NDT (Neurodevelopmental Treatment) — 24 Principles Applied in Detail

What is NDT?

The 24 NDT Principles / Key Points of Control

GROUP 1 — POSTURAL TONE & INHIBITION

• Hypertonia (spasticity) is inhibited; hypotonia is facilitated
• Before any functional movement, tone must be normalized
• Technique: slow rhythmic rotation, weight-bearing through affected limb, prolonged stretch

• Positions and movements that break up abnormal synergy patterns
• Upper limb flexor synergy → inhibited by shoulder depression + external rotation + elbow extension + wrist dorsiflexion + finger extension
• Lower limb extensor synergy → inhibited by hip flexion + abduction + knee flexion + ankle dorsiflexion

• Associated reactions (involuntary movement in affected limb during effort) are inhibited by reducing effort elsewhere
• Tone-inhibiting positioning is maintained throughout activity

GROUP 2 — KEY POINTS OF CONTROL (KPCs)

• Head & neck — controls tone in the entire body (tonic neck reflexes)
• Shoulder girdle — influences upper limb tone and trunk
• Pelvic girdle — influences lower limb tone and trunk

• Hand / thumb — web space of thumb → reduces UL flexor tone
• Foot — dorsiflexion of foot → reduces LL extensor tone
• Fingers and toes

GROUP 3 — NECK CONTROL

• The head leads the body — all postural reactions begin with head righting
• Without neck control, trunk and limb control cannot be established
• Tonic neck reflexes (ATNR, STNR) must be integrated before voluntary control develops

• Patient in supine → therapist rotates head → body follows segmentally
• Develops neck righting → body-on-body righting → full rolling

• Patient sits with therapist behind
• KPC: therapist's hands on shoulders (proximal KPC)
• Facilitate head righting in all planes: anterior, posterior, lateral
• In lateral tilt → head rights vertically (labyrinthine righting response)
• In forward lean → head extends to right (optical righting)

• Tilting reactions: when body tilts, head rights, trunk curves, limb abducts on raised side
• Protective extension (parachute): head raises, arms extend forward/laterally/backward
• These are facilitated through controlled tilting on a tilt board or therapy ball

GROUP 4 — TRUNK CONTROL FOR BALANCE

• All balance reactions originate from the trunk
• Lateral trunk flexors, extensors, and rotators must be active for balance
• Core stability (deep stabilizers: transversus abdominis, multifidus, pelvic floor, diaphragm) is prerequisite for dynamic balance

• During weight shift to one side → ipsilateral trunk shortens, contralateral elongates
• NDT facilitates this through lateral weight shifts in sitting
• KPCs: shoulder girdle bilaterally or pelvis bilaterally

• Dissociation of shoulder girdle and pelvic girdle is critical
• Facilitating trunk rotation: patient in sitting, therapist rotates shoulders against stable pelvis (or vice versa)
• Trunk rotation is prerequisite for reciprocal gait and functional reaching

• Static sitting: no external perturbation, patient holds position
• Dynamic sitting: therapist introduces controlled perturbations (anterior, posterior, lateral)
• Reactive sitting: unexpected perturbations elicit automatic postural reactions

• Righting reactions: keep head/trunk upright against gravity
• Equilibrium (tilting) reactions: shift weight and adjust trunk curve and limb abduction
• Protective reactions: extend limb to prevent fall

• Patient on therapy plinth, feet flat (or on stool)
• Therapist sits behind or to the side
• KPC: bilateral pelvis → facilitate anterior pelvic tilt (lumbar extension) and posterior pelvic tilt
• Lateral weight shifts over each ischial tuberosity
• Forward weight shift: facilitates thoracic extension, posterior hip loading

GROUP 5 — SIT TO STAND (STS)

• Forward trunk flexion (lean forward from hip, not lumbar spine)
• Anterior pelvic tilt
• Weight shift forward over feet
• Ankle dorsiflexion (tibia over foot)
• Symmetrical foot placement (hip width apart, feet slightly behind knees)
• Eccentric quadriceps control on descent, concentric on ascent

