Journal of Occupational Therapy, Schools, & Early

Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: http://www.tandfonline.com/loi/wjot20

Pediatric neurodevelopmental treatment

Ricardo Camacho COTA, MOTS, Brandon McCauley COTA, MOTS & Christy
Szczech Moser PhD, OTR, FAOTA

To cite this article: Ricardo Camacho COTA, MOTS, Brandon McCauley COTA, MOTS &
Christy Szczech Moser PhD, OTR, FAOTA (2016) Pediatric neurodevelopmental treatment,
Journal of Occupational Therapy, Schools, & Early Intervention, 9:4, 305-320, DOI:
10.1080/19411243.2016.1244995

To link to this article: http://dx.doi.org/10.1080/19411243.2016.1244995

Published online: 07 Dec 2016.

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JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
2016, VOL. 9, NO. 4, 305–320
http://dx.doi.org/10.1080/19411243.2016.1244995

REVIEWS, TOOLS, AND RESOURCES

EDITED BY CHRISTY SZCZECH MOSER, PHD, OTR, FAOTA

Pediatric neurodevelopmental treatment

Ricardo Camacho, COTA, MOTS, Brandon McCauley, COTA, MOTS
and Christy Szczech Moser, PhD, OTR, FAOTA
Occupational Therapy Department, Concordia University Wisconsin, Mequon, Wisconsin

ABSTRACT KEYWORDS
Over 70 years ago Dr. Karel Bobath and his wife Bertha Bobath began to Cerebral palsy;
craft the therapeutic intervention now known as neurodevelopmental neurodevelopmental
treatment (NDT). This edition of Reviews, Tools, and Resources will treatment; occupational
highlight a historical review of research studies that have been com- therapy services
pleted, current websites, books, and blogs focusing on NDT.

An introduction to neurodevelopmental treatment

Simply stated, neurodevelopmental treatment (NDT) is a sensorimotor approach focusing
on normalizing tone while incorporating primitive postural patterns and reflexes.
Ultimately this approach strives to attain the development of normalized movement
patterns (Anderson, Hinojosa, & Strauch, 1987). NDT also addresses contracture and
deformity prevention (Butler & Darrah, 2001). Known as the Bobath approach in its
formational years, NDT has been utilized for over 70 years for treating the symptoms
associated with cerebral palsy (Butler & Darrah, 2001; Pendleton & Schultz-Krohn, 2013).
NDT was first conceived by Berta and Karel Bobath in the 1940s (Butler & Darrah,
2001). However, the theoretical foundation of NDT was not established until the 1950s.
Berta Bobath was a physical therapist and her husband, Karel Bobath, was a physician
(Pendleton & Schultz-Krohn, 2013). According to Radomski and Latham (2008), Berta
Bobath discovered that she could improve her client’s occupational performance by
reducing the client's tonicity, which ultimately lead to the development of NDT. As
Berta developed specific treatment techniques, Karel reviewed neurology research to
establish a scientific foundation for Berta’s therapeutic approach. According to
Radomski and Latham, “Bobath and Bobath called their treatment approach a living
concept because they expected it to change and develop over time” (p. 644).

Pediatric NDT literature review

As there is a rich history of publications on the subject of NDT, we will start with a
historical review of the literature. Please note, while we have attempted to create a time
line of articles that have been published over the years, the following publications are only
a small sample of the full extent of scholarly articles that have been written.

CONTACT Christy Szczech Moser Christine.moser@cuw.edu Occupational Therapy Department, Concordia

University Wisconsin, 12800 N. Lake Shore Drive, Mequon, Wisconsin 53097-2402, USA.
© 2016 Taylor & Francis
306 R. CAMACHO ET AL.

