Neurodevelopmental treatment (NDT) is a hands-on treatment approach used by physical therapists, occupational therapists, and speech-language pathologists. NDT was developed to enhance the function of adults and children who have difficulty controlling movement as a result of neurological challenges, such as cerebral palsy, stroke, and head injury. This therapy uses guided or facilitated movements as a treatment strategy to ensure correlation of input from tactile, vestibular, and somatosensory receptors within the body.
NDT was developed with the understanding that patients with brain injuries have a limited repertoire of movement patterns. During treatment interventions, repeated experience in movement ensures that a particular pattern is readily accessible for motor performance. The more a patient performs certain movements, the easier these movements become. Without NDT interventions, the patient likely will develop a limited set of movement patterns that he or she will apply to nearly all tasks. NDT should begin before such generalized movement synergies become hard-wired in the patient's brain.
The NDT-Bobath neurodevelopment therapy is directed towards our youngest patients, due to its non-invasive character, this can be conducted within the first days after the child’s birth. This technique of early rehabilitation tends to give the best results during the first year of a child’s life.
NDT-Bobath therapy is directed at newborns – including prematurely born children, infants and young children, especially those with:
- developmental problems caused by prematurity
- motor development disorders
- muscle tone disorders (too strongly or too weakly tensed muscles)
- problems because of care unsuitable for a child
- feeding, suction and swallowing disorders
- breastfeeding disorders
- asymmetrical body
- children repeating the same movement pattern
- cerebral palsy
- congenital disorder
- children with Down’s syndrome
- problems with sensory integration
- Problems with feet, bowleg or knock-knee.
The therapist’s work is based on controlling the child’s activity from so called “key points,” These areas are the head, neck, shoulder girdle and other body parts, in order to create proper posture patterns of a child, along with teaching him/her how to use and control them.
What are Primitive Reflexes?
Primitive Reflexes are primal movement patterns that develop in the womb. They help us through the process of birth and to survive our early lives, and operate automatically – like the knee jerk reaction. As we mature from birth to two years of age, these reflexes become inhibited by the development of higher brain functions. As we learn to move in more complex ways – the more primitive ways fade into the background. They are still there but are no longer needed.
Shocks and traumas (sometimes ever minor ones) can prevent the natural process of inhibition and this can lead to the body retaining the primitive reflex and being somewhat ‘stuck’ in a more primitive mode. Symptoms can be seen in physical movement but also in emotional and behavioral states.
What can happen if the Primitive Reflexes are not inhibited?
If they are not inhibited at the appropriate time they are said to be retained. The Primitive Reflexes should be inhibited by 12- 18 months of age. If this does not happen, the person may have these or other symptoms:
- Poor gross motor skills (jumping, skipping, etc)
- Poor fine motor skills (hand- eye coordination, manual dexterity)
- Problems with perception – at all kinds of levels
- Poor social skills
- Emotional issues e.g. anxiety, shyness, and aggression
What causes the Primitive Reflexes to be retained?
There can be many suggested causes but the major ones are:
- Severe stress during the pregnancy.
- Traumatic birth e.g. emergency caesarean.
- Prolonged or breach birth.
- Premature birth
- Significant upsets that cause shock – such as operations, concussions separation from Mom.
The most significant Primitive Reflexes are;
The Fear Paralysis Reflex
This reflex is the first one we know about. It is essentially the freeze response and is designed to protect you from shock or pain. From my own clinic experience – it will very often become activated if the body / nervous system feels that is under significant threat. The person is temporarily removed from pain or the threat of pain by being ‘absent’. I’ve worked with several children and adults whose freeze response began because of a car crash.
Some of the symptoms of a retained Fear Paralysis Reflex:
- A layer of fear that is present around most decisions or new experiences.
