Neuro developmental Treatment (NDT)

Neuro Developmental Treatment (NDT)
Tehran CP Workshop, May 2017 1
‫تخصصی‬ ‫کارگاه‬
‫رویکردهای‬ ‫ای‬ ‫مقایسه‬ ‫بررسی‬‫باتم‬‫و‬ ‫آپ‬
‫تاپ‬‫کودکان‬ ‫کاردرمانی‬ ‫مداخالت‬ ‫در‬ ‫دان‬
‫مغزی‬ ‫فلج‬ ‫به‬ ‫مبتال‬
‫بهار‬1396

NDT Definition
• 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 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.

NDT Subsystems
• 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 (ICF) 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

ICF model

Motor Control Approach
• Neuromaturational Theories
1. Reflex/Hierarchical Theory
2. Generalized Motor Program Theory
• Dynamic System Theory
• Neuronal Group Selection Theory

Reflex/Hierarchical Theory
• This theory assumed that the structures of the brain were organized
and developed in a hierarchy and that there was a fixed relationship
between function and structure.
• Each successively higher level of brain structures provided more
precise movement integration. Therefore, as these structures
developed, function changed accordingly.

• The lowest level of fundamental movement
patterns were sensory-elicited reflexes,
which were then integrated into the
automatic postural reflex mechanism as the
higher brain levels developed.
• These automatic movements, including
righting and equilibrium reactions, were
considered to be the basis for skilled
voluntary movements.
Tehran CP Workshop, May 2017
9

• The R/HTs helped to explain the stereotypic movements and postures
seen in persons with neuropathology.
• These were acceptable neural control models until the late 1960s and,
although they did offer explanations for predictable movement seen in
cerebral palsy (CP), their limitation was that they did not account for
context-based movement, variability, individuality, novelty, and context-
based behaviors.

Generalized Motor Programs (GMPs)
• Instruction are specified by the CNS
• Control process is managed by a motor program
• Motor program organizes, initiates, and carries out intended actions
• Linear changes in movement behavior

• Keele proposed the existence of a set of commands in the CNS named
Generalized Motor Programs (GMPs) , which were assembled and initiated
without sensory input and performed in the absence of peripheral
feedback.
• GMPs contain the abstract representation of movement, including the
commands for movement, codes of action, and general features of
movement sequences as well as the recruitment of appropriate agonists
and synergists with adjustment of antagonists of peripheral feedback.

• There could be basic motor plans for reaching and grasping and
rhythmic movements for walking or speaking that are assembled
prior to the need to move.
• Simple sequences could then be linked together to produce complex
actions, such as walking down a slope or singing.
• The richness of the GMPs developed from both experience and
learning.

GMPs and CPGs
• GMPs renewed the interest in the
concept of Central Pattern
Generators (CPGs)
• Neural networks in the spinal cord
capable of producing rhythmic
movement even when isolated from
the brain and sensory systems.
• There was increasing evidence that
specialized neural circuits do exist in
the brain stem of vertebrates for
breathing, chewing, and swallowing,
and in the spinal cord for locomotive
functions.

Body Weight Support Treadmill Training
• Partial body-weight-bearing (PBWB)
gait training is one intervention that
gains support from CPGs.

Dynamic System Theory
• Movement is produced from the interaction of multiple sub systems
within the person, Task, and environment.
• No sub system is most important
• Dynamic system(DS) is complex
• Development is in a non-linear rate, not steady
• A movement pattern emerges (self-organizes) as a function of the ever-
changing constraints placed upon it.

Self organization
• This theory deemphasizes instructions or neural selectivity to achieve
coordinated actions and instead looks for explanations based on physical
parameters.
• Change occurs because one control parameter(Speed, Direction, force),
or variable, reaches a critical value, which causes a change in the entire
system.
• For example, change in velocity regulates a change from walking to
running. Change in the slope alters step frequency and step length in
young children.

What is a constraint?
• They limit the Movement
possibilities (degrees of
freedom) of the individual
1. Biomechanical and
anthropometric properties of
the body system : body shape,
weight, height, emotional, cognitive, etc.
2. Environmental: gravity, temperature,
light, wind, etc
3. Task constraints: rules of the game, goal
of the task, and the object or tools (i.e.
size, shape, weight) manipulated.

