular ball, therapist should also choose a dynamic surface for self.

- Based on these NDT principles Facilitation Techniques were developed which guide

the client through various phases like sitting, long sitting, standing etc, and through

the transitions between these phases. The ultimate aim of NDT and so of Facilitation

techniques is to help the client gain functional independence.

REMEMBER

“Facilitation is a dance with another human being who is struggling to regain motor skills or to learn new motor skill for the first time. Honor the client and understand your impact upon the person’s present, past, and future goals for improvement”- Lois Bly.

Name of the Technique

Sit to Stand: Anterior Weight Shift at the Hips – Facilitation from the

Upper Extremities

Goals

• To increase the client’s trunk extension

• To increase the forward movement of the trunk and pelvis over

the femurs

• To increase the forward movement at the hip joints

Client’s Position

The client sits on a mat table or stable bench with a neutrally aligned

spine. The hips and knees are flexed to 90 degrees. The feet must touch

the floor. The client’s arms are lifted, externally rotated, and flexed

above 90 degrees at the shoulders.

Therapist’s position

Depending on the client’s size, you may stand, kneel, or half kneel in

front of the client. You must be in a position that permits you to weight

shift with the client.

Therapist’s Hands and Movement

Place your hands under the client’s elbows. Extend the client’s elbows,

externally rotated the client’s arms, and lift them over 90 degrees at the

shoulders. Apply diagonally upward and forwards traction to the client’s

arms. The traction facilitates the client’s trunk and pelvis to extend and

move forward at the hip joints. As the client’s weight is brought up and

forward over the feet, the client rises to stand. The client’s arms are

flexed overhead to maintain the trunk extension.

Precautions

• The trunk and spine must remain in a neutral position on all

planes

• The trunk and pelvis must move as a unit

• The movement must occur at the hip joints, that is, pelvis over

femurs

• Do not allow the thoracic spine to flex during the movement

• Do not allow the lumbar spine to flex or hyperextend

• Do no let the client quickly extend the knees when rising

• Do not let the client collapse at the knees when lowering to sit

Maintain proper alignment of the feet. Avoid pronation of the feet.

Component Goals

• Thoracic spine extension

• Movement of the pelvis over the femurs (pelvic-femoral mobility)

• Synchronous movement of the rib cage and pelvis

• Forward movement of the trunk and pelvis over the femurs

• Forwards transfer of body weight to legs and feet

• Lower extremity weight bearing

Graded concentric and eccentric control of knee and hip extensors when

rising to stand and lowering to sit.

Functional Goals

• Graded control of lower extremity movements

• Rising to stand


Sit to Stand: Anterior Weight Shift at the Hips – Facilitation from the

Pelvis

If the client has difficulty moving the pelvis forward over the femurs,

you can facilitate the movement from the client’s pelvis.

Client’s Position

The client sits on a mat table or stable bench with a neutrally aligned

spine. The hips and knees are flexed to 90 degrees, with the feet on the

floor. The client’s arms rest on your shoulders.


Kneel or half kneel in front of the client. You must be in a position that

permits weight shift and movement with the client


Place the palms of both hands laterally on the client’s pelvis with your

fingers posterior on the pelvis. Align the pelvis to neutral. Correct with

your fingers. Once the alignment is correct (ribcage straight over pelvis),

move the client’s pelvis forward over femurs. As the weight is shifted on

the feet, give a slight diagonal shift forwards and upwards. Move back

as the client stands up to provide space.

Precautions

Same as for UE Facilitation

Component Goals


Functional Goals



Sit to Stand: Anterior Weight Shift at the Hips – Facilitation from Lower

Extremities

If client has difficulty controlling legs during transition from sit to

stand, facilitate movement from the client’s lower extremity

Client’s Position

Sitting on mat table or stable bench with neutral spine. Hip-knee

alignment 90-90 degrees. Arms rest on therapists shoulders.


Knee or half kneel in front of the client.


Place both hands proximally on the lateral aspect of client’s femurs.

Rest your arms on client’s femurs and provide weight down into client’s

feet. This contact of your arms assists with stability and control of the

movement. Shift the client’s femur over the feet. Diagonally assist the

client in sit-to-stand.

Precautions :-

Same as for UE facilitation

Component Goals


Functional Goals



Supine to long sitting – Facilitation from trunk

Goals

- Guide the client to supine to sit.

- Facilitate Abdominal activation

Client’s Position

Supine lying on floor, the soon-to-be-wt. bearing UE slightly abducted,

internally rotated at the shoulder, forearm pronated palm placed on the

mat. LE in figure of 4 position i.e. the non-wt bearing LE in hip flexion

and abduction, lateral aspect of thigh resting on the mat, or if the ROM

of abduction-external rotation is reduced, place pillows to support the

non-wt bearing thigh.


