Vol. 20 • Issue 6
• Page 14
A common comparison in therapy is neurodevelopmental treatment versus motor control theory. But in the clinic these theories work hand in hand to improve a patient's function. NDT encompasses many aspects of motor
control. When working with NDT, consider many aspects of the motor control or dynamic systems theory. In order to provide the best therapeutic care, one must understand all theories and incorporate them seamlessly to best benefit the client.
What is NDT?
NDT is a problem-solving approach to treating and managing clients with neuromotor dysfunction. This means NDT is not a specific technique but an overall philosophy that uses the knowledge of typical and atypical development and motor patterns, functional task analysis, functional kinesiology, motor control and motor learning to develop appropriate, individualized treatment plans.
NDT is a living concept, therefore it is not the same technique that was initiated in 1943 by Berta and Karel Bobath. NDT has evolved, using influences from PNF, Rood, patterning and motor control
theories. NDT addresses the person as a whole, using observation and analysis of normal development to compare or contrast problems of dysfunction. NDT is an interdisciplinary approach, and treatment is individualized. The person being treated must be an active participant and be interactive with the therapist. Treatment involves a sensorimotor process and includes hands-on facilitation or inhibition. There is a dual focus of attaining functional independence with quality of movement.
The Bobaths developed what is known as NDT practice framed around the context of reflex, hierarchal and maturation theories. Initially, NDT began with the concept of inhibiting tonic reflex activity through various reflex inhibiting postures. This was very therapist-dependent and static; children did not respond well and had little carryover since they did not learn how to move.
Next, NDT incorporated normal developmental patterns into the reflex inhibition. This still did not work because it incorporated passive isolated patterns. The children could not learn to move through the patterns.
A better understanding of righting and equilibrium reactions led to more dynamic treatment by facilitating normal movement patterns through key points of control at the same time as inhibiting abnormal postures. This was very effective for babies, but in older children with greater tonal influences, there was significant reliance on facilitation. The therapist's hands were the balance the child needed. It was then learned that the therapist must gradually take his hands away and allow the child to learn to control his own movement and balance. This worked well in therapy but carryover at home was limited. They realized that there needed to be a transition to functional activities.
Treatment transitioned into the child's functional settings, using the items that children have around them every day. The focus on strictly following normal developmental sequence was also forgone to work on age-appropriate functional activities. For example, treatment was in the child's home using his own bed and chairs. Therapists worked on transitions on sitting and standing at a table while at the same time inhibiting abnormal postures and facilitating movements.
This gradual evolution of the NDT theory occurred as science developed, but it has caused much confusion about what NDT treatment really is. Depending on when therapists were trained in NDT, they could have either a very reflexive or static perspective of normal movement patterns, or a perspective focused on postural reactions using a ball, or a more current systems perspective that considers the clients as a whole and functional outcomes.
Assessment in NDT now involves observing the child functioning first to see what his abilities are, then looking into the disabilities and what is causing them.
The general goals of an NDT treatment plan are to enhance function, prevent deformities and minimize impairments. This is also the general goal of most therapeutic interventions.
To break down NDT treatment to its most basic elements, first achieve alignment, then elongate, then activate. Facilitation of movement is not beneficial without good alignment.
Good alignment occurs when the center of gravity is within the base of support because this is a stable position. Once appropriately aligned, the system must be activated. This movement should be goal-directed.
The child should be helped through functional patterns and transitions he does not regularly use. In order to move one needs to weight shift; this weight shift should be through the base of support, not over it.
Facilitation should focus on rotation, trunk elongation on the weight-bearing side, limb external rotation and abduction and weight shifts. Rhythm and rate of movement can greatly affect a child's response. Often by slowing down a movement, the child can be more active in the task. It is also important to facilitate range of motion to prevent tightness or increase range.
What is Motor Control?
Motor control theory explains how a control system solves a motor task or behavior. There are two theories of motor control: a motor program-based theory and a dynamic systems theory.
The motor program-based theory relies on a memory-based construct for controlling coordinated movement. This means we develop a centralized mechanism for motor control in which we store more generalized motor programs for certain types of movement. Dynamic systems theory sees human movement as a complex system and that changes in motor behavior do not occur linearly.
Coordinated movement patterns often incorporate some preferred stable patterns, called attractors, that are then subject to other variables such as speed or force. The environment also affects how a movement is coordinated. In order to perform a motor activity, a person must prepare his system. Action preparation activities should include postural organization, sequencing, spatial awareness, rhythm, limb performance and object control characteristics.
Both NDT and motor control theories support the ideas that the therapist can help the patient, function is the most important outcome, sensory input is important, and movement should be made as normal as possible.
NDT is said to focus treatment of motor dysfunction on the CNS dysfunction. In motor control theory, all the systems involved in motor dysfunction are considered: i.e., psychological, environmental, neural, sensorimotor and so on.
Current NDT treatment philosophy and practice also incorporate treatment of the patient as a whole.
Within a basic treatment session, there was not a separation between a therapist "performing NDT" or "using motor control," but instead an awareness of both theories and using them together to best address a client's needs.
Therefore, when actually comparing the two theories, therapists realize that instead of contrasting each other, they work well together and truly overlap.
Joanne Bundonis is a supervisor of physical therapy at 1st Cerebral Palsy of New Jersey in Belleville, NJ. She has authored home study courses for www.ptcourses.com and is a trainer for Litegait.