Attractor States
• We prefer states to be stable. This state or stability is known as attractor
state or what we presently prefer.
• When a change in constraints occur, the stability of the system is
endanger!
• In time, the movement pattern will reorganize and the new one will begin
to take over and stability is regained.

Application in NDT
• The clinicians can identify constraints that limit functional change
and develop intervention strategies which directly target these
constraints.
• For example, in early infancy, the mass of the child’s head relative
to the size of the rest of the body places constraints on, or limits,
the rate at which head lifting and visual following can occur.
• Delays in independent sitting constrain the foundations for manual
development, mother–infant face to face interactions, and
reaching behavior by 6-month-old infants.
• In adults with CP, moderate weakness, increased muscle tone,
bone and joint deformities, and progressive asymmetry in posture
are independently responsible for limitations in independent ADL.

Gravity as a major constraints in
Motor Function
• Introduction of BWST and Anti Gravity
Treadmill
• Reduce gravity’s impact by selecting any
weight between 20% and 100% of your
body weight

Transitions or phase shift
• Specific motor skills emerge from a series of states of stability, instability,
and phase shifts in which new states become stable aspects of behavior.
• During development, as the subsystems of developing systems change,
motor behaviors can either become more stable or destabilize. These
periods of destabilization are referred to as transition states.
• During these times, new forms of movement are most likely to occur.
These transitions are characterized either by an increased latency in
time to return to a stable state after perturbation, or by increased
variability in behavior.

Problems of phase shift in CP
• People with neuropathology with limited repertoires of movements
may lack variability, and destabilizing these limited patterns is
difficult.
• The person continually tries to use the limited repertoires in all
situations, and transitions from one state to another are increasingly
difficult. The result is movement that is stereotyped and rigid

Application in NDT
• The intervention is most effective during periods characterized by
high degrees of variability. These are often the periods during new
experiences (and new environments)
• NDT recognizes that these periods of transition are the times that
intervention can promote and direct efficient motor patterns as the
client is working out new functional movements in increasingly
complex contexts.

Application in NDT
• As a child with hemiplegia experiences a normal growth spurt at age
2, he may appear clumsy, fall more frequently, stand with more of his
weight on the less involved side, or even walk without placing the
heel (on the more involved side) on the ground during the stance
phase.
• This is a time to increase the intensity of intervention to take
advantage of the variability in gait and balance

Neuronal Group Selection Theory
• When hundreds of thousands of strongly interconnected neuronal circuits
act as structural/ functional units, called neuronal groups, they increase their
effectiveness.
• Neural structures are determined by the competition among neural
elements to assure variation(Diversity) in neuroanatomical structures.
• Primary motor repertoires are movements characterized by variability and
are not connected to either sensory inputs(feedback) or function.
• These connected neuronal groups initially develop by genetic encoding
(Evolution).

Primary Neuronal Repertoires
• Orienting the head and eyes to light and sound.
• Orienting the head to clear the airway when prone.
• Coordinating suck and swallow.
• Bringing the mouth to the hand.
• Following moving objects with the eyes.
• Projecting the arm toward objects.
• Reciprocal kicking.
• Sensory elicited reactions and responses (sometimes referred to as
primitive reflexes, such as head and body righting, palmar grasp, rooting
reaction, Moro reflex).
• General motility.
• Attachment to the human face

PNR and NDT
• NDT therapists use a problem-solving approach to plan intervention
strategies that are flexible enough to accommodate the differences of each
individual client.
• Selective competition supports the hypothesis that variability of
movement.
• Primary Variability is part of a primary repertoire, and it is important to
allow clients to select their own way to organize motor responses.
• Intervention includes assisting the client to organize movement repertoires
in relevant contextes

Secondary Neuronal Repertoires
• If PNR are reinforced by a supportive environment, people in it, and the
infant’s success in fulfilling his or her needs, they lead to an even richer,
purposeful secondary repertoire of responses.
• The brain instantaneously “selects” the response that adapts to external
conditions and that is the most fit for each individual person.
• SNR is developed based on experience-dependent selection of the most
effective neuronal networks.
• The infant organizes postural control as an essential element of all
movement repertoires.
• Secondary repertoires link sensory features to specific motor behaviors.
• Children with mild to moderate forms of CP develop SNR, but at a slower
pace and in a reduced form

