NeuroDevelopmental Therapy in Cerebral Palsy

NDT is a technique to facilitate the movements which are not present in the Cerebral Palsy children.

Facilitation is a process in which therapist hand gives a direction to the child’s body how to move. In this technique therapist holds the complete control of child’s body weight and the movement. Therapist gives a direction to the body to shifts its COG (Center of Gravity). As the COG shifted to some direction the control over the balance in the child is lost. Therapist should teach the child how to gain control again, by shifting weight to another side. This whole procedure is the part of NDT.

Equipments used in the NDT are Ball, Bolster, or Table/Bench.

Equipments are to challenge the body weight, to help accommodation the structural deformities of the child. These facilitation techniques are used improve the postural control of the child by challenging the posture.

BOLSTER/ROOSTER: is devices which is used to for prone, sitting and sit to stand facilitating techniques. It should be firm, provides a mobile surface that is easy to control because it rolls predictably front to back when child lies prone or sit on it.

BALL: is the most challenging device for the facilitation techniques. It is not firm because it can move in any direction and the base of support is very less.
There are two type of cerebral palsy according to the tone, Hypertonic and Hypotonic. Facilitation is given according to the tone of child. Hypertonic child is given facilitation techniques to decrease its tone and to improve its posture. Hypotonic is given different facilitation to increase the tone and posture.
 

First of all we should check the child’s stage and milestones before taking in the NDT.

Neck holding is the first step which should come in the child if it is absent then just facilitate neck extensors to extend the neck. On bolster put child in prone then ask him to hold the neck in extension by facilitating trapezius muscle or taking the shoulders in retraction. On ball put child in creep/crawl positions then the same facilitation done. Facilitation on the spine can also be done to make spine in extension and neck in hold position.

Quadruped position is the next position attends by the child. In this weight bearing on all four limbs is essential. So the power on all four limb must be good. This posture is attended on the ball. We can make it more challenging by rolling the ball so that the COG of the child’s body shifts and the opposite muscles work to prevent a fall.

Pelvic control facilitation techniques can be done on the ball and bolster both. On the bolster we can make child sit and the roll the bolster to shift COG and facilitate muscles to prevent any fall. Like this we can make child sit on the ball and can move ball too to shift the base of support and facilitate muscles. On ball different positions can be attended like cross sitting, kneeling, sitting by legs open wide on ball, sitting and hands are extended and sitting with hand in overhead position. Rankly decrease base of support and increase pelvic control. In all these positions we can facilitate pelvic muscles by rolling ball, shifting base to either side, ask child to reach an object to either side, make base less supportive by tilting ball on opposite side. All these make the muscles work and repetition of this strengthen the muscles.

The main purpose of the NDT is to improve balance with less support. Facilitation technique is more effective then passive movements. Resistive exercises are difficult in cerebral palsy child because they are not so cooperative and not following commands. So the most effective technique is NDT in the cerebral palsy.

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Classifications of Cerebral Palsy

Cerebral Palsy is an umbrella term that covers a spectrum of different problems including motor control disturbance, epilepsy, vision, speech, hearing and recurrent chest infection. Once the diagnosis has been made on the basis of medical history and physical examination, child physical disability is classified for ease of communication among health professionals as well as for suggesting proper prognosis and treatment. The classification system is based on the physiology of the motor dysfunction, the number of limbs involved and the functional status of the child.

Physiological Grouping - Depending upon type of muscular control loss.

Spastic Cerebral palsy plasticity is defined as a velocity-dependent increased muscle tone, determined by passively flexing and extending muscle groups across a joint. It is the commonest type of cerebral palsy and has much better prognosis than other varieties.

Dyskinesia - Dyskinesia is defined as abnormal motor movements that become obvious when the patient initiates a movement. When the patient is totally relaxed, usually in the supine position, a full range of motion and decreased muscle tone may be found.

 Dyskinetic patients are divided into two subgroups.

The hyperkinetic or choreo-athetoid children show purposeless, often massive involuntary movements with motor overflow, that is, the initiation of a movement of one extremity leads to movement of other muscle groups. b, The dystonic group manifest abnormal shifts of general muscle tone induced by movement. Typically, these children assume and retain abnormal and distorted postures in a stereotyped pattern.

Both types of dyskinesia may occur in the same patient. Simply stated, spasticity you feel; dystonia you see. Ataxias -Patients with ataxia have a disturbance of the coordination of voluntary movements due to muscle dys-synergia. These patients may be hypotonic during the first two or three years of life. They commonly walk with a wide-based gait and have a mild intentional tremor (dysmetria). Mixed Group-- Patients in this category commonly have mild Spasticity, dystonia, and / or athetoid movements. Ataxia may also be a component of the motor dysfunction in patients placed in this group.

Hypotonic – Decrease tone in whole body. This type of cerebral palsy usually converts in athetoid or mixed cerebral palsy as time passes.

Anatomical Grouping depending upon no. and extend of limbs affected

Diplegia-  Diplegia refers to involvement predominantly of the legs. Quadriplegic refers to dysfunction of all four extremities; in some children one upper extremity might be less involved; the term triplegia then would be substituted.

Hemiplegia - Hemiplegia refers to individuals with unilateral motor dysfunction; and in most children the upper extremity is more severely involved than the lower. Finally, an unusual situation may occur, where the upper extremities are much more involved than the lowers; the term Double Hemiplegia is applied to this group of patients.

Functional Classifications of Cerebral palsy Depending upon the degree of functional independence.

• Clumsy Child. Uses no resistive devices (such as crutches), Can walk indoors and outdoors and climb stairs , Can perform usual activities such as running and jumping, Only has decreased speed, balance and coordination.

• Walks Independently. Limited in outdoor activities, Has the ability to walk indoors and outdoors and climb stairs with support of railing, has difficulty with uneven surfaces, inclines or in crowds, has minimal ability to run or jump.

• Uses Assistive Mobility Devices Walks with assistive mobility devices indoors and outdoors on level surfaces May be able to climb stairs using a railing, may propel a manual wheelchair (with assistance needed for long distances or uneven surfaces).

• Severely Limited, Self-mobility severely limited even with assistive devices, uses wheelchairs most of the time and may propel their own power wheelchair.

• No Self-Mobility.  They have physical impairments that restrict voluntary control of movement.

The ability to maintain head and neck position against gravity is impaired in all areas of motor function, children cannot sit or stand on their own even with equipment, cannot do independent mobility; though may be able to use a powered Wheel chair.

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