Neurodevelopmental (NDT) Frame of Reference and Sensorimotor Approaches in OT
The NDT (Bobath) frame of reference explained, with Rood, Brunnstrom and PNF sensorimotor approaches, key principles, examples and what the evidence says today.
When the brain or spinal cord is damaged, as in cerebral palsy, stroke or traumatic brain injury, the problem isn’t just weakness: muscle tone, posture and the control of movement change. The neurodevelopmental (NDT) frame of reference and other sensorimotor approaches were developed for exactly these situations.
If you’re new to frames of reference, start with our frames of reference guide.
What is the neurodevelopmental frame of reference?
The neurodevelopmental frame of reference, also known as NDT or the Bobath concept, was developed by physiotherapist Berta Bobath and neurologist Karel Bobath in London from the 1940s. It began with children with cerebral palsy and was later applied to adults after stroke.
NDT views movement problems in central nervous system (CNS) damage as a result of changes in tone, posture and coordination. The therapist uses handling to guide the person towards more efficient, typical movement during functional activities.
Theoretical base
Early NDT drew on a hierarchical, reflex-based view of the nervous system. Over time, the Bobath concept has moved towards systems and motor learning theories, putting more emphasis on function, active participation and practice in real tasks.
Key assumptions:
- CNS damage disrupts posture, tone and movement control.
- Abnormal patterns of movement and tone interfere with function.
- Through handling and guided experience of more typical movement, the nervous system can learn more efficient patterns.
- Movement should be practised in meaningful, functional tasks.
Function–dysfunction continua
| Area | Function | Dysfunction |
|---|---|---|
| Muscle tone | Tone appropriate for posture and movement | High tone (spasticity) or low tone (hypotonia) |
| Postural control | Stable, upright posture with balance reactions | Poor trunk control, asymmetry, falls |
| Movement patterns | Selective, varied, efficient movement | Stereotyped synergies, compensatory patterns |
| Function | Uses both sides of the body in daily tasks | Neglects or avoids the affected side |
Evaluation
The OT observes posture and movement in sitting, standing and during tasks, looking at:
- alignment and symmetry
- muscle tone at rest and in movement
- balance and righting reactions
- quality of reaching, grasping and release
- how movement affects self-care, play or work
Intervention principles
-
Prepare
Positioning and alignment; reduce excessive tone through movement.
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Handle
Hands on key points of control (shoulders, trunk, pelvis).
-
Facilitate
Guide the person through more typical movement.
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Fade
Reduce hands-on support as the person takes over.
-
Function
Practise in a real task: reaching for a cup, dressing, play.
- Key points of control: usually proximal (shoulders, trunk, pelvis), from which the therapist influences the whole body
- Facilitation: guiding more typical movement and active participation
- Weight bearing: through the affected arm or leg to promote awareness and stability
- Positioning: in sitting, lying and standing to support alignment
- Functional practice: carrying the movement into everyday occupations
Other sensorimotor approaches
| Approach | Developed by | Key idea | Example techniques |
|---|---|---|---|
| NDT (Bobath) | Berta and Karel Bobath | Handling to improve posture and movement quality | Key points of control, facilitation, weight bearing |
| Rood approach | Margaret Rood (OT and PT) | Sensory stimulation can facilitate or inhibit muscle activity, following developmental motor sequences | Fast brushing, tapping, icing (facilitation); slow stroking, neutral warmth (inhibition) |
| Brunnstrom movement therapy | Signe Brunnstrom (PT) | Recovery after stroke follows predictable stages; synergies are used as a stepping stone | Using synergy patterns, then moving out of synergy |
| PNF (proprioceptive neuromuscular facilitation) | Herman Kabat, Margaret Knott, Dorothy Voss | Movement in diagonal, spiral patterns with proprioceptive input | D1 and D2 patterns, rhythmic initiation, hold-relax, contract-relax |
Brunnstrom’s stages of motor recovery
Recovery ↑
-
Stage 6: Isolated joint movements6
Coordination close to normal.
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Stage 5: More complex combinations5
Movement increasingly independent of synergies.
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Stage 4: Spasticity declines4
Some movement out of synergy.
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Stage 3: Spasticity peaks3
Synergies performed voluntarily.
