The ABC's of NDT
NDT has gotten a bit of a bad rap recently. Neurodevelopmental therapy (Bobath) has been a mainstream approach to treating children with cerebral palsy since Karel and Berta Bobath introduced their theories sometime in the 1970’s. What was it about this approach that catapulted it into an accepted approach to treating cerebral palsy all over the world? And why, despite the poor evidence, do intelligent, scientifically minded, educated and experienced therapists still value it? Or do they?
I wonder if other pediatric NDT trained therapist think their NDT training was a waste of time? If we want to be effective and offer the best to our little clients and their families, we do have to sit up and ask the hard questions.
Is it time for us NDT therapists to leave Bobath behind?
Well I for one don’t think so. It’s the backbone of everything I do. The way I think, the way I analyse, understand and problem solve. To me knowing NDT is like knowing my ABC’s.
It's like this...Imagine we did a study that asked what approach was better at teaching kids literacy? In this study, we would measure the outcomes by the amount of words the kids could read at the end of the study.
Method 1: Teach the alphabet, blends and language rules,
Method 2: Teach kids to recognize flash cards of the words being tested.
The kids that were taught the flashcards would most likely do better in the testing. This would “prove” that learning the alphabet, blends and rules is not as effective as using flashcards in learning literacy right?
It’s true you know, you can teach kids to recognize words much quicker with flashcards, but flashcards are just a tool to learning. They offer a fairly one dimensional way to learn to read. If you are going to read and write effectively, you’d better learn your ABC’s … and if you are going to practice pediatric therapy, you’d be better off having had some training in NDT.
iPads are another great tool for teaching literacy. There are a growing number of schools using iPads and some people wonder if it will replace ink and paper? I imagine there is probably a place for both, but no matter which they use, an understanding of the ABC's is still essential. Similarly, as a therapist we could use constraint induced therapy or bimanual training for a client with a hemiplegia. We might even decide there is a place for both with the same client. They are both effective tools that we may choose for different reasons, but I believe having an understanding of NDT principles when applying them would be essential in achieving a richer and more holistic outcome.
In the systematic review of interventions for children with cerebral palsy (Novak et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. DevMedChildNeurol.2013), the authors noted that most NDT therapists do use an “eclectic approach”, incorporating motor learning strategies, botox, splinting and other “green-light” methods into their treatment. They thought this made it difficult to judge the effectiveness of NDT treatment alone. Well I have to ask – what exactly do they think NDT is?
It is not a bunch of reflex inhibiting patterns, it is not a recipe of exercises on a ball – these were concepts that were easy to learn and perhaps became what those without a good understanding of the Bobath concept accepted as being an “NDT” treatment.
NDT is not a tool, it's a way of understanding the importance of alignment, weight-shifts, pelvis, trunk, quality, effort, tone, patterns of movement and neurodevelopment - and then using that understanding - to analyze needs, practice skills, find key points of control and develop function. It is a working framework.
Therapists with an NDT background have a rich and complex understanding of how abnormal neurology impacts movement. They learn to see the whole child. How to link the pelvis to the pencil grip and the obliques to the oropharynx, so to speak. No mater what other approach is used, having an NDT scaffold to hang it on will give the therapist an in-depth understanding of what is working and why. To the authors of the systematic review, it’s the reason that those of us clinicians who call ourselves NDT therapists, love it. It’s also the reason that we blend it with other evidenced based tools and it's probably the reason Dr Edward Taub used NDT trained therapists when he started his research on CIMT in stroke and cerebral palsy.*
Yes, some older concepts like RIP's are no longer used. NDT is a living framework after all and it changes as new science becomes available. Knowing your ABC’s without actually using it to write and read sentences, to make up paragraphs, and chapters, and books – is not particularly useful. As NDT therapists, we do need to add function and participation to quality; and we do need to have a toolbox filled with a variety of different evidenced based treatments, but we don’t need to throw Bobath out with the bath water.
I believe it’s time to understand that NDT is not a treatment tool. It is a concept, an important baseline of understanding cerebral palsy and other developmental delays that enables the NDT trained therapist to take newer treatment approaches and apply them as a specialist, rather than as a technician.
I think the question is NOT, is NDT better than CIMT (or any other technique) the questions should be...
Is there a difference in how NDT trained therapists apply CIMT (or any other technique) and is THIS more effective than therapists who are not NDT trained?
Where do you think we should be shining the light on NDT research?
* Dr Ed Taub Explains CI Therapy with Ginger Campbell MD http://brainsciencepodcast.com/bsp/119-taub1