Luke Adan Lo Saechao Lyle Silverthorn Mikki Connor Chris Lovelace Michelle Smith.
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Transcript of Luke Adan Lo Saechao Lyle Silverthorn Mikki Connor Chris Lovelace Michelle Smith.
Luke AdanLo Saechao
Lyle SilverthornMikki Connor
Chris LovelaceMichelle Smith
Learning Objectives
At the completion of this presentation, the learner will be able to:
Describe the main principles of NDT Describe early NDT vs. recent NDT Describe the effectiveness of WSTT vs. NDT for
improving gait Describe how NDT compares to other conventional
therapy approaches. List common problems with reviews of NDT
NDT Background• NDT approach began in the early
1940’s from the work of Mrs. Berta Bobath (Physical therapist) and pediatric neurologist Dr. Karel Bobath (Psychiatrist/Neurophysiologist).
• Based on their experience of working with children with CP and adults with hemiplegia
• Observations were based on the Reflex/Hierarchical model
NDT and Adult Hemiplegia
Main problems in patients with UMN lesions: Abnormal coordination Abnormal postural toneThus, aims should be: Introduction of more selective movement
patterns in preparation for functional skills Reduction of spasticity
Bobath, 1990
Early NDTBobath originally believed in reflex inhibiting
postures (RIPs) Placed and held patients in RIPs to break up the
abnormal postural and movement patterns. Believed this would change the activity of the
whole body due to the “normalization” of postural tone.
No spontaneous carry over into movement and function occurred.
Treatment was too static and was not continued in this way Bobath, 1990
Revised NDTTheory: Dynamic “autoinhibition” by using reflex
inhibiting movements As patient moves, PT prevents the unwanted
parts of the abnormal movement by using “key points of control”Particularly proximal joints
PT should gradually withdraw control as the movement continues
Bobath, 1990
NDT Main Principles It is impossible to superimpose normal
movement patterns on abnormal ones, so abnormal patterns need to be inhibited
Movement is a sensory-motor experience: We do not learn a movement but the “sensation of a movement”
By moving the proximal part of the body it is possible to influence and change movements of the distal parts
Bobath, 1990
Evolution of NDT Principles NDT in North America is currently based on an
interactive complex systems model Problems in tone, posture, balance, and
movement are equally important in producing atypical synergies that interfere with functional activities.
NDT recognizes that it is essential to evaluate measurable changes in functions as well as changes in motor and body systems that support those functions. Neuro-Developmental Treatment Association, 2007
Evolution of NDT PrinciplesOriginal Core Concepts Still Applicable Bobath’s therapeutic handling techniques make
normal posture/movements more easy/likely to occur
Bobath’s focus on the interaction of impairments, function, and life participation (expanded to ICF)
Bobath’s focus on taking a “holistic” approach to treating patients
Neuro-Developmental Treatment Association, 2007
NDT in the ClinicTherapeutic handling allows the therapist to: Feel the client’s response to changes in posture or
movement Fascilitate postural control and movement synergies
that broaden the client’s options for selecting successful actions
Provide boundries for movements that distract from the goal
Inhibit or constrain those motor patterns that, if practiced, lead to secondary deformities, further disability, or decreased participation in society
Howle , 2002
Treadmill Training With Partial Body Weight Support Compared With Physiotherapy in Nonambulatory Hemiparetic Patients
Heese, S. et al.Stroke. 1995;26:976-981
Purpose Compare the efficiency of PT based on NDT
vs. WSTT in gait training for post stroke chronic hemi paretic patients.
Heese et al. 1995
Participants
7 nonambulatory hemiparetic patients 52 to 72 years old
Heese et al. 1995
Methods A-B-A single case study design 3 phases were administered to the
participants 1st phase= WSTT 2nd phase=NDT 3rd phase= WSTT
Heese et al. 1995
Results-Functional Ambulation Category
Heese et al. 1995
Results-Rivermead Motor Assessment
Heese et al. 1995
Results-gait velocity
Heese et al. 1995
Conclusion (Big Picture)
WSTT is superior to NDT because WSTT is…Task oriented exercise More independentHigher dosage
Heese et al. 1995
Thaut, Leins et al. Rhythmic Auditory Stimulation Improves Gait More Than NDT/Bobath Training in Near-Ambulatory Patients Early Poststroke: A single-Blind, Randomized Trial. Neurorehabil Neural Repair 2007;21:455
Subjects 155 hemiparetic patients were randomly
selected to (RAS group or NDT group). Age: 69 ± 11
Thaut et al. 2007
Methods
RAS - metronome and music tapesNDT – Bobath principlesMajor gait parameters measured: velocity,
stride length, cadence, and swing symmetry.