DeGangi, G. A., Hurley, L., & Kinsheid, T. (1983). Toward a methodology of the short-
term effects of neurodevelopmental treatment. American Journal of Occupational Therapy,
37(7), 479–484.
Over 30 years ago professionals in the field of occupational therapy were already investi-
gating the impact NDT could have on children with cerebral palsy (CP). This single-subject
design study was replicated with four children all having CP. The intent of the authors was to
ultimately design a means to measure the usefulness of an NDT approach to treatment. Of
interest is the follow-up Letters to the Editor from Magrun, deBenabib, and Nelson (1983)
who identify concerns related to the research design. Also included in the Letters to the Editor
is a follow-up response by DeGangi, Hurley, and Kinsheid. (Please see the December, 1983
American Journal of Occupational Therapy for the full criticism of the study.)
Ottenbacher, K. J., Biocca, Z., DeCremer, G., Gevelinger, M., Jedloved, K. B., &
Johnson, M. B. (1986). Quantitative analysis of the effectiveness of pediatric therapy;
Emphasis on the neurodevelopmental treatment approach. Physical Therapy, 66(7), 1095–1101.
The authors provide an overview of the effectiveness of NDT, circa 1980s. A total of
nine research studies were analyzed in preparation for their publication.
Lilly, L. A., & Powell, N. J. (1990). Measuring the effects of neurodevelopmental
treatment on the daily living skills of 2 children with cerebral palsy. American Journal
of Occupational Therapy, 44(2), 139–145. doi:10.5014/ajot.44.2.139
The authors examined the effects of an NDT intervention on the daily living skills of
two children diagnosed with cerebral palsy. This investigation was conducted as a single
subject design. Two female children, ages 27 months and 32 months participated in the
study. For the single subject design, one child received NDT treatment once a week for 12
weeks, and the second subject received NDT twice a week for the same 12 weeks. NDT in
combination with play was provided to both subjects for six of the 12 treatment sessions.
In contrast, in the following six treatment sessions the subjects received only NDT. The
results of the study determined that there was no significant difference in daily living skills
by using NDT alone or in conjunction with play.
DeGangi, G. A., & Royeen, C. B. (1994). Current practice among neurodevelopmental
treatment association members. American Journal of Occupational Therapy, 48(9),
803–809. doi:10.5014/ajot.48.9.803
Completed over 20 years ago, this study provides an early view on the use of NDT. A
questionnaire was provided to members of the NeuroDevelopmental Treatment
Association (NDTA) with the focus on examining the current practice and use of NDT.
The sample of participants included 243 physical therapists, 168 occupational therapists,
18 speech and language therapists, and two special education teachers. Of the 431
participants, 24 were NDTA instructors. The study concluded that individuals that
identified as using NDT also responded to using NDT in conjunction with other treat-
ment interventions. The study further concluded that the underlying tenets of NDT need
to be readdressed to consider current theoretical thinking and practice.
Fetters, L., & Kluzik, J. (1996). The effects of neurodevelopmental treatment versus practice
on the reaching of children with spastic cerebral palsy. Physical Therapy, 76(4), 346–358.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 307

This study focused on identifying the effects of providing NDT versus practice as an
intervention strategy. Eight children participated, including 2 females and 6 males ranging
in age from 10 to 15 years old who were diagnosed with spastic quadriplegic CP. Reaching
capabilities of the subjects were assessed utilizing the Waterloo Spatial Motion Analysis and
Recording Technique (WATSMART). Subjects were provided NDT intervention for 5 days,
followed by five days of continued practice with reaching tasks (with a focus on movement
time, path, and smoothness). The findings of the study suggest that NDT and practice may
need to be combined in order to produce enhanced reaching abilities, or each individual
intervention may require a greater intervention period to produce desired results.
Law, M., Russell, D., Pollock, N., Rosenbaum, P., Walter, S., & King, G. (1997). A
comparison of intensive neurodevelopmental therapy plus casting and a regular occupa-
tional therapy program for children with cerebral palsy. Developmental Medicine and
Child Neurology, 39, 664–670.
The study conducted by Law et al. (1997) is a randomized crossover study conducted on
50 children with a diagnosis of cerebral palsy with spastic diplegia, hemiplegia, or quad-
riplegia. Children ranging in age from 18 months to 4 years were included in the study. The
focus of this study was to identify the effects of the combined interventions of intensive NDT
intervention and casting in improving upper extremity quality of movement. The interven-
tion was provided over a 4-month, 6-month, and 10-month period. The participants were
split into a treatment group that included intensive NDT and casting, while the control
group focused only on regular OT programming. The authors concluded that there was no
significant difference in hand function or quality of upper extremity movement between the
two treatment groups. The authors of the study also recommended that further research
needed to be conducted to determine effectiveness of this treatment intervention.
Adams, M. A., Chandler, L. S., & Schuhmann, K. (2000). Gait changes in children with
cerebral palsy following a neurodevelopmental treatment course. Pediatric Physical
Therapy, 12(3), 114–120. doi:10.1097/00001577–200012030-00003
This study analyzed changes in gait characteristics (pre/post) in children with cerebral palsy
due to participation in a 6-week neurodevelopment treatment (NDT) intervention program.
The study utilized a quasi-experimental design. Sample size consisted of 40 ambulatory
children between the ages of 2.6 to 10.2 years with a diagnosis of cerebral palsy. Specific
cerebral palsy diagnoses included diplegia, hemiplegia, spastic triplegia, ataxia, and athetosis.
The study found that there was a significant change in several categories, including improved
stride length, improved step length, and improved foot angle and an increase in cadence and
base of support attributed to the 6-week NDT intervention. Children diagnosed with spastic
diplegia fared better than children diagnosed with spastic triplegia. The authors noted that lack
of a control group weakened their overall ability to assess the impact of NDT on gait changes.
Brown, T., & Burns, S. (2001). The efficacy of neurodevelopmental treatment on
paediatrics: A systematic review. British Journal of Occupational Therapy, 64(5), 235–244.
The authors completed a systematic review of 17 research studies. All studies utilized a
randomized research design. Their conclusion stated that an NDT approach to treatment
of children with neurological disorders identified in the literature “does not clearly
demonstrate the efficacy or inefficacy of NDT as a treatment approach” (p. 242).
308 R. CAMACHO ET AL.