• Prepare tone: normalize extensor tone in LL, inhibit extensor spasticity before STS
• Position patient at edge of plinth, hips slightly higher than knees (raises seat → easier STS)
• Feet flat, hip-width apart, slightly behind vertical of knee

• Phase 1 — Flexion-momentum: trunk forward lean over hip, pelvis tilts anteriorly, CoM shifts forward
  • KPC: therapist's hands on pelvic crest bilaterally → guide anterior tilt + weight shift forward
• Phase 2 — Momentum transfer: CoM passes forward over BOS, hip/knee extension begins
  • Therapist: hands remain on pelvis, guides vertical rise
• Phase 3 — Extension: full hip and knee extension, upright standing achieved
  • Ensure symmetrical weight bearing through both LL

• Extensor thrust: patient pushes back into extension → inhibit by slowing movement, maintaining forward trunk lean, reduce seat height gradually
• Asymmetrical weight bearing: affected LL unloaded → use mirror feedback + facilitation through affected side pelvis/knee
• Posterior trunk lean: due to hip flexor tightness or poor anterior pelvic tilt → facilitate trunk lean with hand on sternum guiding forward
• Circumduction at hip: due to extensor synergy → inhibit before STS using RIPs
• Knee collapse (valgus): weak hip abductors → KPC at knee or use hand to guide knee alignment over 2nd toe

• Reverse of STS: controlled lowering requires eccentric quadriceps
• Patient prone to drop rapidly → therapist uses pelvic KPC to slow descent
• Facilitate anterior trunk lean during lowering (same as STS Phase 1 in reverse)

GROUP 6 — FACILITATION TECHNIQUES

• Tapping: quick light tap on muscle belly → increases tone, facilitates muscle activation
• Pressure: sustained pressure on tendon/bone → decreases tone
• Compression: axial loading through joint → stimulates co-contraction and joint stability (e.g., through shoulder or knee during weight bearing)
• Placing: therapist moves limb into position, then removes support gradually → patient learns to hold (co-contraction)
• Holding: patient holds a position against gravity; therapist gives minimal assistance

• Affected UL weight bearing (e.g., hand flat on plinth beside patient) → reduces spasticity, improves proprioception, stimulates extensor tone in hypotonic limb
• Affected LL weight bearing in standing → stimulates extensor tone, activates postural muscles
• Vibration over tendon → facilitates muscle (Tonic Vibration Reflex)

GROUP 7 — SPECIFIC NDT TECHNIQUES (Points 24)

Summary of Core NDT Sequence for a Typical Patient

1. Assess tone → normalize (inhibition or facilitation)
2. Supine: inhibit ATNR, facilitate head control
3. Rolling: trunk rotation, transitional movement
4. Sitting: establish balance reactions (righting → tilting → protective)
5. Neck control in sitting: all planes
6. Trunk control: lateral shifts, rotation, elongation/shortening
7. STS: prepare pelvis, guide through 3 phases
8. Standing balance: static → dynamic → reactive
9. Gait preparation: weight shifting, step practice
10. Functional activities: incorporate all above into daily tasks

Key NDT Principles to Remember

NDT — Neck Control: Step-by-Step Demonstration

Why neck control comes first: In NDT, the head is the key proximal control point for the entire body. Tonic neck reflexes (ATNR, STNR) dominate if neck control is absent, making all other voluntary movement impossible. You must establish head/neck control before trunk, sitting, or standing work.

STAGE 1 — SUPINE: Establishing Basic Head Control

Setup

• Patient lies supine on a firm therapy mat/plinth
• Therapist kneels or sits at the head end

Step-by-Step

• Passively move the head side to side, flex and extend
• Feel for: rigidity (hypertonia), floppiness (hypotonia), or ATNR dominance (head turning causes arm extension on face side)

• Keep head in midline — this is mandatory before any movement
• KPC: Place both hands gently on the patient's head/temporal regions
• Hold head centered for 10–15 seconds until tone normalizes

• Slowly rotate the head to one side
• Observe: does the body follow segmentally (neck righting response)?
• If absent → gently rotate head → wait → assist shoulder to follow → then pelvis (teaching segmental rolling)

STAGE 2 — PRONE ON ELBOWS: Antigravity Neck Extension

Step-by-Step — Prone on Elbows

• Patient prone, elbows directly under shoulders, forearms flat
• Therapist in front of patient, face-to-face