- Fear of new things
- Insecurity/ social isolation
- Temper tantrums- often screaming loud & long in a new situation or one they consider threatening- or May go into “freeze mode” unable to think & move at the same time
- Selective Mutism– failure to speak in certain situations and yet be able to speak freely otherwise
- Excessive anxiety over seemingly trivial matters
- Very often present in children with autism
The Moro Reflex
This reflex is basically the ‘fight or flight’ response. Our most basic reaction to threat is to freeze – after that we either fight or run. And again, these actions are controlled by the primal or instinct part of the brain. As babies the Moro reflex occurs so that we can do something to announce to Mom that we are in danger – that’s the theory behind why it is there. So what does it make us do?
In tiny babies their reaction to threat is to fling their arms open, scream and go pale or red in the face. This is the early ‘flight or fight’ reaction. Later in life we will still do this action if we get enough of a fright.
When the Moro reflex is retained the person is ‘stuck’ in fight or fright and the feeling that was present when the shock occured (i.e. car crash) is being triggered.
- The child may be hypersensitive and immature or over reactive.
- Moro driven people dislike change and are fearful of new things.
- A change of routine in the classroom, even for something pleasurable, may cause a child to throw a tantrum that seems a huge overreaction to the rest of us.
These children may also react in one of two ways with their peers:
- they may shrink away and be the withdrawn wallflower, observing but not participating, or
- they may want to be the boss of the game all the time.
Other behaviours include;
- constantly on the alert against perceived threat.
- The eyes are constantly wandering to the periphery of the page, the blackboard or the classroom, so that they don’t remain on task.
- They may also have difficulty when reading with the contrast of black print on white paper. Moro driven people can be extremely sensitive in many situations
- The constant stress involved in its frequent emergence can cause a depleted immune response.
- Difficulty showing and receiving affection as well as problems socialising, They often prefer to play with younger children.
The Bonding Reflex
The reflex has a huge impact on feelings of safety and security. If a child doesn’t feel safe in general, then a whole host of symptoms may be present. Common symptoms include;
- The need for constant reassurance ( needing Mom’s/ Dad’ attention)
- Over sensitive to others feelings
- Difficulties with authority
- The child may be inclined to reject themselves and others with hostility and aggression.
- Learning is made difficult because the child needs constant praise from the teacher.
The Palmar Reflex (11weeks in utero-3months of age)
These symptoms may indicate a retained Palmar reflex.:
- Poor manual dexterity
- Making movements with mouth when drawing
- Speech problems pencil grip
- The Palmar reflex is the automatic grasping movement of the hand if the palm is touched. It needs to be inhibited for efficient fine motor skills such as writing and sewing movements.
Asymmetric Tonic Neck Reflex (18 weeks in utero- 6 months of age)
These symptoms may indicate a retained ATNR:
- Difficulty copying symmetrical figures
- Balance affected if head moves to the side
- Awkwardness skipping
- Homolateral marching (same leg & arm)
- Difficulty crossing the midline of the body
- Poor eye tracking especially across the midline
- Difficulty writing if looking at the board
- Difficulty getting ideas onto paper
- Difficulty learning to ride a bike
The mother’s contractions at birth stimulates this reflex and the baby’s movements then cause another contraction to occur. Hand- eye coordination is developed through this reflex: The baby turns its head, the eyes fixate on the hand stretching out or grasping an object. This is the start of awareness of distance. This reflex needs to be inhibited for smooth cross pattern crawling and creeping to develop. Trying to focus on the body position for writing and hanging on to the pencil so that the arm does not extend and fling it away, can require huge effort so it is not surprising that these children avoid written tasks & find school assignments really stressful.
Spinal Galant (20 weeks in utero – 9months of age)
If retained you may see these:
- Poor short term memory & concentration
This reflex like the ATNR plays a part in assisting in the birthing process- as the hip moves it helps the baby into the birth canal. The lower spine on either side is very sensitive to touch so stimulation such as the elastic in underpants or moving against the back of a chair can result in a squirming movement. Stimulation on both sides of the spine simultaneously can cause defecation or wetting if this reflex is strongly retained. It may also affect fluency and mobility in sporting activities.