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. doi:10.1017/s0012162201001414
The authors completed a systematic review investigating a variety of interventions that
address developmental disabilities. A total of 21 articles were reviewed with publication dates
ranging from 1973 to 2000. Based on the research available, it was determined that NDT
interventions increased improvement in dynamic range of motion. However, evidence to
support that NDT had a positive effect on changing abnormal motoric responses, decreasing
or preventing contractures, or improving motor development was not consistent. The authors
offer suggestions for future research studies, including utilizing NDT as a control intervention.
Kerem, M., Livanelioglu, A., & Topcu, M. (2001). Effects of Johnstone pressure splints
combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in
spastic cerebral palsy. Developmental Medicine and Child Neurology, 43(05), 307.
doi:10.1017/s0012162201000585
This study was conducted in order to identify the effects of the combined use of Johnstone
pressure splints and NDT in addressing spasticity and cutaneous sensory inputs with children
diagnosed with spastic cerebral palsy. For the purposes of this study, 34 children diagnosed
with diplegic cerebral palsy were selected. The participants were split into two groups
consisting of a treatment group that used both the Johnstone pressure splints and NDT as a
treatment intervention and the control group, which used only the Johnstone pressure splints
and exercises. The study was performed 5 days a week for 3 months. The authors concluded
that the combined use of both the Johnstone pressure splints and NDT as a treatment
intervention was effective in inhibiting spasticity and abnormal motion patterns.
Knox, V., & Evans, A. L. (2002). Evaluation of the functional effects of a course of
Bobath therapy in children with cerebral palsy: A preliminary study. Developmental
Medicine and Child Neurology, 44(07). doi:10.1017/s0012162201002353
This repeated-measures-design study focused on identifying how the use of Bobath
therapy affects children diagnosed with cerebral palsy. Fifteen children were selected, all
diagnosed with cerebral palsy. The authors used the Gross Motor Function Measure
(GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI) as assessment
tools to gather data. The participants of the study received standard intervention for 6
weeks to determine a baseline. Following the baseline assessment, a Bobath intervention
was performed from weeks 7 through 12, followed by a final assessment of performance at
week 18. The results of the study indicated an improvement in motor function and self-
care performance following the use of Bobath therapy interventions.
Tsorlakis, N., Evaggelinou, C., Grouios, G., & Tsorbatzoudis, C. (2004). Effect of
intensive neurodevelopmental treatment in gross motor function of children with cerebral
palsy. Developmental Medicine and Child Neurology, 46(11), 740–745. doi:10.1111/
j.14698749.2004.tb 00993.x
The focus of this randomized controlled study was to identify the effectiveness of an
intensive NDT intervention. Children (n = 34) diagnosed with cerebral palsy with mild to
moderate spasticity and hemiplegia, diplegia, or tetraplegia were included in the study.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 309

After randomization, two groups were formed. Group A was provided with NDT twice a
week, and group B was provided with NDT five times a week. NDT was provided to both
groups over a 16-week period. Gross motor function was assessed with the Gross Motor
Function Measure. The results of the study showed that use of NDT provided a significant
improvement in hand function. The study also showed there was a significant improve-
ment in gross motor hand function within the group that was provided intensive NDT
over the 5-day intervention period. The authors further recommended that additional
research needs to be conducted to objectively assess the benefits of NDT as a treatment
intervention for children with cerebral palsy.
Blauw-Hospers, C. H., & Hadders-Algra, M. (2005). A systematic review of the effects
of early intervention on motor development. Developmental Medicine and Child
Neurology, 47(6), 421–432. doi:10.1111/j.1469–8749.2005.tb 01165.x
This systematic review describes how early intervention with children between birth and
corrected age of 18 months with developmental disorders progress with intervention. The
study focused on three types of interventions: the Newborn Individualized Developmental
Care and Assessment Program (NIDCAP), Neurodevelopmental Treatment, and other
specific or general developmental programs. The study identified that the NIDCAP inter-
vention did benefit the motor development of infants that were deemed to be at a higher
risk for developmental disorders. The study also concluded that NDT was the leading
method of intervention but also concluded that NDT did not produce any measurable
positive effects on motor development.
Sheppard, L., Mudie, H., & Froude, E. (2007). An investigation of bilateral isokinematic
training and neurodevelopmental therapy in improving use of the affected hand in
children with hemiplegia. Physical and Occupational Therapy in Pediatrics, 27(1), 5–25.
doi:10.1080/j006v27n01_02
The focus of this study was to identify the effects of NDT and Bilateral Isokinematic
Training as an intervention strategy on three children diagnosed with hemiplegic
cerebral palsy. The authors utilized a single-case–time-series experimental research
design. Thirty-two total combined sessions were conducted over an 8-week period.
Treatment was performed 4 times a week. The study used an ABAC design to admin-
ister interventions. Two females and one male were chosen for the study with an
average age of 8 years, 7 months. The authors found that NDT was not an effective
treatment intervention to improve hand function with the children in this study. The
authors further suggested that the use of Bilateral Isokinematic Training did have
positive effects. In conclusion, the authors recommended that further research needed
to be conducted to identify more-appropriate treatment approaches for children with
hemiplegic cerebral palsy.
Wuang, Y., Wang, C., Huang, M., & Su, C. (2009). Prospective study of the effect of
sensory integration, neurodevelopmental treatment, and perceptual-motor therapy on the
sensorimotor performance in children with mild mental retardation. American Journal of
Occupational Therapy, 63(4), 441–452. doi:10.5014/ajot.63.4.441
This study sought to identify the effects of multiple intervention strategies on the
sensorimotor performance of children diagnosed with mild mental retardation. For the
310 R. CAMACHO ET AL.

