NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT

1. MRS. M.PRADEEPA MPT (NEURO)
VICE PRINCIPAL
PPG COLLEGEOF PHYSIOTHERAPY
COIMBATORE,TAMILNADU, INDIA

3.  NDT originated with work by Berta Bobath and Dr.
Karel Bobath in England in 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
 It is not a method , it is a approach/concept
 In 1960’s Berta bobath renamed it as
Neurodevelopmental therapy

4. The NDT Approach is used for
management and treatment of
individuals with Central
Nervous System
pathophysiology.
The individual’s strengths and
impairments are identified
and addressed in relation to
functional abilities and
limitations.

5. The NDT Approach continues
to evolve with the emergence
of new theories, models,
research, and information in
the movement sciences.
NDT is a hands-on, problem
solving approach.
Intervention involves direct
handling and guidance to
optimize function.
Approach is guided by the client’s
reactions throughout every
treatment session.

6.  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 rehabilitation of individuals with
neurological pathophysiology
 Living concept: It has undergone changes in its
theoretical base to accommodate developments in the
fields of neurophysiology, biomechanics, and typical
development
 Holistic approach: It involves the whole patient, his
sensory, perceptual and adaptive behaviour, and motor
problems

7.  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 caregivers.

9.  The abnormal patterns must be stopped not by modifying the
sensory input, but by giving back to the patient the lost or
undeveloped control over his out put in developmental sequence.
 The basic patterns of posture & movement , the righting reaction
& equilibrium responses are elicited by providing the appropriate
stimuli while the abnormal patterns are inhibited.
 In this way patient the patient is given the opportunity to
experience normal movement.
 The sensory information of correct movement is absolutely
necessary for the development of improved motor control.
 Treatment therefore, concentrate on handling the patient in such
a way as to inhibit abnormal distribution of tone & abnormal
postures while stimulating or encouraging the next level of motor
control.

10. 1. Analysis of normal movement
2. Analysis of the deviation from normal for
that individual
3. Understanding of the concepts of systems
control, and neural and muscle plasticity
4. Appropriate use of treatment techniques to
facilitate normal alignment, movement and
tone

11.  Normal movement is the development of the
efficiency of the human phenotype.
 Phenotype is the proportion of the genetic
material being expressed

12.  To develop the ability to selectively extend
(extension of the hips and posterior pelvic tilt
give a unique form of alignment for head control
which facilitates speech)
 Mature vestibular system for postural stability
through the development of equilibrium
reactions
 Mature righting reactions (trunk righting, head
righting, stepping reactions, protective
extension)

13.  To use upper limbs selectively in space
against a background of a mature balance
mechanism
 The ability to receive and integrate sensory/
proprioceptive information and to be able to
adapt the threshold level of firing of specific
receptors and therefore change motor
response and performance
 To be able to plastically adapt and therefore
learn at the synaptic level

14.  The Bobath Concept expresses the common
characteristics of the phenotype in the
Central Postural Control Mechanism.
 It provides us with a mobile trunk, pelvis and
feet which allows us to balance against the
force of gravity via our equilibrium and
righting reaction, which frees our upper limbs
and head for skilled movements

15. a) Appropriate postural tone
b) Reciprocal innervation
c) Patterns of movement
d) Sensory and proprioceptive controls

16.  Sherrington(1947) stated that normal
movement need a background of normal tonus
 Inhibition is very important factor in control of
posture & movement.
 With increase of inhibitory control of the
maturing brain, the organism increasingly gains
more selective control of posture against
gravity.
 This process follows cephalocaudal direction.

17.  The action of total pattern has to be inhibited
prior to the inhibition of a localized action.
 This means that normal functional & skilled
activity are largely a matter of inhibitory control.
 The quality of coordination & its development in
early childhood depends, therefore, on increase
of inhibitory control & not on increase of muscle
power.
 Inhibition is a active at every level of the CNS.
 The difference between lower & higher levels of
integrations only the matter of complexity.

18.  Selective movement of parts of body & limbs need
inhibition of those parts of patterns which
unnecessary for specific function.
 Inhibition doesn't only make selective movement
possible, but plays a imp role in the grading of
movement, I.e. it is an important factor in reciprocal
innervations. It is the balanced activity of excitation
& inhibition during a movement which control
speed, range & direction.
 Inhibition on excitation & changes & moulds it for
the purpose of coordination. It modifies & control
action one might say that inhibition is control.

19.  The brain damaged patient suffers from a lack of
inhibitory control over his movements.
 This itself show release of tonic reflex activity, i.e.
spasticity in abnormal total patterns.
 Spasticity will increases, producing deterioration of
his movements. Movements become slowed down,
laboured, or he may become too stiff to move
altogether
 Spasticity shows itself in definite pattern of
abnormal coordination & that is not confined to a
few isolated muscles

20.  In intact organism, spinal inhibition becomes
modified by higher central nervous influences &
allows reciprocal innervation, a more adequate
response to the multitude of stimuli which
enters the central nervous system in normal
condition of life.
 Agonist, antagonist & synergists are pitted
against each other in finely graded way giving
necessary interplay of muscles group for fixation
with mobility & optimal mechanical conditions
for muscle power.

21.  In normal circumstances all the required degrees
of reciprocal interaction in various parts of the
body and limbs necessary for postural fixation,
grading of movement & for the maintenance of
equilibrium are present.
 Disturbed reciprocal innervation described
above are responsible for the way in which a
patient is fixed n few abnormal patterns, & for
the difficulty in coordinating movement & their
grading.

