VanSant, Ann F. PT, PhD, FAPTA
Recently, I heard several colleagues express concern about the manner in which we characterize neurodevelopmental treatment (NDT). Their concern is that NDT has evolved into many different types of intervention, based on newer theories, many of which were not part of NDT as developed by the Bobaths. These colleagues argued that NDT in that contemporary form is not different from what is now very much standard practice in pediatric physical therapy. I am not so sure I agree that NDT in contemporary form is similar to standard practice of pediatric physical therapy, but I do agree that there is theoretical muddling that has occurred over time and that in NDT we may be dragging an anchor of the past. Thinking about this dilemma I consulted a number of colleagues asking their opinions, and also of course I read Diane Damiano’s recent editorial on the subject.1
I consider myself to be one of the fortunate members of my generation to have had the opportunity to receive training from the Bobaths—in their “eight week course.” I also consider myself to have been fortunate to have taken the course in a unique situation with Signe Brunnstrom sitting beside me during the Bobaths’ lectures and demonstrations related to hemiplegia.
Now what did I learn in that course? Most of all I learned how better to observe human posture and movement, something that in my mind is fundamental to physical therapy, and something that takes a good deal of practice, even longer than 8 weeks! To learn to observe from individuals such as the Bobaths and Brunnstrom was something I valued highly.
But I also learned something else. The neural control model from the early 20th century that provided theoretical underpinnings for Bobath’s work2 was the same model that provided theoretical underpinnings for Brunnstrom’s approach3 to therapy. To say that there were some contradictions between their interpretations of the underlying neural model and its application to clinical practice would be a bit of an understatement. I saw first hand how we can use theory to promote our individual perspectives and I also learned that immensely talented and intelligent therapists are wont to disagree! But it was much later that I learned that the way to examine such differences is through research, because at the time research was not directing practice.
For those who weren’t born soon enough to experience the 1960s and 1970s as members of the physical therapy profession, it was a time of competing theories—Bobath, Brunnstrom, proprioceptive neuromuscular facilitation (PNF), and Rood. In hindsight, the development of these theoretical camps seems to have ridden forward on the wave of astute and charismatic individuals who made sense of their clinical observations and were good communicators, able to share their experiences and teach others what they had learned.
But now the Bobaths have passed on, and clearly NDT instructors who have taken command of the ship have not done so with eyes closed, rather they have incorporated newer theories and ideas into their courses. But as Damiano has pointed out,1 therein lies a problem that I believe is clearly evidenced in the fact that there are approximately 80 NDT instructors here in the United States. As I learned in my original Bobath course, even if a theoretical model remained constant (which is far from reality), intelligent and talented therapists are wont to disagree. And despite what I believe are well-motivated attempts to sustain a single NDT curriculum, with so many instructors what good is served by being NDT trained? Why is the presentation of a new set of theoretical underpinnings anchored to NDT/Bobath? This situation no longer makes sense to me.
Contemporary practitioners must use evidence to guide their interventions. Learning when and how to apply specific therapeutic procedures is no longer enough, rather today’s therapists must know what evidence-based interventions are—they must use their experience and knowledge to adapt that evidence to individual clients. And they must know how to assess research publications, to take clinical bottom lines from them, and to use those bottom lines in the context of individual patients. In my view these skills are of greater importance than perpetuating remnants of past glory days. As professionals, we must be ready to give up older ideas in favor of newer concepts with firm grounding in research.
Now why would I write this editorial when in this very issue an article is published investigating an NDT anchored protocol? I believe the strength of Arndt’s report4 is the description and testing of a clinical intervention. Further, as with every clinical study, the challenges to design and implementation are enormous hurtles and Arndt and her co-investigators have met this challenge and gone one further, they have persevered to have their findings published. Not surprisingly, as a result of this work a large number of additional questions arise, and the authors have done an excellent job of identifying the need for additional study and exposing the limitations of this work. The unanswered questions that remain about this trunk protocol are not trivial and point to the significant amount of future work needed to come to strong conclusions about this intervention.
But as readers, I challenge you to ask yourself—is the article clearer, more important, or of greater value because it is anchored in NDT? Does that anchor uniquely separate this work from other theories that might be used to explain the findings? Would the findings be less significant if the study was not linked to NDT? In each instance I believe the answer is “no,” and therefore I believe it is time to hoist the anchor.
Ann F. VanSant, PT, PhD, FAPTA
1. Damiano D. Pass the torch please! Dev Med Child Neurol. 2007;49:723.
2. Bobath B. Abnormal Postural Reflex Activity Caused by Brain Lesions. London: William Heinemann; 1965.
3. Brunnstrom S. Movement Therapy in Hemiplegia—A Neurophysiological Approach. New York: Harper & Row; 1970.
4. Arndt SW, Chandler LS, Sweeney, JK, et al. Effects of a neuro-developmental treatment-based trunk protocol for infants with posture and movement dysfunction. Pediatr Phys Ther. 2008;20:11–22.
© 2008 Lippincott Williams & Wilkins, Inc.