purposes of this study, 120 children were selected between the ages of 7 and 8 years old.
The participants were diagnosed with mild mental retardation and were able to follow test
instructions. Interventions provided in this study included sensory integration (SI), NDT,
and perceptual-motor therapy (PM). Results of the study indicated an improvement in
sensorimotor functioning in children with mild mental retardation with the use of all
three intervention strategies: SI, NDT, and PM. The authors also recommended that when
determining the proper intervention strategy for a specific client, the child’s particular
needs have to be considered.
Bar-Haim, S., Harries, N., Nammourah, I., Oraibi, S., Malhees, W., Loeppky, J., &
Lahat, E. (2010). Effectiveness of motor learning coaching in children with cerebral palsy:
A randomized controlled trial. Clinical Rehabilitation, 24(11), 1009–1020. doi:10.1177/
0269215510371428
Bar-Haim et al. (2010), researched whether the use of motor learning coaching would
prove to be more effective than neurodevelopment treatment as an intervention for children
with cerebral palsy. This randomized controlled trial included 78 children with diagnoses of
spastic or mixed cerebral palsy with either diplegia or quadriplegia. Interventions were
provided three times a week for 3 months for an hour each visit. Results of the study identified
that there was a significant improvement in retention and transfer over the course of the
intervention of learned motor functions from the motor learning group as opposed to the
neurodevelopmental treatment group. The authors of the study identified the following
limitations to the study: the inability to precisely control the therapy interventions, and
generalizability of the results for children who are outside of the 6- to 12-year range.
Shamsoddini, A. (2010). Comparison between the effect of neurodevelopmental treat-
ment and sensory integration therapy on gross motor function in children with cerebral
palsy. Iranian Journal of Child Neurology, 4(1), 31–38.
The authors of this study conducted a randomized study to identify and compare the
effects that NDT and sensory integration therapy interventions have on the gross motor
function of children diagnosed with cerebral palsy. For the purposes of this study the
authors identified 22 children with a diagnosis of spastic CP ranging in age from 2 to
6 years. Half of the children had diplegic CP and the other 11 children had quadriplegic
CP. The 22 children were randomly divided into two equal groups. The first experimental
group received an NDT intervention, while the second group received a sensory integra-
tive approach to treatment. All children received therapy three times a week, with each
session lasting 90 minutes, over a 3-month period. The Gross Motor Function Measure
(GMFM) was used to gather data. The results of the study indicated that there was
significant improvement in rolling, sitting, crawling, and kneeling after the use of NDT
and SI. The study further indicated that there was little improvement in the client’s
performance with walking, running, or jumping.
Choi, M., Lee, D., & Ro, H. (2011). Effect of task-oriented training and neurodevelop-
mental treatment on the sitting posture in children with cerebral palsy. Journal of Physical
Therapy Science, 23(2), 323–325. doi:10.1589/jpts.23.323
The authors of this randomized study looked to identify what would be the outcome
of using task-oriented training and neurodevelopmental treatments on the sitting
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 311