Heese et al. 1995
Results
Heese et al. 1995
Conclusion (Big Picture)
According to this study RAS is superior to NDT because…RAS gives the pt. an external cue to regulate
parameters of gait.
It only works when its on. When off only a few minutes will transfer.
Heese et al. 1995
Paci, M. PHYSIOTHERAPY BASED ON THE BOBATH CONCEPT FOR ADULTS WITH POST-STROKE HEMIPLEGIA: A REVIEW OF EFFECTIVENESS STUDIES. J Rehabil Med 2003; 35: 2–7
Systematic Review of 15 trials out of 726 6 RCTs, 6 CTs, 3 Case Series No level 1 studies due to small sample size or weak evidence from P-
value Age range 15-95 years
“NDT is the most widely used approach in the rehabilitation of hemiparetic subjects in Europe, and it is well known and frequently used in many countries, including the USA, Canada, Japan, Australia and Israel”
Purpose: Is there evidence that NDT is effective? Is NDT more effective than other treatments for adults with
hemiplegia?
NDT Vs. EMG Feedback No difference found in all outcome measures
Upper Limb EMG activity Upper Extremity Function Test Finger Oscillation Test Health Belief Survey Mood and Affect Tests
Basmajian et al, 2003
Lower Limb EMG activity ROM Gait analysis
Mulder et al., 1986
NDT Vs. Traditional Functional RetrainingGeneral Rx
NDT group improved more on Barthel Index than TFR
No significant difference in all measuresFunctional Independence Measure (FIM)Box & Block TestNine-hole Peg Test
Salter et al., Gelber et al., Lewis, 2003
NDT vs. BrunnstromGeneral Rx
No significant difference in all outcome measuresAction Reach Arm TestBarthel IndexGait speed
Wagenaar et al., 2003
NDT Vs. Motor Relearning ProgrammeGeneral Rx
MRP group improved more in:Barthel IndexMotor Assessment ScaleSodring Motor Evaluation Scale
No difference found inNottingham Health Profile
Langhammer et al., 2003
NDT Vs. Forced UseUpper Limb
Forced Use group had more improvements than NDT in Action Reach Arm Test (dexterity)
No difference in all other outcome measuresRehabilitation Activities ProfileFugl-MeyerMotor Activity Log
Van der Lee et al., 2003
Conclusion No evidence supporting NDT as the optimal type
of treatment.
Important to note:So even though NDT may NOT be superior, it does
positively effect recoveryThere was a significant improvement in most of the
measured parameters for the NDT groups, but the improvements weren’t significantly different than other treatments
Paci, 2003
Hiraoka, K. Rehabilitation Effort to Improve Upper Extremity Function in Post-Stroke Patients: A Meta-Analysis. J Phys Ther Sci. 2001(13), 5-9.
Studies ranged between 1966 - 1999
14 trials reviewed All RCTs
Interval Since Stroke 0 days to 8 years
Length of Treatment 2 to 50 weeks
Sample Size 20 to 282 people
Methods Interventions Assessed
NDT vs. Conventional PT Conventional PT vs. No Rx EMG biofeedback vs. Conventional PT EMG biofeedback vs. No Rx
Upper extremity function assessed by: Rivermead Motor Assessment Arm Scale, Action Reach Arm Test, Fugl-Meyer Assessment, Upper Extremity Functional Test, Frenchay Arm Test.
Hiraoka, 2001
Results Used Cohen’s criteria to determine effect size
- Large effect (significant difference) = ≥0.8- Medium effect (difference) = 0.5 – 0.8- Small effect (no difference) = 0.2 – 0.5
Interventions AssessedNDT vs. Conventional PT: effect size = (0.01)Conventional PT vs. No Rx: effect size = 0.51EMG biofeedback vs. Conventional PT = 0.75 EMG biofeedback vs. No Rx = 0.85
Conclusion
The effects of NDT and conventional treatment are almost identical
EMG Feedback had a larger effect on improving UE function in post stroke patients than NDT or conventional PT
Hiraoka, 2001
Yelnik, A. et al. Rehabilitation of Balance After Stroke With Multisensorial Training: A Single-Blind Randomized Controlled Study. Neurorehabil Neural Repair 2008; 22: 468
Objective: Compare 2 physical rehabilitation approaches to restore balance after
recent stroke: NDT vs Multisensorial Training
Methods: 68 patients who were able to walk without human assistance 3 to 15 months post first stroke Received NDT or Mulitisensorial Rx for 20 sessions in 4 weeks
Sample Size NDT = 35 patients Multisensorial = 33 patients
Outcome MeasuresStanding balance Berg Balance Scale
Dynamic balance Assessed during walking by percentage of double-limb stance time
Daily Independence Functional Independence Measurement (FIM)
Quality of Life Nottingham Health Profile
Yelnik et al., 2008
AssessmentDifferences between groups on Day 30 No difference between groups
Differences between groups on Day 90 Both the NDT and Multisensorial approach showed significant
improvements in all outcome measures compared to baseline measures, but the Multisensorial approach showed more improvement.