Kneel next to the client’s pelvis, on the soon-to-be-wt. bearing side.


G- Hand - under the client’s opposite scapula, gives the wt.shift with

the heel of your hand. A- Hand - placed on top of the soon-to-be-wt.

bearing palm holding the forearm and the palm down on the mat. Give

the wt. shift from the heel of your G- hand causing the wt to transfer

entirely on the to-be wt. bearing side. Continue the wt. shift until the wt

transfers from shoulder on to the elbow then to the forearm finally to

the palm of the hand. Once this is accomplished the client will

automatically, be upright facing you with shoulder turned to your side.

If during this transition the client finds difficulty due to weak

abdominals or due to inadequate fixation of the pelvis, once the wt is

stable on the wt. bearing forearm and palm; stabilize the same side

pelvis with your A- Hand and give a diagonally downward traction. This

will help fixing the pelvis and the traction will elongate and therefore

activate the same side abdominals.

Precautions

- Do not push the opposite shoulder into protraction, this causes

both shoulders to protract and the sitting will be achieved by

pectorals rather than abdominals.

- Do not elevate the shoulders as this will block wt. shift side ways.

Component Goals

- UE placement facilitates wt bearing through it.

- Shoulder wt. bearing causes co-contraction and therefore

stabilization of the shoulder flexors and extensors

-

Functional Goals

- Precursor to sitting activities


Upper extremity weight bearing into Quadruped –Facilitation from Upper

Extremity

Goals

- Facilitate UE protective extension ( i.e a protective reaction of

reaching or holding side ways when body wt tends to shift to the

sides)

- Weight shift of body over the arm in preparation for reaching

- Preparation for transition from sitting to Quadruped.

Client’s Position

Long sits on the floor with neutral alignment of the spine, hips flexed, &

knees extended.

If long sitting is not feasible, then the client can Semi-long sit i.e long

sitting on the floor with slight knee flexion.


Kneel behind the client in a position that permits you to wt. shift with

the client.


Place the client’s soon-to-be-wt. bearing hand beside and slightly

behind trunk. Once the client is in a wt-bearing position, keep the

dorsum of your G- hand on the client’s side near the lateral border of

the scapula, with your fingers curled around the inner and upper 1/3 of

the humerus. Move the arm of your G- hand in a circular direction

toward the client’s trunk, facilitating the client to pivot over the wt-

bearing arm. Simultaneous with the movement of your arm, slightly

externally rotate the client’s humerus with your fingers of G-hand. This

external rotation helps facilitate the wt-shift.

When the client’s trunk pivot over the arm, the client spontaneously

transitions to quadruped. The client’s nonweight-bearing arm follows

the trunk around to a wt-bearing position.

Precautions

Do not hike the shoulders, but elongate the entire side of the trunk.

Component Goals

- UE placed in an extended position for protective extension.

- Elbow extension, wrist and finger extension

- Wt. shift in hand to facilitate various arches of hand

- Pivoting of the trunk at the shoulder over the wt bearing arm.

- Shoulder ROM into external rotation.

Functional Goals

- UE protective extension to control/prevent falling

- Transition from sitting to quadruped


Quadruped to Kneeling- Facilitation from trunk.

Goals

- Increase hip joint & lower extremity mobility

- Increase eccentric control of hip muscles

- Increase synergistic activation of hip extensors and abdominal

muscles

- Increase the client’s control in transition from quadruped to

kneeling

Client’s Position

The client is quadruped, shoulders relaxed; pelvis and the rib cage

should be in same line & Pelvis should be neutrally aligned.


Half kneel beside the client in a position that permits you to weight shift

with the client


Guiding hand - on the client’s anterior trunk, fingers spread so that

your thumb and index finger are on client’s lower ribs & remaining

three fingers spread over the abdominals to the pelvis. Align ribs &

pelvis. Assisting hand – on client’s gluteus maximus.

With your Guiding Hand shift client’s wt straight back, continue post wt

shift unless the client indicates that CG is stable {indicated by hand

lifting or neck extension i.e. neck righting reaction}. When the client’s

indicates righting reaction by lifting head; hands &/or trunk, carefully

use your assisting hand to guide the hip forwards into extension.

Precautions

- Do not place assisting hand on client’s lumbar spine or sacrum

as this will cause Lumbar extension, anterior pelvic tilt or hip

flexion

- Do not place assisting hand on client’s hips as this will assist in

post pelvic tilt & trunk flexion.

- Do not facilitate forward movement of the hip and hip extension

before the righting reaction begins.