posture of children diagnosed with cerebral palsy. For the purposes of this randomized
study, 10 children (five boys and five girls) diagnosed with spastic diplegia cerebral
palsy (ranging in age from 2 to 9 years) were selected. The control group of five
children received NDT as the intervention, while the experimental group received task-
oriented interventions. Both interventions primary focus was on improving the client’s
sitting balance and posture. Methods for gathering data included administration of the
Gross Motor Functional Measure (GMFM) and an electromyography (EMG). An EMG
was completed to take readings of the rectus abdominus and the erector spinae
muscles, respectfully. Measures were gathered pre- and postintervention. The interven-
tions were provided over a 6-week period, five times a week with each session lasting
30 minutes. The results of the study indicated that there was significant improvement
in muscle vitalization of the erector spinae muscles post treatment, but no differences
were identified in the GMFM and EMG between the NDT and the task-oriented
groups. The authors further acknowledged that there was improvement in muscle
vitalization during sitting with both interventions. However, due to the small sample
size of the study results cannot be generalized.
Dirks, T., Blauw-Hospers, C. H., Hulshof, L. J., & Hadders-Algra, M. (2011).
Differences between the family-centered “COPCA” program and traditional infant physi-
cal therapy based on neurodevelopmental treatment principles. Physical Therapy, 91(9),
1303–1322. doi:10.2522/ptj.20100207
The authors of this study conducted a two-arm randomized trial. Quantitative video
analysis was utilized to determine the differences between the use of Traditional Infant
Physical Therapy (TIP) and NDT as an intervention and the Coping with and Caring for
Infants with Special Needs (COPCA) program. For the purposes of this randomized trial,
46 infants (that were identified as high risk in the neonatal intensive care unit due to
having abnormal general movements) were included in the study. Males (n = 20) and
females (n = 26) were included in study, ranging in gestational age from 25 to 36 weeks.
The interventions were conducted between 3 and 6 months. The group receiving the
COPCA sessions met with one of four COPCA coaches for a 1-hour treatment session
twice a week. For the TIP group, treatment interventions ranged from two to 28 sessions
for a duration of 12 to 50 minutes per session. Video recordings of the sessions showed
progress after 4 and 6 months. Statistical data were collected and processed with SPSS
software. The results of this randomized trial indicate that there is a wide difference in
intervention approaches between TIP and COPCA, indicating the differences as follows:

(1) COPCA is client- and family-centered with the focus on play using a hands off
approach, which would in turn facilitate the child's exploration.
(2) In regard to TIP, the intervention revolved around the therapist and his or her use
of NDT handling techniques as the intervention.
(3) The authors further suggest (as a result of video observations) that therapists docu-
ment and indicate performing tasks other that what was identified in the video.

Gillen, G. (2014). What is the evidence for the effectiveness of interventions to improve
occupational performance after stroke? American Journal of Occupational Therapy, 69(1),
6901170010p1. doi:10.5014/ajot.2015.013409
312 R. CAMACHO ET AL.

This editorial sought to identify the available evidence that addressed the effectiveness
of stroke interventions in improving occupational performance. In this report, the author
acknowledged how little evidence was currently available in identifying NDT as a viable
treatment intervention in addressing stroke. The author further concluded that there was
no evidence that NDT as a treatment intervention did not improve patient function in
sensorimotor control, dexterity, mobility, or ADLs.
Acar, G., Altun, G. P., Yurdalan, S., & Polat, M. G. (2016). Efficacy of neurodevelop-
mental treatment combined with the Nintendo® Wii in patients with cerebral palsy.
Journal of Physical Therapy Science, 28(3), 774–780. doi:10.1589/jpts.28.774
The authors of this study looked to identify the possible benefits of combining NDT
interventions along with the use of the Nintendo Wii with patients diagnosed with
cerebral palsy. The study used a random number generator to sort two groups of 15
children ranging in age from 6 to 15 years. The subjects were assessed according to the
following criteria:

(1) The Manual Ability Classification System was used and the child needed to score
between levels one and three.
(2) The Gross Motor Function Classification System was used with a required score of
one to two.
(3) No surgery or Botox treatment within the previous 6 months.
(4) The ability to grasp and release objects

The study was conducted over a period of 6 weeks, with treatment provided twice a week
for a duration of 45 minutes per session. Data were collected using the Quality of Upper
Extremity Skills Test (QUEST), the Jebsen Taylor Hand Function Test (JTHFT), the
ABILHAND-Kids test, and the WeeFIM. The results of the study demonstrated that there is
benefit to the combined use of NDT and Nintendo Wii virtual reality games. The group with
the combined treatment intervention saw greater improved scores in the QUEST, JTHFT, and
the ABILHAND-Kids test over those individuals who were treated with NDT alone.

