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In Pursuit

By Kara Lardinois, PT, DPT, C/NDT

Reflect on pastimes of the 1980s and you may remember a popular game called Trivial Pursuit. This game was played with a box of cards each containing a set of questions, which each team tried to answer. Sports and Leisure, History, Language... some questions were easy and others were difficult. As my aunts, uncles, and grandparents played this game, I eagerly anticipated the next question, thinking maybe, just maybe, I would know the answer. What I didn't know then was that my career as a therapist would find me seeking "the answers" with even more conviction than I felt in the game I played with my family. As a therapist, I always hope to have an answer for the clinical questions that come my way.

Are there other therapists out there who have felt like clinical practice is similar to a game of Trivial Pursuit? We entertain questions such as: Why does this child move that way? What is the best treatment strategy for that problem? How do I know this treatment strategy is working? Will the child I am treating be able to walk?

In physical therapy school, my professors emphasized main points, as it was nearly impossible to prepare me for the depth and breadth of clinical problems that lay ahead. I learned that certain interventions are helpful, in general, for clients with certain problems. One piece of sound advice, however, still rings in my ear. Don't fall down that slippery slope to mediocrity, one of my professors would say. We were encouraged to never stop asking questions.


We were encouraged to never stop asking questions.

Early in my career, I found APTA's Guide to Physical Therapist Practice (Guide) to be helpful as I began to evaluate and treat children with cerebral palsy. The Guide helped me to recognize general categories of impairments, such as decreased strength or decreased coordination. I then implemented exercises and activities to address those general impairments. I could see functional limitations, and I anticipated that the sum of all the interventions would lead to improved function. Over time, I realized that the problems I was trying to solve, the questions I was trying to answer, with respect to children with cerebral palsy and other neuromotor disorders, were not that cut and dry. The answers were not so black and white. Some children responded well but others had more complex presentations. I found myself feeling stuck, especially with children with more significant physical challenges. I continued to attempt to field questions from parents, students, and colleagues who were seeking advice from a seasoned therapist. I also questioned myself. I realized that after practicing for nearly nine years, I had questions that I didn't know how to answer. I had found some techniques that worked, but I just wasn't sure if my hands were in the best place, doing the best thing. I wanted to know more. I wanted a change of pace. I wanted to stay away from that slippery slope to mediocrity.

The Guide provides appropriate boundaries for designing and implementing a PT plan of care, but it is not, nor is it intended to be, a tool for treatment planning. NDT provides a problem solving approach to treatment that starts with observation of posture and movement, leading the therapist to hypotheses regarding treatment strategies. I completed the pediatric NDT certification course last year. The NDT approach has helped me to plan treatment sessions more effectively. Here are two examples of how the NDT approach influenced my thought process as I planned treatment sessions for two of my clients.

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My Problem-Solving Process Using NDT with Two Clients
Meet Nadia
Nadia is a two-year-old girl with cerebral palsy and schizencephaly. She delights in communicating with her family and peers through eye contact, facial expression, and soft vocalizations. When I evaluated her, she had significant difficulty holding her head upright, even in supported sitting. In sitting, she required trunk support and exhibited posterior pelvic tilt, spinal flexion, shoulder internal rotation, scapular abduction, elbow flexion, knee extension, and ankle plantar flexion. With input from her parent, I set a functional goal detailing ideal bench sitting posture with trunk support, with head lifted to make eye contact with a person in order to communicate. I knew this stable sitting position would be important for sitting on the toilet, eating, reaching, and learning to rise up to standing.

I decided to address her impairments of decreased extensibility in pectorals first. Her difficulty co-activating gluteals and obliques was an impairment that I had begun to recognize easily in many of my clients. With another client with similar impairments and functional limitations, I had found sidelying on a large ball to be an ideal position to facilitate co-activation of gluteals and obliques. When I tried this strategy with Nadia, she remained inactive through her trunk. There was minimal to no difference in her sitting posture at the end of this session. A different strategy was required.

Left: Nadia looks for someone playing "peek-a-boo" as her therapist facilitates thoracic extension/rotation. Middle: Nadia sitting with intermittent facilitation toward the end of her physical therapy session. Right: Nadia initiates stepping with her mom.
I made note of Nadia's tendency to initiate movement muscles before muscles of postural control, specifically her tendency to activate pectorals before obliques, gluteals, and multifidi. I decided to try facilitation of trunk extension/ rotation to address three impairments: initiation of movement muscles before muscles of postural control, difficulty sustaining muscles of postural control, and decreased extensibility in pectorals. I had some hesitation that this would work, since Nadia required at least intermittent head support in most positions, and this strategy demanded some level of control in all three planes. In the past, I would have chosen a more simple strategy for such a complex scenario. To my surprise and delight, Nadia was able to maintain her head position without support intermittently as we practiced trunk extension rotation over the next two sessions.