Change the PNR to SNR
• Transition occurs at function-specific ages
• All changes are not just changes in synaptic formation and neural circuitry.
• The development of secondary repertoires also depends on changes in the
musculoskeletal system, perception, experience, and a gradual change in
agility, adaptability, and the ability to make complex movement sequences.
• The development of successful reaching and grasping emerges during the
first 4 months, changing from movements that are variable in path, speed,
and accuracy, to reaching movements with mature kinematics involving
fewer movement units

NDT and SNR
• NDT intervention strategies provide very specific sensory input that grades
the intensity, rhythm, and duration of somatosensory, visual, and auditory
inputs while allowing the client to attend to specific aspects of the task.
• NDT intervention recognizes that repetition is an important component in
motor learning. Motor activities that are task specific and repeated
throughout a session with variability and are included in a home program
have a better chance of becoming part of the client’s favored functional
repertoire.

Forming and Connecting Global Maps
•The continual selection of neuronal groups during
development and through repeated selection binds
neuronal groups together to form neuronal maps.
• When maps are repeatedly selected to produce meaningful
behavior, they form global maps.
•Essential to the development of global maps is sufficient
experience with slightly different tasks to permit the
neuronal maps to respond differently to various objects and
events in the environment.( secondary variability)

DS versus NGS
• Like the theory of NGS, the theory of DS maintains that interactions
among the elements of a system give rise to patterns without
instructions or without a controller.
• Both theories propose that individuals who explore a variety of
possible solutions to motor problems will increase their movement
repertoires, have greater success, and have an easier time meeting
the demands of tasks in their daily lives.

DS versus NGS
• In DS the neural substrate plays a subordinate role than
environment whereas in NGS, development is the
result of a complex intertwining of information from
genes and environment.
•A central issue for DS is that, although movement
possibilities (or degrees of freedom) may be constrained
by any of the body systems, they are primarily
constrained by the biomechanical and anthropometric
properties of the musculoskeletal system.
• The variation in NGS is not random, but determined by
criteria set by genetic information

NDT effectiveness
Evans-Rogers et al reported on outcomes of short-term
intensive NDT intervention based on parental perspectives
and functional outcomes
 Girolami and Campbell reported on the efficacy of NDT
treatment for infants born prematurely and found
improved motor control
Arndt et al report on the effectiveness in an NDT based
trunk protocol in infants.
 Tsorlakis et al showed the effectiveness of NDT and
underline the need for intensive application of the
treatment.

COPCA (Coping with and Caring for infants with
special needs - a family centered program)
• COPCA has educational and motor goals.
• Learn 2 move 0-2 and learn 2 move 2-3
• Components:
1. A family involvement and educational component as coaching
2. A NDT based on the principles of the Neuronal Group Selection
Theory
• Its effectiveness has been showed (Hielkema et al 2010, Ketelaar
et al 2010)

NDT Critics
• Butler et al(2001)
 More intensive therapy did not seem to confer a greater benefit
 There was also no clear evidence that NDT produced other
potential benefits such as enhancement of social–emotional,
language, or cognitive domains of development, better home
environments, improved parent–child interactions, or greater
parent satisfaction
 There was not consistent evidence that NDT changed abnormal
motoric responses, slowed or prevented contractures, or that it
facilitated more normal motor development or functional motor
activities

NDT Critics
• Diane L. Damiano(2009)
1. Therapies that involve multiple types of exercises, such as NDT are an
issue from a scientific standpoint because they each have multiple
components that are likely to have varying degrees of evidence. These
programs should be dissected so that the active ingredients can be
identified and retained if
superior to other alternatives and ineffective ones discarded.
2. The fact that NDT has failed to demonstrate superiority over any
alternative treatments to which they have been compared is also a
concern

NDT Critics
• Novak et al(2013)
1. regarding contracture, high-quality RCTs showed
that casting was a superior treatment to NDT
2. regarding tone reduction, the highest quality
evidence suggested that NDT was ineffective for this
indication and other evidence shows BTX exists as a
highly effective alternative
3. NDT is time-consuming and expensive for families,
and, what is more, a high-quality RCT shows that
substantially better functional motor gains are
achieved from motor learning than from NDT at
equal doses

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Neuro developmental Treatment (NDT)

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