Nonresearch-based articles
Anderson, J., Hinojosa, J., & Strauch, C. (1987). Integrating play in neurodevelopmental
treatment. American Journal of Occupational Therapy, 41(7), 421–426.
The authors offer an occupational therapy perspective related to utilizing the concept of
play within a NDT-based treatment approach. It serves as an example of how occupational
therapists have long been working to incorporate appropriate child-centered activities
within a therapeutic framework.
Bly, L. (1991). A historical and current view of the basis of NDT. Pediatric Physical
Therapy, 3(3), 131–135.
The author reviewed the first 50 years of NDT as a developing framework for the
treatment of children with movement disorders. If you are curious as to the specifics of
how NDT evolved from 1940 to 1990, we would highly recommend reading this article.
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 313

Valvano, J., & Long, T. (1991). Neurodevelopmental treatment: A review of the writing
of the Bobaths. Pediatric Physical Therapy, 3(3), 125–129.
The authors present a wealth of information related to the professional writings of
Karel and Bertha Bobath. In a very succinct manner, Valvano and Long highlight
information related to such topics as mechanisms for motor control, normal motor
development, and treatment principles and methods.

Books and manuals

Bierman, J. C., Franjoine, M. R., Hazzard, C. M., Howle, J. M., & Stamer, M. (2016).
Neuro-developmental treatment: A guide to NDT clinical practice. New York, NY: Thieme.
This textbook is a comprehensive source of information for both novice and experi-
enced clinicians. The authors provide the latest theoretical fundamentals of NDT includ-
ing clinical examples. It is noted that this textbook is the primary resource in NDT
certification courses. The outcome of a 5-year project completed by certified instructors
of the NDT approach, the text contains an overview of NDT, a literature review of current
evidence, and a variety of illustrations, diagrams, and videos demonstrating therapeutic
intervention using the NDT sensorimotor approach. The videos can be accessed through
the publisher’s MediaCenter. In addition, the text also contains an overview of how NDT
is utilized by a variety of therapeutic professions including physical therapy, speech
therapy, and occupational therapy. Another special feature of the text is that it provides
educators with instructional materials and guidelines for individuals interested in learning
the NDT approach.
Blanche, E. I., Botticelli, T. M., & Hallway, M. K. (1998). Combining neuro-developmental
treatment and sensory integration principles: An approach to pediatric therapy. Tucson, AZ:
Communication Skill Builders/Therapy Skill Builders.
This manual focuses on informing clinicians of ways to provide interventions that
combine key principles of NDT and sensory integration (SI). The manual provides
detailed information on both therapeutic approaches, including assessment methods to
determine when it is appropriate to combine NDT and SI principles. The manual also
provides clinicians with reproducible checklists, which are reported to be useful when
evaluating a client’s movement and sensory disorders. Finally, the manual provides
clinicians with case studies that support the importance of using a combined approach
that incorporates principles from NDT and SI frameworks.
Pendleton, H. M., & Schultz-Krohn, W. (2013). Pedretti’s occupational therapy: Practice
skills for physical dysfunction (7th ed.). St. Louis, MO: Elsevier Mosby.
This text provides readers with a thorough introduction to the profession of occupa-
tional therapy. The textbook contains 48 chapters including one dedicated specifically to
therapeutic sensorimotor approaches. Within the text, Pendleton and Schultz-Krohn
provide information regarding the history of NDT and the key components of NDT
intervention. Pendleton and Schultz-Krohn also describe the philosophy of NDT and how
it can utilized as an intervention to improve a client’s ability to perform occupations. In
addition, the authors identify how NDT is utilized during evaluation and intervention.
314 R. CAMACHO ET AL.

Toward the end of the chapter, references on the effectiveness of NDT are highlighted.
The authors conclude that higher-level research is needed.
Vining Radomski, M., & Trombly Latham, C. (2008). Occupational therapy for physical
dysfunction (6th ed.). Baltimore, MD: Lippincott Williams & Wilkins.
Chapter 24 of the Vining Radomski and Trombly Latham (2008) textbook is dedicated
to NDT. Within the chapter, the authors provide a detailed history of the principles of an
NDT approach to treatment. In addition, they thoroughly outline the components of NDT
treatment such as the goal of remediating normal movement and handling techniques
such as inhibitory and facilitory techniques. They also emphasize that key points of
control are crucial for controlling a client’s movement, and provide a connection between
NDT and occupational performance. The authors further suggest that clinicians providing
NDT utilize purposeful activities as a form of therapeutic exercise to produce motor
learning. Such a situation is referred to as “Occupation-as-means” (p. 647). In addition,
the authors also suggest that NDT clinicians develop occupation-as-end techniques, which
focus on incorporation of involved extremities during occupational performance. A
special feature provided by Radomski and Trombly Latham includes suggestions for
treatment goals using the NDT approach. It is clear that this textbook would be very
useful for clinicians utilizing NDT.
Zanon, M. A., Gustavo, J. M., & Riera, R. (2015). Neurodevelopmental treatment
approaches for children with cerebral palsy. Cochrane Database of Systematic Reviews
2015, 11, 1–19.
This protocol offers therapists the tools they need to evaluate the effectiveness of an
NDT approach to treatment, specifically when handling children with CP. In addition, it
provides numerous resources not highlighted in this review.

