When the evidence says "no": an exploration of NDT

Preamble

Being an evidence based OT isn't easy. Even when the evidence is staring you in the face it can be hard to know what direction to take. Sometimes it’s straight-forward, but most of the time it’s a real mess to sort out.  In some cases, what you’ve been using successfully for years doesn’t seem to show in the literature. What the hell is going on?

Well, making choices on evidence based practice related to OT interventions requires more than simply reading the evidence. Our practices are intimately connected to both who you are as an clinician (you background, skills, interests, etc..) and who the patient is (wants, needs, etc..). Proving if something works or doesn’t is only part of the picture.  

To highlight this conundrum, we’ve chosen to take a look at Neurodevelopmental treatment (NDT) this week.

[This is a longer post (10 minute read). If you’re short on time, skip to the summary]

Some Background

In the 1940-1950s Karel and Berta Bobath developed their Bobath Concept to treat individuals with neurological illnesses using hands-on facilitation methods which were largely passive.  Their concepts evolved into Neurodevelopmental treatment (NDT) by the 1960s and by then represented more ”clinical reasoning rather than a series of standardised techniques” (Graham 2009).  

The NDTA defines NDT as:

“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 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. 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 throughout the lifespan, 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”

Evidence on NDT

A conceptual review of Bobath/NDT by Vaughan-Graham et al. in 2015 adds: “The integration of posture and movement with respect to the quality of task performance remains a cornerstone of the redefined Bobath concept”

NDT has a plausible mechanism, in that the core feature of therapeutic handling could help to facilitate neurological changes.  NDT is probably the most popular intervention of it’s type, but longevity and popularity don’t equate to effectiveness. Fortunately, because NDT has existed in some form for almost 80 years there have been plenty of opportunities to study it.

Two of the most popular applications of NDT approaches is to stroke and cerebral palsy.  It’s a natural fit, since people in these populations struggle with neuromotor deficits and can benefit from intensive, hands-on treatments.  A challenge for us as therapists is to pick and choose from the almost unlimited number of treatment approaches for a given client.

As we explored in our past post it’s important to interpret individual study findings with a high degree of caution.  Taking a look at multiple studies over time is a better (but not perfect) indicator of positive research findings.  


Cerebral Palsy

Unfortunately, reviews of NDT usage in cerebral palsy published over the last few decades have been quite damning. For example in Novak, et al. (2013) stated that NDT should be discontinued since alternatives exist.

“Craniosacral therapy, hip bracing, hyperbaric oxygen, NDT, and sensory integration have all been shown to be ineffective in children with CP, and are therefore not recommended for standard care. Appropriately, effective alternatives exist that seek to provide the same clinical outcome of interest.”

And later:

“Consequently, there are no circumstances where any of the aims of NDT could not be achieved by a more effective treatment. Thus, on the grounds of wanting to do the best for children with CP, it is hard to rationalize a continued place for traditional NDT within clinical care.”

Concerns about the efficacy of NDT go back several decades, including a report by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) from 2001, which concluded:

“The preponderance of results...did not confer any advantage to NDT over the alternatives to which it was compared....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”

Stroke

As you can imagine, the story is not much different for NDT and stroke. There have been fewer studies looking at NDT use in stroke rehab, but several high quality studies have shed light.

A comparative study back in 1995 by Gelber et al. was already questioning how effective NDT was compared with traditional approaches (TFR), concluding that:

“This data suggests that TFR and NDT approaches are equally efficacious in treating pure motor hemiparetic strokes in terms of functional outcomes, gait measures, and upper extremity motor skills”

A critical review in 2003 by Barreca et al. summarized the high quality evidence available at the time:

“From the synthesis of...5 RCT studies that compared neurodevelopmental techniques (NDTs) to other therapeutic approaches, NDT was not found to be superior to other types of interventions such as forced use and traditional rehabilitation functional training”

A few years later a study by Dutch researchers found similar results, determining that NDT did not effectively improve functional outcome or QOL compared with conventional rehab (Hafsteinsdóttir et al., 2005).


Why the disconnect?