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Stage 2: Synergies and spasticity begin2
Minimal voluntary movement.
-
Stage 1: Flaccidity1
No voluntary movement.
Early
Some sources add a seventh stage: normal motor function. Recovery may stop at any stage.
PNF diagonal patterns (upper limb)
| Pattern | Flexion | Extension | Functional example |
|---|---|---|---|
| D1 | Flexion, adduction, external rotation (hand to opposite ear) | Extension, abduction, internal rotation (hand down and out) | Eating, combing hair on the opposite side |
| D2 | Flexion, abduction, external rotation (reaching up and out) | Extension, adduction, internal rotation (hand to opposite hip) | Reaching to a high shelf, putting on a seat belt |
What does the evidence say?
- In cerebral palsy, a major systematic review (Novak et al., 2013) found weak, low-quality evidence for NDT. Approaches with stronger evidence included constraint-induced movement therapy (CIMT), bimanual training, goal-directed training and home programmes.
- After stroke, a systematic review (Kollen et al., 2009) found no evidence that the Bobath concept is superior to other approaches.
- Modern practice therefore often combines NDT handling skills with motor learning and task-oriented practice.
NDT vs related frames
| NDT | Biomechanical | Motor learning | |
|---|---|---|---|
| For | CNS damage affecting tone and control | Intact CNS; limits in range, strength, endurance | Learning or relearning motor skills |
| Therapist role | Hands-on handling and facilitation | Graded exercise and activity | Coach: practice, feedback, task variation |
| Example | Facilitating trunk alignment while a child reaches | Graded putty for grip after a fracture | Repeated practice of dressing with faded feedback |
Case example
Aarav, 6, has spastic diplegic cerebral palsy. He sits with a rounded back and finds it hard to reach forward to play.
- NDT: the OT handles at the pelvis and trunk to support upright sitting while Aarav reaches for blocks, gradually fading support.
- Biomechanical: a supportive chair with a footrest and a slanted table for positioning.
- Motor learning and goal-directed training: daily practice of Aarav’s own goal, building a Lego tower at school, with varied tasks and feedback.
Quick self-check
0 / 3 correct
-
Key points of control in NDT are usually…
Show answer
B. Therapists usually handle at proximal key points to influence posture and movement throughout the body.
-
Which approach uses D1 and D2 diagonal patterns?
Show answer
C. PNF uses diagonal, spiral movement patterns, D1 and D2.
-
In Brunnstrom stage 3…
Show answer
B. Stage 3: spasticity is at its peak and the person can perform synergy patterns voluntarily.
Summary
The neurodevelopmental frame of reference and other sensorimotor approaches were developed for people with central nervous system damage. NDT uses handling and facilitation to improve posture and movement quality in functional tasks; Rood, Brunnstrom and PNF add other sensorimotor tools. Because evidence for these approaches is weaker than for task-oriented methods, today’s OTs usually combine them with motor learning and goal-directed practice. Read more about OT for stroke and OT for children.
References
- Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed. Butterworth-Heinemann.
- Novak I, McIntyre S, Morgan C, et al. A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental Medicine & Child Neurology. 2013;55(10):885–910.
- Kollen BJ, Lennon S, Lyons B, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence? Stroke. 2009;40(4):e89–e97.
- Pendleton HM, Schultz-Krohn W, eds. Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction. Elsevier.
- Brunnstrom S. Movement Therapy in Hemiplegia: A Neurophysiological Approach. Harper & Row; 1970.
- Kramer P, Hinojosa J, Howe TH, eds. Frames of Reference for Pediatric Occupational Therapy. Wolters Kluwer.
Frequently asked questions
What is the neurodevelopmental frame of reference?
Who developed NDT?
What are key points of control in NDT?
What are Brunnstrom's stages of motor recovery?
Is NDT evidence-based?
What is the difference between NDT and the biomechanical frame of reference?
Written by
Deepam Pawar, OT
Deepam Pawar is an occupational therapist and co-founder of Occupational Therapy OT. He focuses on clinical frameworks, assessment, and evidence-based practice.
All articles by Deepam →This article is for general education and is not a substitute for individualized assessment or treatment by a licensed occupational therapist. Always seek the guidance of a qualified professional for specific concerns.