• Place hands on bilateral shoulder girdle (posterior surface)
• Apply gentle downward compression → stimulates co-contraction → stabilizes the base so the head can move freely

• Use a visual target (bright toy, mirror) held at eye level
• Patient attempts to lift and hold head against gravity
• If unable → therapist places one hand under chin, gives minimal assistance, then removes gradually

STAGE 3 — ON PHYSIOBALL: Dynamic Neck Control

• Drape patient prone over the physioball
• Hips and chest supported by ball, arms hanging or on floor
• Therapist stands behind or to the side

• Hands cup the head gently — do NOT grip tightly
• Feel the tone in the neck muscles through your hands

• Tilt ball gently forward → head drops into flexion (gravity-assisted)
• Then bring ball back → patient must extend head to keep it level
• This is eccentric–concentric neck extensor training

• Tilt ball to the right → head should right itself to vertical (labyrinthine righting)
• If head falls with the body → patient has absent righting reaction → provide gentle facilitation to bring head to upright

• Ball tilted further → elicits protective extension of head and arms

STAGE 4 — SUPPORTED SITTING: Neck Control for Balance

Step-by-Step — Neck Control in Sitting

• Patient sits on plinth or therapist's lap (for child)
• Feet flat on floor or footstool
• Therapist sits behind the patient

• Therapist places both hands on the patient's shoulders
• Provides gentle postural support — enough to free the head to move

• Therapist gently tilts patient's trunk to the right (by depressing right shoulder)
• Head should right itself to vertical → labyrinthine righting response
• If absent → therapist uses one hand to gently guide head to vertical while other hand tilts trunk

• Therapist gently tilts trunk forward
• Patient must extend neck to keep head upright (optical righting, labyrinthine)
• Use a mirror in front so patient gets visual feedback

• Therapist slightly tilts trunk backward
• Patient must flex neck to bring head forward
• Watch for: head falling straight back (poor flexor control) vs. chin tucking first (normal)

• Head rotates independently of trunk
• KPC: hold trunk stable at shoulders → ask patient to look left, then right
• This is critical for visual tracking and eventually for gait

Summary — NDT Neck Control Progression

LEVEL 1 → Supine: midline head hold, ATNR inhibition
     ↓
LEVEL 2 → Prone on elbows: antigravity neck extension
     ↓
LEVEL 3 → Physioball prone: dynamic flexion/extension, righting reactions
     ↓
LEVEL 4 → Supported sitting: lateral righting, anterior/posterior control
     ↓
LEVEL 5 → Unsupported sitting: head control with trunk perturbations
     ↓
LEVEL 6 → Standing: head control integrated into gait and functional movement

Key NDT Handling Rules for Neck Control

NDT — 2nd: Trunk Control for Balance — Step-by-Step Demonstration

Why trunk control is second: After neck control is established, the trunk becomes the next foundation. All limb movements, balance reactions, and functional activities (including sit-to-stand) require a stable, mobile trunk. In NDT, trunk control = the ability to stabilize AND move the trunk selectively — not just hold stiffly.

CORE NDT CONCEPT: What "Trunk Control" Actually Means

STAGE 1 — SUPINE / BRIDGING: Trunk & Pelvic Foundation

Bridging

• Patient supine, knees bent, feet flat hip-width apart
• Therapist kneels beside at pelvis level

• Therapist places both hands on the pelvic crests
• Feels the asymmetry: does one side lift more? Does pelvis rotate?

• Cue: "Press your feet into the floor and lift your bottom"
• Therapist guides: equal upward lift through both hands on iliac crests
• If one side lags (common on affected side in hemiplegia) → apply upward pressure on that side

STAGE 2 — SUPPORTED SITTING: Building Trunk Stability

Setup

• Patient sits on firm plinth, edge of bed, or therapy mat
• Feet flat on floor (use a footstool if needed — feet must be grounded)
• Hips and knees at 90°
• Therapist sits behind or to the side of the patient

STEP 1 — Establish Neutral Pelvis (Anterior Pelvic Tilt)

• KPC: Therapist places both hands on bilateral iliac crests (pelvic KPC)
• Guide pelvis into anterior tilt — lumbar spine comes into mild lordosis, trunk lifts tall
• Cue: "Sit tall, let your back arch slightly, chest forward"
• Common error in hemi patients: posterior pelvic tilt, trunk collapses into flexion — always correct this FIRST

NDT rule: You cannot build trunk control on a posteriorly tilted pelvis. The pelvis is the foundation of the trunk.