Blogs
Dingman, T. (2013). Therapy talk: What is NDT? Retrieved from https://neurochangers.
com/2013/03/12/therapy-talk-what-is-ndt/
Dingman’s blog on NDT can be located through the neurochangers website. Within her
blog, she describes NDT, including the philosophy of the approach. She also describes her
clinical experience as an NDT therapist, what she is seeing within her clinical settings, and
how she utilizes NDT as not only an intervention technique, but also an assessment tool.
The blog is rather short, but provides an interesting perspective on NDT.
Laurenson, H. (2015). Relax it’s Bobath! Retrieved from http://relaxitsbobath.wee
bly.com/
This blog was developed by Laurenson (2015) during her time as an occupational
therapy student. Within the blog, Laurenson provides a well-written summary of her
findings as she studied NDT. In addition, Laurenson shares an interesting YouTube clip,
which depicts how NDT in combination with occupation-based activity can be utilized to
promote functional outcomes. Laurenson also developed an area of information that
describes the NDT approach and how it promotes normalized motions. A great feature
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 315

of Laurenson’s blog is a reference list of different textbooks and journal articles that focus
on the NDT approach. The reference list may be helpful for clinicians seeking additional
information.
Tools to Grow, Inc. (n.d.). Re: Pediatric neurodevelopmental treatment [Web log entry].
Retrieved from http://www.toolstogrowot.com/blog/category/pediatric-neurodevelopmental-
treatment
The Tools to Grow, Inc. (n.d.) website provides a blog specifically on NDT, includ-
ing the philosophy of the approach. It features such topics as primitive motor reflexes
and their impact on a child’s functional performance and the importance of tummy
time from the perspective of an occupational therapist who utilizes the NDT approach.
The blog moderator encourages readers to join the discussion by posting questions or
comments.
Wired ON Development. (2013). The ABC’s of NDT. Retrieved from http://wiredonde
velopment.blogspot.co.nz/2013/10/the-abcs-of-ndt.html
The ABC’s of NDT is a blog available through the Wired ON Development website. This
blog provides an excellent overview of how therapists utilize NDT during their clinical
practice. To further explain, the ABC’s of NDT describes how NDT therapists view children
in a holistic manner and emphasizes that an understanding of NDT results in a greater
understanding of a child’s occupational performance. According to the ABC’s of NDT, NDT
is not simply a tool, but instead it is a concept or a way of understanding the characteristics of a
child, including his or her alignment, movement, and neurodevelopment.

Websites
Bobath Centre for Children with Cerebral Palsy. (n.d.) About. Retrieved from https://
www.bobath.org.uk/about-us/welcome
The Bobath Centre is located outside of the United States, but the training center’s
website provides an excellent description of NDT intervention provided by occupational
therapy, physical therapy, and speech therapy. This website also provides information
regarding cerebral palsy as a diagnosis including causes of cerebral palsy, types of cerebral
palsy, and associated functional impairments. The training center’s website also features
an area specifically for clinicians. This area provides evidence to support NDT, outcome
measures that can be utilized during NDT, and research articles. In general, this is an
excellent website for clinicians seeking information regarding NDT and cerebral palsy.
Neuro-Developmental Treatment Association (NDTA). (2016). Education. Retrieved
from https://www.ndta.org/
The Neuro-Developmental Treatment Association (NDTA, 2016) provides a compre-
hensive website that includes subsections for “membership, resources, family/caregiver
support, and education” (n.p.). The NDTA website also provides a search option that is
useful for locating an NDT therapist, vendor marketplace, or NDTA Centers for
Excellence. This website is helpful for individuals and clinicians seeking information
regarding NDT as a therapeutic approach. Resources provided through the NDTA website
316 R. CAMACHO ET AL.

include research summaries, advocacy resources, employment classifieds, and information

regarding small-grant awards. The research summaries provided by the NDTA identify
NDT as an evidence-based sensorimotor approach, as they outline the benefits of NDT
supported by scientific studies. A special feature of the NDTA website is the family and
caregiver support section. Within this section there is a family forum, which requires a
membership to access. In addition, there are helpful links for clients and family members
who are currently engaged in NDT interventions. In order to become a member of the
NDTA, there is an annual cost. However, the website offers a vast variety of information
for clinicians and clients.
Diamond PT Continuing Education. (2016). What is neuro-developmental treatment
(NDT)? Retrieved from http://www.diamondpt.info/NDT.html
The Diamond PT continuing education website provides an adequate amount of
information on NDT intervention. The Diamond PT website also describes the benefits
of being certified in NDT and provides a calendar of upcoming certification courses.
Another special feature of the website is the feedback from course participants, which may
help clinicians determine whether a continuing education course focused on NDT is
relevant to their clinical practice.