Tonic Labyrinthine Reflex
If retained you may see these symptoms:
- Poor posture / stooping or walking on toes
- Poor sense of balance
- Car sickness
- Poor sequencing skills
- Lack of organisation
- Poor sense of time
- Stiff jerky movements / poor muscle tone
- Difficulty judging distance, speed and depth
Some of these may seem contradictory symptoms. It is because there are two aspects to this reflex, one related to bending the neck down with the limbs bending & the other in tilting the neck back accompanied by straightening of the limbs. The development of this reflex takes the baby from its floppy curled up foetal position to one of strong muscle tone and the ability to straighten out & walk upright.
Symmetrical Tonic Neck Reflex ( 6- 9 months age — 9- 11months age)
These symptoms may indicate a retained STNR:
- Poor posture
- Can’t sit still
- Slumps when sitting at a desk
- Slow at copying tasks
- Poor hand –eye coordination
- Messy eater
- Difficulty with overarm swimming
This reflex helps the baby to defy gravity & get up on hands and knees to crawl. It enables the child to move the two halves of the body independently. If retained the child may not crawl on hands & knees but do a “ bear walk” on hands & feet or shuffle along on their bottoms. A very important reflex for training the eyes to cross the midline, looking from one hand to the other as crawling develops. In reading they need to be able to read fluently across the page without losing the words on the midline. Crawling develops interaction between the vestibular, visual & proprioceptive systems. Without this, balance, space & depth perception will be poor.
Neurodevelopmental Technique/ Bobath Approach (opposite of Brunnstrom Approach)
Therapeutic handling is used to influence the quality of the motor response and is carefully matched to the patient’s abilities to use sensory information and adapt movements. It includes neuromuscular facilitation, inhibition, or frequently a combination of the two. Manual contacts are used to:
- Direct, regulate, and organize tactile, proprioceptive and vestibular input
- Direct the client’s initiation of movement more efficiently and with more effective muscle synergies
- Support or change alignment of the body in relation to the BOS and with respect to the force of gravity prior to and during movement sequences
- Decrease the amount of force the client uses to stabilize body segments
- Guide or redirect the direction, force, speed, and timing of muscle activation for successful task completion
- Either constrain or increase the flexibility in the degrees of freedom needed to stabilize or move body segments in a functional activity
- Dense the response of the client to sensory input and the movement outcome and provide nonverbal feed-back for reference of correction
- Recognize when the client can become independent of the therapist’s assistance and take over control of posture and movement
- Direct the client’s attention to meaningful aspects of the motor task
Key Point of Control:
Key points are parts of the body that the therapist chooses as optimal to control (inhibit or facilitate) postures and movement. Proximal key points include the shoulders and pelvis, which are used to influence proximal segments and trunk. Distal key points upper and lower extremities (typically the hands and feet). Key points of control are also used to provide inhibition of abnormal tone and postures. Examples include:
- Head and trunk flexion decreases shoulder retraction, trunk and limb extension (key points of control: head and trunk)
- Humeral external rotation and flexion to 90 degrees decreases flexion tone of the upper extremity (key point of control: humerus)
- Thumb abduction and extension with forearm supination decreases flexion tone of the wrist and fingers (key point of control: the thumb).
- Femoral external rotation and abduction decreases extensor/adductor tone of the lower extremity (key point of control: hip).
- Facilitation: Components of posture and movement that are essential for successful functional task performance are facilitated through therapeutic handling and key points.
- Inhibition: Components of posture and movement that are atypical and prevent development of desired motor patterns are inhibited. While originally this term referred strictly to the reduction of tone and abnormal reflexes, in current NDT practice it refers to reduction of any underlying impairment that interferes with functional performance.
It can be used to:
- “Prevent or redirect those components of a movement that are unnecessary and interfere with intentional, coordinated movement,
- Constrain the degrees of freedom, to decrease the amount of force the client uses to stabilize posture
- Balance antagonistic muscle groups
- Reduce spasticity or excessive muscle stiffness that interferes with moving specific segments of the body.”