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Neurological Treatment Approaches

These charts review the traditional neurological treatment approaches of Neurodevelopmental Treatment (NDT), Proprioceptive Neuromuscular Facilitation (PNF), the Brunnstrom approach and the Rood approach.

Neurodevelopmental Treatment Approach (NDT) – developed by Berta Bobath PT, and Karel Bobath, M.D.
Basis – The sensations of movement are learned, rather than the actual movements. Abnormal movement patterns must be stopped so that the person can gain control over movement in a developmental sequence. Basic patterns of posture and movement, righting reactions, and equilibrium responses can be facilitated by providing appropriate stimuli while abnormal movement patterns are inhibited.
-Early intervention is necessary to avoid abnormal patterns and/or contractures.
-Once the person has gained control of basic movement patterns, he will automatically be able to expand upon these patterns to learn more skilled movements.

Treatment Technique Treatment Technique Example Picture/Video
Reflex-Inhibiting Patterns Patterns of movement that inhibit abnormal muscle tone or reflexes.
-initiated at key points on the body to inhibit the abnormal muscle pattern of the more distal body part.
-controls muscle tone distribution
-pattern is applied to the proximal end of the body part to allow voluntary movement in the distal part.		 An occupational therapist working with a child with spastic quadriplegic cerebral palsy lifts the child’s head into slight hyperextension of the neck to inhibit the flexor tone in the child’s shoulders and trunk so that the child can reach up. An occupational therapy instructor and a student demonstrate the use of reflex-inhibiting movement patterns to release a spastic hand contracture.
Handling The technique used to move a patient through reflex-inhibiting patterns and facilitation of righting and equilibrium reactions.
-used to influence postural tone and inhibit abnormal patterns.
-regulates coordination of agonists, antagonists, and synergists.
-facilitates normal automatic responses
-completed passively at first and then gradually withdrawn as the patient gains the ability to move in normal patterns.
-constantly changes to inhibit undesired responses and facilitate desired responses during activity.		 While working with a woman with right upper extremity flexor tone following a stroke, an occupational therapist repeatedly positions the woman’s shoulder girdle in retraction so that the woman can pull her arm away from her body and straighten her elbow. While working with a child with severe quadriplegic cerebral palsy on a therapy ball, an occupational therapist uses handling techniques to inhibit reflexes and facilitate the child moving his head to midline to kiss his mother.
Righting Reactions Reactions that are evoked through a sequence of postures to help the patient change position.
-Neck righting and body righting reactions are used to move the patient from supine, to prone, to on-elbows, to quadruped, to tall kneeling, to standing.
-Labyrinthine righting reactions are used to help the patient regain normal position in space after being displaced.
-The head is used as a key handling point for neck and body righting reactions. The shoulders are used as key handling points for labyrinthine righting reactions.		 An occupational therapist positions a child with cerebral palsy in side lying on one elbow to facilitate labyrinthine righting reaction of the head so that the child can look at and reach for a toy. A therapist handles a child in a pool by his shoulders and upper arms, using labyrinthine righting reactions to facilitate the child keeping his head above water while kicking his legs.
Equilibrium Reactions Reactions are evoked by displacing the patient’s center of gravity while that patient is in a developmental pattern.
-does not begin until the patient can maintain the pattern against gravity.
-can be elicited by either moving the patient or moving the surface that the patient is on.
-the patient is moved in all directions within each developmental pattern – back and forth, side to side, and obliquely.
-as the patient improves moving surfaces can be used to elicit reactions.
-handling is completed by the therapist at the shoulders or hips, leaving the head and extremities free to react to the position.		 While working with a child with hemiplegia resulting from a seizure disorder, an occupational therapist holds the child on a therapy ball and handles his hip and pelvic region to facilitate upper body equilibrium responses as she moves the child through all the planes of movement on the ball. Equilibrium reactions are demonstrated by moving a mat under a 6 month old baby to elicit a response.
Sensory Stimulation Sensory stimulation techniques are used to facilitate muscle activity when hypotonic muscles are observed.
-always done when the patient is in a reflex-inhibiting pattern.
-stopped if the response is abnormal or results in hyperactive tone.
-three types of sensory stimulation
1. Weight bearing – pressure and resistance are used to increase muscle tone and decrease involuntary movements.
2. Placing and Holding – the patient’s limb is moved to various positions with assistance from the therapist, and then the patient is instructed to hold each position.
3. Tapping – manual muscle facilitation through one of four techniques:
a. joint compression to increase tone and maintain posture
b. inhibitory tapping by releasing the body part and catching it after a very short fall to stimulate stretch reflexes
c. alternate tapping by very lightly pushing the patient to and from mid position
d. sweep tapping where the therapist sweeps a hand over the desired muscles in the desired direction of movement to activate synergic patterns		 While working with a man who has flexor muscle tone in his left arm following a stroke, an occupational therapist positions the man’s arm, performs joint compressions to his shoulder and elbow, then has him place his hand on the mat and lean on it with his elbow straight. An occupational therapy instructor demonstrates muscle tapping with a student.

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