She is now improving her ability to sustain midline head control in bench sitting, with more optimal trunk and pelvis alignment. I have noticed that she is more visually attentive to her environment when she is upright, so I consider this in treatment planning.

Now Meet Emma
Emma is an 8-year-old girl with Rett Syndrome, scoliosis, and seizures. Over the past few sessions, I have been working with Emma on the transition from sitting to standing. In bench sitting, I initially observed a posterior pelvic tilt with asymmetry, pelvic elevation on the left, lateral lumbar and thoracic flexion to the left, scapular elevation, elbow flexion, hips flexed 90 degrees and slightly abducted, knees flexed 90 degrees, right hindfoot varus with ankle inversion and midfoot supination. As I held her above the elbows to assist her to standing, she did not move until I initiated the transition by lifting gently on her arms. She responded with a posterior weight shift, partial hip extension, and knee extension. Her pelvis remained tilted posteriorly and she remained flexed through her lumbar and thoracic spine.

Before my NDT certification course, I was satisfied with this strategy for assisting Emma because she required minimal assist and I could not envision her being able to initiate the transition on her own. In the NDT course, I began to see children with significant neuromotor problems improve alignment and become active. I pictured in my mind how this task for Emma would be ideally performed and set the following functional goal: Emma will initiate rising from bench sitting to standing, with pelvis moving anteriorly, lumbar and thoracic spine neutral, with forward weight shift, with hindfeet neutral and ankles moving into dorsiflexion, with minimal assist from therapist.

I hypothesized that lateral weight shifting to the left in sitting would be important to address her asymmetry. She needed to sustain co-activation of multifidi, gluteals and obliques to hold her trunk upright, just as Nadia did. However, her initial posture was different. Although the impairment of sustaining co-activation was similar, I considered Emma's differences in terms of body system involvement and her reliable, relatively quick response to my facilitation. In addition, the functional goal I was working to achieve with Emma was different than the goal I was working to achieve with Nadia.


With Emma, I facilitated prone to sit transitions on the ball with an emphasis on transitions over her left side. Next I facilitated the transition from sit to stand using distal humerii as the key point of control, providing slight shoulder external rotation and input toward her thorax. She demonstrated slightly improved alignment in her thoracic spine but her pelvis remained tilted posteriorly and her first response came from her upper body, not from her lower extremities. Based on what I felt with my hands and what I observed, I knew that Emma was not yet initiating the transition by activating her base of support.
Left: Emma is active during the transition from sidelying to sit. Middle: This is the distal key point of control that is effective for Emma to activate her base of support. Right: Emma completes the transition to standing.

As I considered Emma's response, I recalled how she had become more active over the past few months when she was positioned in left sidelying in response to the weight of her body as I guided her transition from lying to sitting.

I knew that the interventions to address her core activation and alignment were a priority, but I wondered if her difficulty generating pressure through her lower extremities into the floor needed my attention. In the next session, I placed my forearms on her proximal femurs and my hands on her gluteals, but I felt like I was lifting her. I changed my key point of control to her distal femurs and waited. She responded with a small phasic burst, co-activating her gluteus maximii and her quadriceps. I kept my hands in the same place and involved a colleague to give light input to Emma's gluteals. Working together, with minor adjustments based on what we felt, we were able to feel and see Emma activate her base of support. She is on her way to meeting her goal.

Reflections on Treatment Choices
I have the privilege as a therapist to see children make positive changes in terms of posture, movement, and function. I have learned that if two children have similar functional limitations, one treatment strategy may not work the same way with each child. This is because each child has specific, not general, body system impairments. Each child also presents with his or her own specific motivations and contextual factors. Treatment strategies that are not effective now prompt me to look for alternative explanations, reconsidering my previous conclusions. Are there impairments in another body system that I need to reconsider? Should I change the child's position? Should I modify the amount of input or the key point of control? As therapists, we can be certain that asking questions is just the beginning of our pursuit for answers. I wish that the problem solving that assists me in my treatment today had worked when I tried to answer those Trivial Pursuit questions!

Kara Lardinois, PT, DPT, C/NDT is a physical therapist at Duke Children's Hospital and Health Center. She can be reached at spore001@mc.duke.edu.



 

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