NDT why it is unethical to practice it
Physiotherapy is an emerging science, yet it remains plagued by pseudoscience, outdated models, and unfounded practices. One such problematic approach is Neurodevelopmental Therapy (NDT). Despite its obsolescence, NDT continues to be widely endorsed, particularly in many pediatric clinics in Tamil Nadu, where practitioners often boast of their certification in this outdated method. This situation is deeply concerning.
I wanted to high;ight the issue of NDT because of the news which was shared in Facebook.
Unlike the comments on the post and probably many physiotherapists in India, I think this is a good start. The next step is to encourage people in India to stop teaching and practicing this nonsense and deeply unethical treatment method.
As recently as last year, the Society for Physiotherapists invited a practitioner who is stuck in the 1970s to give a talk on NDT. It seems I must again point out what is wrong with the scientific committees and those who teach and practice this outdated and ineffective method.
What is NDT?
well like most pseudoscience it is has a vague definition of what it is.
if you havent read what it is, this is the defnition of Bobath or NDT
NDT is a problem-solving approach used in the evaluation and treatment of individuals with movement, tone, and functional impairments due to a lesion of the central nervous system
You might ask, what is the problem with that definition? Well, children, it is not a definition of NDT at all. It is what anyone studying in their final year would write if asked about neurorehabilitation.
So whats special about NDT then.
well there is no answer everyone will accept but thats the way to muddle the waters more than anything else. So here goes
Let's start with problem-solving in the definition. What is a problem in cerebral palsy? It's fairly straightforward: the child is unable to perform functional activities like a neurotypical child, from milestones to play.
Why is this? Here's where it gets muddled. When I learned about it in college, it was attributed to abnormal tone, poor sensory-motor processing, and abnormal reflexes. To address these, handling techniques were used to reduce them—and they still are.
What is a handling technique?
Here's a free lesson that would otherwise cost you thousands: it involves where to hold the child. Really? Yes, that's essentially it. What else can you do?
What happens if you apply proper handling techniques?
Well, when you hold a child correctly, the child will be stable. That's all. Will the tone reduce? Not really, as tone is a product of movement and not to be tested at rest. Will they move better? Maybe. Will that lead to better functional outcomes—will the child learn to walk better or faster than a child who does not receive NDT? Sadly, no. Will sensory-motor processing improve? If you think yes, you might need to revisit high school biology.
Treatment of muscle tone and movement:
The second part of the decription of the technique says they manage tone and movements. what do they do for it- well some fancy terms but just passive and some active assited movemments.
The comon methods used in NDT is to stretch the msucle and hold them in such a way to produce movements and normalize tone. Well here is a lesson no one teaches in college- no you cannot stop contracture by streching and abnormal postures dont go away because you make the child roll on a ball and improve righting reflex. only thing this does is make many chidren scream in pain. Postural and movements are a product of the biology interacting with the environmament. As the child is never going to on a ball like your child and mine it is preaty useless. There is no normal movement so dont be trying to bring that out. there is no normal tone so dont be trying to bring them.
IF YOUR CHILD IS CRYING DURING THERAPY YOU ARE DOING IT WRONG- AS THE CHILD IS NOT LEARNING ANYTHING EXCEPT TO THINK THIS IS HELL
Functional training? the last part of the descption
they will also do some functional training nowadays as people like me have pointed out what they are doing is rubbish. But dont get fooled- go to any therapy room and you will have children tortured on a ball or stretched for most of the time.
If you're wondering, "Well, I've seen children get better with NDT in my clinic," I have two words for you: "what if."
That is, what if you don't use NDT? Will the rate of recovery or the timeline for the child to attain milestones or functional activities, like going to school, change? the right answer if you are a clinical theapsit or a NDT therapist is “ i dont know”. However, research for the last 50 years have shown NDT does not work better than any other treatment.
The next technique they use which everyone uses is inhibiting abnormal tone and abnormal posture. For this the child is literally tortured from stretching as though there is no tommorow to putting them on a swiss ball and rolling them around.
what does it mean?
It means most of NDT consist of antiquated ideas and also has no evidence to back it up. Most of the time in spent of normalising tone, movements which cannot happen. less time on practising functional movement training.
there are many other models which have better evidence, so moving to those is the ethical way.
So, what’s the way forward?
I don't want to delve into too many details, but here’s a summary of the evidence-based approach:
Build an Alliance with Your Child: This may take time, but it's crucial.
Learn GMFC Classification: If you don't know it, learn it today. Never take on a pediatric patient without this knowledge.
Assess and Understand: Evaluate the child's abilities and set realistic expectations based on the GMFC.
Set Meaningful Priorities: Focus on outcomes that matter to the child, not just clinical metrics like tone and abnormal movements. Priorities should include practical goals like sitting, toilet training, and attending school, tailored to the child's abilities.
Practice Functional Activities: Engage the child in functional activities. Provide manual support or assistance as needed, based on what’s best for the child.
Involve Parents and Caregivers: Ensure that the practice environment includes parents and caregivers.
Create an Enriched Environment: The environment should be stimulating and child-friendly, filled with toys and opportunities for discovery learning.
Empower Parents: Teach parents how to help their children learn activities and support their development.
Acceptance of Disability: Help patients and families accept the child’s disability. This is a tough process but necessary.
Set Realistic Expectations: Understand that some things cannot be changed, such as moving from one GMFC level to another or certain movement patterns. Avoid overselling potential outcomes.
There are many unkowns in cerebral palsy rehabilitation. Have a open mind in learning about newer things. let the old be in history books.
with so much of love
Hariohm
Sir, Perfectly said. Simple n to the point.👍
Good one sir