In 2015 Vaughan-Graham et al. conducted a scoping review to attempt to sort out why NDT was still such a popular framework given the lack of support and evidence in the scientific base.  To summarize their findings:

  • Bobath/NDT continues to evolve and therefore there lacks a consistent definition and practice that can easily be studied.  In other words, NDT is a heterogeneous mix of stuff that can’t be well defined across time.

  • NDT is used across a wide variety of populations and conditions and for varying lengths, and has been measured in various ways making specific conclusions difficult.

  • NDT is compared to a wide variety of other interventions and each study investigates the relative effectiveness

  • Lack of evidence does not equal lack of effect, and RCT “evidence” has serious limitations.

  • The current Bobath evidence base has focused on effectiveness studies, primarily RCT designs, but the resulting lack of direction and clinical applicability is disappointing and frustrating for clinicians and researchers alike

  • N-of-1 randomized trials  should be considered as valid ways of testing the interventions.

  • A more pragmatic approach to investigating the Bobath concept is encouraged, as the Bobath concept is not a single intervention that can be investigated devoid of context.

In Summary: what do we do now!?

It’s complicated.  

One of the most up to date meta-analysis on the topic of stroke rehab from Lin et al. (2018) does a great job summarizing what all of this means:

“On the basis of our study, we believe that rehabilitation professionals can now tailor effective rehabilitative programs more freely to patients based on social, cultural, and patients-related factors to increase treatment diversity, reduce boredom, and potentially increase patient participation”

NDT was never intended to be practised in isolation, as the sole treatment approach.  Like so many of the modalities we have available to us, it is a single tool in our toolbox.  There are probably scenarios where aspects of the NDT approach are valuable - but using it as a primary modality appears unwise.  We need to be careful to not become our modality.

In spending the last several years digging deep into (a very small slice of) the science, we feel the evidence continues to point away from using any one intervention and towards being pragmatic and flexible. That means choosing whatever tool the client is responding to, providing an explanation that fits with what the science and remaining wholeheartedly occupation-focused.







REFERENCES

Barreca, S., Wolf, S. L., Fasoli, S., & Bohannon, R. (2003). Treatment interventions for the paretic upper limb of stroke survivors: a critical review. Neurorehabilitation and neural repair, 17(4), 220-226.

Brown, G. T., & Burns, S. A. (2001). The efficacy of neurodevelopmental treatment in paediatrics: a systematic review. British Journal of occupational therapy, 64(5), 235-244.

Butler, C., & Darrah, J. (2001). Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence report. Developmental medicine and child neurology, 43(11), 778-790.

Hafsteinsdóttir, T. B., Algra, A., Kappelle, L. J., & Grypdonck, M. H. F. (2005). Neurodevelopmental treatment after stroke: a comparative study. Journal of Neurology, Neurosurgery & Psychiatry, 76(6), 788-792.

Graham JV, Eustace C, Brock K, Swain E, Irwin‐Carruthers S. The Bobath concept in contemporary clinical practice. Topics in Stroke Rehabilitation 2009;16(1):57‐68. [

Lin, I. H., Tsai, H. T., Wang, C. Y., Hsu, C. Y., Liou, T. H., & Lin, Y. N. (2018). Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months After Stroke: A Systemic Review. Archives of physical medicine and rehabilitation.

Morgan, C., Darrah, J., Gordon, A. M., Harbourne, R., Spittle, A., Johnson, R., & Fetters, L. (2016). Effectiveness of motor interventions in infants with cerebral palsy: a systematic review. Developmental Medicine & Child Neurology, 58(9), 900-909.

Novak, I., Mcintyre, S., Morgan, C., Campbell, L., Dark, L., Morton, N., ... & Goldsmith, S. (2013). A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine & Child Neurology, 55(10), 885-910.

Vaughan-Graham, J., Cott, C., & Wright, F. V. (2015). The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part I: conceptual perspectives. Disability and Rehabilitation, 37(20), 1793-1807.

Vaughan-Graham, J., Cott, C., & Wright, F. V. (2015). The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part II: intervention studies perspectives. Disability and rehabilitation, 37(21), 1909-1928.


Other links:

Cochrane Review Protocol for NDT and Cerebral Palsy

Evidence Based practice summary from Cairo University