YouTube videos
Clinician’s View. (2015). Introduction to NDT [Video file], presented by Linda Kliebhan,
PT, C/NDT. Retrieved from https://www.youtube.com/watch?v=0axMHCqnh74
Introduction to NDT is a YouTube video produced by Clinician’s View (2015). This
video provides clips from a seminar that focuses on a basic introduction to the principles
of NDT. The video does not provide the seminar in its entirety, but it does provide a solid
description of multiple components of the NDT approach, which may be helpful for
clinicians who are considering attending a seminar to enhance their knowledge of NDT.
Components of NDT that are briefly addressed within the video include the essence of
NDT and atypical movement patterns, In addition, the video provides a brief clip of NDT
being utilized within a clinical setting with a pediatric client.
Health Care Volunteers International. (2016). Cerebral palsy neuro-rehabilitation:
Bobath concept training video [Video file]. Retrieved from https://www.youtube.com/
watch?v=wcArvJPe71E
This YouTube video produced by Health Care Volunteers International (2016) features
two clinicians demonstrating pediatric therapeutic exercises based on components of
NDT. It is implied that the exercises could be utilized during neuro-rehabilitation for
pediatric clients with cerebral palsy.
Kids iPads. (2011). NDT crawling for ball [Video file]. Retrieved from https://www.
youtube.com/watch?v=yogpQ6K2vgE
Kids iPads (2011) provides a YouTube video that features a pediatric client receiving
occupation-based NDT. This video provides an excellent visual example of how handling
techniques can be utilized to promote functional outcomes. During the video, clinicians
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 317

can observe how the therapist’s handling techniques assist the child as she attempts to
crawl toward her ball. This video is brief but strongly demonstrates how NDT and
occupation can be utilized by clinicians working with pediatric clients.
Rehab Therapy Center. (2011). NDT [Video file]. Retrieved from https://www.youtube.
com/watch?v=mCiBehv_FOw
Provided by Rehab Therapy Center (2011), this brief video demonstrates NDT being
utilized with multiple children in a variety of different clinical scenarios. During the video,
the Rehab Therapy Center also provides an excellent description of NDT including the
goal of intervention and the components of NDT.

Should occupational therapists be utilizing an NDT approach in treatment?

In regard to the evidence supporting NDT, an editorial in the American Journal of
Occupational Therapy (Gillen, 2014) states:

The research related to NDT is far from compelling. A systematic review of randomized trials
evaluating the effectiveness of NDT concluded that there was no evidence of the superiority
of NDT in improving sensorimotor control of the upper and lower limbs, dexterity, mobility,
ADLs, health-related quality of life, and cost-effectiveness. (p. 2)

The article further identifies that while little evidence is available to support the use
of NDT, many therapists and educational institutions continue to use and teach this
technique in spite of the goal of providing strong evidence-based intervention
techniques.
Natarajan et al. (2008) states that “therapists seem to adopt an eclectic approach and
combine principles from different approaches in their current practice, which may indi-
cate the need for an optimal approach to be developed through more research” (p. 846).
The above statement appeals to the idea that occupational therapists need to be proficient
in a variety of intervention strategies, because the varied diagnoses that clinicians see may
require more than one approach.
As has been discussed throughout this edition of Reviews, Tools, and Resources,
the primary objectives of NDT are to normalize tonicity, facilitate normal postural
reactions and inhibit primitive reflexes (Pendleton & Schultz-Krohn, 2013). NDT
focuses on the establishment of normal motor development and also includes a
sensorimotor perspective that addresses muscle tonicity, atypical motor patterns,
postural stability, sensation, perception, and even memory (Butler & Darrah, 2001).
Early in their development, children who received an NDT approach to treatment
were typically considered passive recipients of NDT as it involves handling techni-
ques and various forms of sensory stimulation (Butler & Darrah, 2001). Therapy
clinicians using NDT should use occupation-as-means, which involves providing
purposeful activities that encourage motor learning (Vining Radomski & Trombly
Latham, 2008). In addition, the NDT approach also involves using occupation-as-end,
which entails teaching the client to confirm that improvements gained during rehabilita-
tion are transitioned into occupational performance (Vining Radomski & Trombly
Latham, 2008).
318 R. CAMACHO ET AL.

In closing
We realize that there are countless pieces of information (including textbooks, journal
articles, papers, etc.) that we were not able to review in this publication. Secondly, we hope
that at minimum this publication will inspire you to further investigate the value of NDT
in your current practice. We would like to encourage you also to review the AOTA
Evidence Briefs that have been completed on cerebral palsy and NDT, available on the
AOTA website (www.aota.org). Finally (and ideally), we hope that we have planted a seed
for practitioners to consider completing a research study to substantiate or negate the
continued use of an NDT approach in your daily occupational therapy treatment sessions.

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