STEP 2 — Lateral Weight Shifting (Most Important Trunk Control Exercise)

• Therapist's hands: one on each iliac crest (bilateral pelvic KPC)
• Gently shift patient's weight onto the RIGHT ischial tuberosity
• Patient should feel RIGHT buttock loading into the plinth

• Normal response: RIGHT trunk elongates (lengthens), LEFT trunk shortens
• Abnormal: whole trunk tips like a rigid block with no lateral curve → needs facilitation

• Therapist's right hand: on right iliac crest pushing DOWN (loading)
• Therapist's left hand: on left ribcage, gently LIFTING upward to encourage left shortening
• This creates the lateral curve artificially until the patient's muscles learn it

• Add a reach: place a toy/object to the RIGHT → patient reaches right → weight naturally shifts right
• Then place object to LEFT → patient reaches left → weight shifts left
• Reaching is the most natural way to drive trunk weight shifting

STEP 3 — Anterior Weight Shift (Forward Lean)

• Patient sitting, therapist behind with hands on iliac crests or bilateral shoulders

• Guide trunk forward from hip joint (NOT lumbar spine)
• Anterior pelvic tilt must be maintained throughout — watch for lumbar rounding
• Cue: "Lean forward from your hips, not your back"

• Patient holds forward lean 3–5 seconds
• Returns to upright under control (eccentric trunk extensors)
• This directly prepares for sit-to-stand Phase 1 (momentum phase)

STEP 4 — Trunk Rotation (Dissociation)

• Therapist sits in front of patient (or to side)
• KPC: hands on bilateral iliac crests — hold pelvis STILL

• Ask patient to turn shoulders to the right while pelvis stays forward
• Therapist's hands on iliac crests RESIST any pelvic rotation
• Observe: can the patient rotate shoulders independently of pelvis?

• Therapist now holds bilateral shoulder girdle stable
• Ask patient to rotate pelvis/hips to the right
• This dissociation = prerequisite for reciprocal gait

STAGE 3 — DYNAMIC SITTING ON PHYSIOBALL: Reactive Trunk Control

Step-by-Step — Physioball Sitting

• Patient sits on ball, feet flat, hip-width apart
• Ball size: hips = 90°, knees = 90°
• Therapist stands to the side or behind

• Gently roll ball forward → patient's trunk must extend to maintain upright
• Roll ball backward → patient's trunk must flex to maintain balance
• Roll ball left/right → trunk lateral righting reactions triggered automatically

• KPC: hands on bilateral iliac crests OR bilateral shoulder girdle
• Use slow rhythmic perturbations — ball is already doing the work
• Grade: begin with small controlled movements → progress to unexpected perturbations

STAGE 4 — BALANCE REACTIONS IN SITTING (3 Types)

1. Start with righting reactions (slowest, most controlled)
2. Progress to tilting/equilibrium reactions (medium speed)
3. Finally introduce protective reactions (fast, functional)

Full Trunk Control Progression in NDT

LEVEL 1 → Bridging (supine): pelvic control, posterior chain
     ↓
LEVEL 2 → Supported sitting: neutral pelvis, static hold
     ↓
LEVEL 3 → Lateral weight shifts: elongation + shortening
     ↓
LEVEL 4 → Anterior weight shift: forward lean from hip
     ↓
LEVEL 5 → Trunk rotation: dissociation of shoulder/pelvic girdle
     ↓
LEVEL 6 → Perturbations: righting → tilting → protective reactions
     ↓
LEVEL 7 → Physioball: dynamic reactive trunk control
     ↓
LEVEL 8 → Sitting + reaching: functional integration
     ↓
LEVEL 9 → Transition to SIT-TO-STAND

Key NDT Handling Rules for Trunk Control