However, the differences between-groups were of no statistical significance
Yelnik et al., 2008
Conclusion
No significant differences between NDT and Multisensorial Training
No evidence that one approach is superior to the other
Yelnik, A. et al
Kollen, B.J. et al. The Effectiveness of the Bobath Concept in Stroke Rehabilibation: What is the Evidence? Stroke (Journal of the American Heart Association). 2009(40), e89-e97.
16 trials reviewedSample size: 813 patients total (21-120 in individual
studies)Inclusion criteria:
○ Involvement of adult patients with a cerebrovascular accident
○ The effects of the Bobath Concept were compared with those of an alternative method
○ Randomized, controlled clinical trial (RCT)○ Only English or Dutch publications were considered for
inclusion.
Inclusion Criteria (Cont.)Rehab outcomes were measured in one or more
of the following:○ Sensorimotor function of the upper and/or lower
extremity○ Balance control○ Mobility (The ability to (re)position the body by
transfer or gait)○ Dexterity (Reaching, grasping, fine hand use)○ Activities of Daily living (ADLs)○ Health-Related Quality of Life (HRQOL)○ Cost effectiveness
Boudewijn et al. 2009
Results
There was no evidence of the superiority of NDT for sensorimotor control of the upper and lower limb, dexterity, mobility, ADLs, HRQOL, and cost-effectiveness
Only limited evidence was found to support the superiority of NDT for balance
Boudewijn et al. 2009
Common Problems with reviews of NDT
Little homogeneity between studiesStage of stroke recovery Treatment intervalAge of patientsOutcome measuresTreatment comparison
Failure to clarify exact methods used
Why Do We Use NDT? Personal Experience of the Therapist
Authority
Evidence Based PracticeNDT works, but not better or worse than other
methodsIf you are going to put your hands on a patient
NDT is a good intervention to use
HOWEVER, today there is good evidence to support other interventions: CIMTBWSTTTask-Specific TrainingMental Imagery
WE NEED TO BE EDUCATORS IN THE CLINIC!
Learning ObjectivesAt the completion of this presentation, the learner will be
able to: Describe the main principles of NDT Describe early NDT vs. recent NDT Describe the effectiveness of WSTT vs. NDT for
improving gait Describe how NDT compares to other conventional
therapy approaches. List common problems with reviews of NDT
Works CitedBobath, B. (1990). Adult Hemiplegia: Evaluation and Treatment, 3rd Edition.
Oxford: Heinemann Medical Books.Foley, N. et Al. Upper Extremity Interventions. Evidence-Based Review of
Stroke Rehabilitation. 2009; 1-109.Hesse, S. et. al. (1995). Treadmill Training with Partial Body Weight Support
Compraed With Physiotherapy in Nonambulatory Hemiparetic Patients. Stroke. 26:976-981.
Hiraoka, K. Rehabilitation Effort to Improve Upper Extremity Function in Post-Stroke Patients: A Meta-Analysis. J Phys Ther Sci. 2001(13), 5-9.
Howle, J.M. (2007). NDT in the United States: Changes in Theory Advance Clinical Practice. Retrieved April 2009 from www.ndta.org
Howle, J.M. (2002). Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice. Neuro-Developmental Treatment Association.
Kollen, B.J. et al. (2009). The Effectiveness of the Bobath Concept in Stroke Rehabilibation: What is the Evidence? Stroke (Journal of the American Heart Association);40:e89-e97.
Works CitedLennon, S. & Ashburn, A. (2000). The Bobath concept in stroke
rehabilitation: a focus group study of the experienced physiotherapists’ perspective. Disability and Rehabilitation, 22 (5): 665-674.
Paci, M. Physiotherapy based on the bobath concept for adults with post-stroke hemiplegia: a review of effectiveness studies. J Rehabil Med 2003; 35: 2–7.
Thaut, M.H. et al, (2007). Rhythmic Auditory Stimulation Improved Gait More that NDT/Bobath Training in Near-Ambulatory Patients Early Poststroke: A Single-Blind, Randomized Trial. MeurorehabilNeuralRepair; 21: 455-459
Yelnik, A. et al, (2008). Rehabilitation of Balance After Stroke With Multisensorial Training: A Single-Blind Randomized Controlled Study. Neurorehabil Neural Repair; 22: 468