Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice.

Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice

Howle JM. Laguna Beach, CA 92651, Neuro-Developmental Treatment Association, 2003, hardcover, 381 pp, illus, ISBN: 0-9724615-0-7, $65 (NDTA members), $85 (nonmembers).

This book was written for members of the Neuro-Developmental Treatment Association (NDTA) and for the scientific and therapeutic communities. Its primary purpose is to describe the current state of neurodevelopmental treatment (NDT), because the approach has been criticized over the years for a lack of research published in evidence-based sources. This book attempts to remedy that criticism and also attempts to define how the approach has changed since the deaths of the Bobaths, the original developers.

The book contains 5 chapters. Chapter 1, "Current Theoretical Foundations," describes original assumptions to the approach as well as 10 additional assumptions that are currently being promoted by the Neuro-Developmental Treatment Association. Text boxes titled "NDT Focus," which discuss a variety of topics such as beliefs/philosophy, interventions, examination principles, and treatment approaches, are used before current research and evidence-based concepts are presented to support that topic. Theories and research used to support the approach include systems theory, dynamic systems theory, neuronal group selection theory, and general motor programs (ie, schema theory). Assumptions concerning motor development, postural control, and sensory system organization are supported by literature on postural control, reaching development, and sensory integration. A section on motor learning and its application to NDT completes the chapter.

Chapter 2, "Movement Dysfunction," begins with a description of the NDT Enablement Model of Health and Disability, which is based on the World Health Organization's International Classification of Impairments, Disabilities, and Handicaps (ICIDH-2). The chapter continues with a discussion of the diagnoses of cerebral palsy (CP) and cerebrovascular accident (CVA), including pathology and classification of diagnostic patterns. Impairments and their relationships to functional limitations are described in detail for the musculoskeletal, neuromuscular, sensory processing, respiratory, perception/cognition, arousal/regulatory, cardiopulmonary, and gastrointestinal systems. Multisystem impairments also are discussed and include pain, edema, and impaired motor planning. Motor function and dysfunction from the NDT perspective are described next. The discussion includes the hallmarks of the approach--linking functional limitations with system impairments through an in-depth analysis of alignment, weight-bearing, muscle reflex activity, balance/postural control, coordination, and the kinesiological/ biomechanical components of movement. A clinical example is applied to the NDT Enablement Model to clarify the previous content. The chapter ends with a review of recovery and compensation following a neurological insult and a review of the available evidence of NDT-based studies using Sackett's levels of evidence.

Chapter 3, "Principles and Process of Examination," clarifies how the NDTA uses the terminology in APTA's Guide to Physical Therapist Practice, Second Edition. A model of examination and evaluation is presented with descriptions of each area that are based on the NDT model. This process now includes using objective, norm-referenced, criterion-based, self-referenced (ie, patients are their own control subjects) tests to supplement the clinician's examination. The chapter concludes with 2 case examinations: a child with CP and an adult with a CVA. A guide for organizing an NDT exam is also provided.

Chapter 4, "Principles and Process of NDT Intervention," describes 23 intervention principles, which include additional hallmarks of the approach: therapeutic handling, key points of control, facilitation of active movement, and inhibition of undesired movement. All the principles are integrated into both a pediatric case study and an adult case study. This chapter uses a different pediatric case to illustrate the interventions based on the evaluation; however, it continues the adult case presented in chapter 3. Photographs with extensive descriptions are provided.

Chapter 5, "Development of the Bobath Approach," is a review of the personal history of the Bobaths and the historical literature of neurophysiological principles. It illustrates how the Bobaths redeveloped their ideas over time as the literature evolved. The chapter concludes with a table illustrating how the approach has changed between the 1950s and the 2000s.

One of the strengths of this book is its extensive list of citations, which includes references to approximately 518 journal articles, 242 books, and 43 newsletters. The citations include classic references as well as the key contributions to neuroscience made in the past 20 years. The consistent format of text boxes followed by discussion helps readers to keep focused on the relevance of the discussion to NDT. I noted one exception to this organization in chapter 1 where the order of the motor learning discussion was changed. The chapter first presents theories and strategies of motor learning, then presents the "NDT Focus" box midway through the chapter. This produced some confusion and interrupted the flow of the presentation of information.

Overall, the writing style was readable and consistent throughout. Several of the chapters repeated many points. For example, the presentation of literature in chapters 1 and 5 overlapped. Because of the extensive integration of the literature in chapters 1 and 2, these chapters would be better understood by clinicians who are well-versed in the existing science than by physical therapist students. In chapter 2, little discussion was spent on the ICIDH-2. It would be difficult for readers to comprehend the NDT Model of Enablement unless they were familiar with the World Health Organization model.

Chapters 3 and 4 would make suitable reading for a student in a clinical setting under the guidance of a physical therapist with experience in the approach. The continuation of the adult patient case from chapter 3 to chapter 4 made for comprehensive reading. Although the pediatric case used to describe interventions in chapter 4 was well done, it would have been more comprehensive to carry over the pediatric case from chapter 3 to provide the same level of reading satisfaction.

Chapter 5 is an excellent reference for the academic instructor presenting the NDT approach, as is the entire book. The entire book is geared to a higher level than that typical of professional physical therapist education; however, it would be an essential reference for instructors.

The purpose of this book was to provide NDTA members and the scientific and therapeutic communities with the current state of the approach. This has clearly been done; the book is a long-awaited and much-needed resource. The preface indicated that what was unique to NDT would be presented. This was done in the body of the work, but it was difficult to keep track of the truly unique aspects of the approach without a summary or table synthesizing this information. This book should dispel many of the myths and criticisms used against NDT. Without follow-up studies to prove the efficacy of NDT, however, the book will be a vain attempt to quiet the critics, Fortunately, this point is also made in a very similar fashion within the book. I look forward to the second edition.

Patricia R Curatti, PT, PCS 

University of Michigan-Flint Flint, Mich

Ms Curatti is Clinical Assistant Professor in the Department of Physical Therapy, School of Health Professions and Studies.