Component Goals

- Activation of abdominals with hip extensors

- Elongation and eccentric activation of hip extensors followed by

concentric activation

- Elongation and eccentric activation of quadriceps followed by

concentric activation

- Synchronous hip and trunk extension

- Post and Ant wt. shifts

Functional Goals

This transition is needed for transition to stand.


Kneeling to half kneeling – Facilitation from arm

Goals

- Elongation of the latissimus dorsi

- Facilitate lateral weight shift

- Lateral flexion of trunk

- Elongation of weight bearing side

- Eccentric control of the trunk and hip muscles on the weight bearing

side

- Transition from kneeling to half kneeling

Client’s Position

Client kneels with arm on side of the soon-to-be weight bearing hip held

in full shoulder flexion and external rotation


Half kneel beside/behind the client


Place assisting hand on far side of client’s rib cage (use it to guide and

stabilize trunk during weight shift, or you can also use your body to

stabilize Client hip during weight shift)

Place guiding hand over client’s elbows (use to flex and externally rotate

client’s shoulder)

To facilitate transition, to use guiding hand, to externally rotate and

apply upward traction to the client’s arm, to elongate latissimus dorsi

Shoulder is flexed overhead so that arm reaches to the ceiling

Elongation of lat dorsi facilitates lateral weight shift to that side, the un-

weighted leg responds by moving forward into half kneeling

Precautions

Apply slow traction, never quickly

Traction to proximal and not distal joints

Do not apply in case of ligamentus laxity

Apply traction upwards, not outwards else the client will fall side ways

Client must have some active control of hips for the weight shift

Component Goals

Elongation of lat dorsi for lateral weight shift in trunk

Lateral righting of the client’s head, trunk and pelvis

Balance reaction and un-weighted leg

Lower extremity dissociation

Functional Goals

Transitions from kneeling to half kneeling with elongation of weight

bearing side

Preparation for weight shift and elongation of weight bearing side to be

used in gait


Anterior Weight shift to stand: Facilitation from the arms

Goals

- To facilitate balance reactions for various weight shifts that the client

may experience in half kneeling

- To activate and elongate the lower extremity and trunk muscles

Client’s Position

Half kneel in front of you with shoulders flexed and externally rotated.

Leg should be in line with pelvis not abducted, one hip extended and

the other flexed, forward foot flat and back foot plantar-flexed


Stride stand in front of client


To facilitate rising to stand, hold the client’s arms near the elbows, and

flex and externally rotate the client’s shoulders. Traction the client’s

arms diagonally forward and up so that the client’s weight is transferred

to the forward leg. Continue to flex the client’s shoulders forward and

up until the client’s weight is stable on the forward foot. Rise

simultaneously with the client, using a diagonally backward weight

shift. This guides the client forward and up. You and the client both end

in a step-stance position.

Component Goals

- Graded activation of the hip extensors and quadriceps

- Forward weight shift to one leg stance

- Lower extremity dissociation

Functional Goals

- Rising to stand from half kneeling

- Step- stance position of gait


Walking Facilitation from UE: Arms Externally Rotated and Flexed to 90

degrees

Goals

- To increase scapular abduction – adduction - Upper trunk rotation while walking forward

Client’s Position

In front of you with shoulders flexed to 90 degrees and externally

rotated, and elbows extended


Behind client, both hands on client’s humeri, nearer over the elbows


Hold a client’s arms at elbows, flex arms to 90 degrees, adduct them

into line with body, and externally rotated the arms to neutral.

Counter rotation: Once achieved, maintain the alignment with your

hands as they facilitate upper trunk counter rotation and scapular

abduction and adduction while the client walks forward.

E.g. Walking with right leg ahead – as a client’s weight shifts to left leg,

right leg steps forward. As the client’s right leg moves forwards,

carefully apply forward traction to left arm to abduct the scapula and

rotate the left side of trunk forward. At the same time, guide right side

of client’s (C) trunk and right scapula rightly backward with your hand

and approximate the humeris into scapula. This traction of one arm and

approximation of other produces counter rotation between upper and

lower trunk. As the client steps forwards, repeat the same technique for

the other side.

Precautions

1. Do not hyper extend lumber spine

2. Do not elevate the shoulders, keep elbows extended

3. Maintain shoulder flexion and external rotation on both sides

Component Goals

Shoulder flexion to 90 degrees, thoracic extension, humeral external

rotation with elongation of medial rotaters, shoulder girdle depression

with elongation of upper trapezius, upper trunk counter rotation

Functional Goals

Trunk extension during gait, upper trunk counter rotation with

reciprocal arm swing

NDT by Dr. Rati.

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Transcript of NDT by Dr. Rati.