22.  The degrees of fixation in stereotyped postural
patterns depends on the severity of spasticity in
individuals case & are the result of the release of
abnormal postural reflexes which interact with
each other.
 Treatment aims at inhibition of abnormally
release patterns of coordination & the
facilitation of the higher integrated automatic
reactions of normal postural control & of those
of more voluntary activity.

23.  Treatment helps the patient to develop &
increase his control over the disinhibited
action of tonic reflex activity by use of
patterns which inhibit spasticity.
 Through inhibition his movement are
channeled into more normal patterns of
function.
 With the helps of therapist, the patient gains
control over the released abnormal non-
functional motor patterns

24.  Concepts of system control is based on neurophysiological
theories
• Older - Reflex, Hierarchical theory
• Newer – System Model theory
 The structures undergoing modification which need to be
considered during motor learning are neural plasticity and
muscular plasticity.
 Neuroplasticity: The brain's ability to reorganize itself by forming
new neural connections throughout life. Neuroplasticity allows the
neurons in the brain to compensate for injury and disease and to
adjust their activities in response to new situations or to changes
in their environment
 Muscle plasticity is defined as the ability of a given muscle to
alter its structural and functional properties in accordance with the
environmental conditions imposed on it

25.  The righting reactions are automatic
reactions which serve to maintain & restore
the normal position of head in space & its
normal relationship with the trunk, together
with normal alignment of trunk & limbs.
 They develop in childhood & are well
advanced at age of 5 months of age.
 Rotation around the body axis plays an
important role in these activities.

26.  Gradually modifies & become integrated into
more complex activities, such as the
equilibrium reactions & voluntary movement.
 There are essential in the building up of
motor patterns for adult life.
 Throughout life they are necessary for
getting up from the floor, for getting out of
the bed, for sitting up, for kneeling down, etc.

27.  WALSHE (1923) described associated
reactions as tonic reflexes, i.e. postural
reactions in muscles deprived of voluntary
control.
 In hemi associated reactions produces
widespread increase of spasticity throughout
the hole of the affected side.this accentuate
the hemiplegic attitude.

28. 1. There are less spasticity & after contraction if
movement are done slowly.
2. The spread of excitation into total spastic
patterns can be counteracted by inhibiting
parts of these patterns.
3. The therapist should inhibit spasticity
immediately the movement begins to
deteriorate.
4. At the start of treatment, excitation & effort
are kept to a minimum, then it is gradually
increased.
5. Therapist helps the patient to learn to inhibit
this spasticity by the use of selective
movements.

29.  Equilibrium reactions are automatic reactions
which serve to maintain & restore balance
during all our activities, especially when we are
in danger of falling.
 All equilibrium reactions reactions, tonus
changes & movement changes have to be well
coordinated, quick, adequate in range & well
timed (Rademaker, 1935,Weisz1938)
 Tested either by the body moving body against a
fixed support such as the ground, or by means of
a movable platform or tilting table.

30.  These automatic reactions can be observed in
trunk & limbs, and they overlap to some
extent with the equilibrium reactions.
 In a normal person, the central postural
control mechanism governs the weight of a
limb during movement both into & against
gravity.
 This mechanism may be called ‘postural
adaptation to gravity’.

31.  A normal person is active when being moved
against gravity.
 Relaxation, unless full support is given, is a
voluntary learned ability.
 Normal person controls every stage of
movement actively & automatically.
 We call this maneuver as ‘placing’.

32.  Treatment should avoid movements and activities that
increase muscle tone or produce abnormal reflex patterns
in the involved side
 Treatment should be directed toward the development of
normal patterns of posture and movement.
 The hemiplegic side should be incorporated into all
treatment activities to re-establish symmetry and
increased functional use
 Treatment should produce a change in the quality of
movement and functional performance of the involved
side
 Increase active use of the involved side
 Provide practice to improve motor performance that lead
to motor learning

33.  Initial Flaccid Stage:
Treatment focus on positioning and
movement in bed to avoid the typical postural
patterns of hemiplegia
 Stage of Spasticity:
Treatment is a continuation of the previous
stage with the goal of breaking down the total
patterns by developing control of the
intermediate joints
 Stage of Relative Recovery:
Treatment aims at improving the quality of
gait and the use of the affected hand

34.  Treat the child as a whole
 Basis for intervention is normal movement
and their interrelationships
 Treatment incorporates facilitation and
inhibition using key points of control
abnormal tone is always inhibited normal
responses, once elicited, are always repeated

35.  Parts of the body where the therapist can
most effectively control and change patterns
of posture and movement in other body parts
 Proximal: shoulder/scapula, pelvis/hip
 Distal: jaw, wrist, ankle
 Head may be a proximal or distal KPC

37. KCP
CKP:
1. ANTERIOR –
XIPHOID
PROCESS
2. POSTERIOR –
T7,T8
PKP:
1. HEAD,
SHOULDER
AND PELVIS
DKP:
1. HAND AND
FOOT

44.  Facilitation is a mean by which movement is
made easy, made possible, and made necessary
 Inhibition involves decreasing the use of
pathological movements and the effects of tonal
dysfunctions on movement
 Facilitation and inhibition may be used
simultaneously and may be applied throughout
the session
 Facilitation and inhibition can be done by using
proper positioning and using KPC

45.  Manner of controlling the patient through
tone influencing patterns
 Normal patterns of activity used to modify
abnormal patterns of posture and movement
 TotalTIPs: whole body is controlled in a
reversal of the abnormal pattern
 PartialTIPs: some body parts remain free to
move
 TIPs are utilized via KPCs