MEMBER SPOTLIGHT: SEPTEMBER/OCTOBER 2018
Stacy Kirsch, MS, OTR/L, C/NDT, CKTP
The Neuro-Developmental Treatment Association was fortunate to have Stacy Kirsch present a poster at the NDTA Conference in Salt Lake City in May 2018. Her poster was “Planning and Outcomes of a Two Week NDT Intensive for Children with Cerebral Palsy Using the Goal Attainment Scale and Other Outcome Measures.”
Stacy began taking NDT courses shortly after she graduated from OT school. Her first course in 2010 was with Gail Ritchie, OT, and Rona Alexander, SLP. The course was on NDT principles and treatment of the upper extremity, shoulder, and rib cage. At the time, her main clientele were children with brachial plexus injuries. From the upper extremity, shoulder girdle, and ribcage course, she learned how to slowly prepare the pectoralis muscle for elongation and activate the posterior shoulder and scapular retractors to help children with brachial plexus injuries reach outwards and away from their bodies to help improve upper body dressing and play skills.
Stacy worked with one child who had significant difficulty with horizontal abduction, often rotating at her thoracic spine and elevating her rib cage to move her arm outwards. With time, preparatory work, and facilitation of her shoulder with elongation of her rib cage, her reach improved with less trunk compensation.
In 2014, Stacy completed the 8-week “NDT/Bobath Certificate Course in the Management and Treatment of Children with Cerebral Palsy and Other Neuromuscular Disorders,” which she reports has changed how she observes and treats her patients. She reports that she loves how a little touch of her hands can change a child’s posture and movement to help them to be more efficient in their daily life.
Stacy currently works at New York University’s Langone Orthopedic Hospital in the Rusk Outpatient Pediatric Clinic. Taking her pediatric NDT certification course led Stacy to eventually pitch the idea of an intensive NDT-based occupational and physical therapy program to her supervisors. She based this idea on a comprehensive plan backed by evidence from a literature review on NDT and the advantages of an intensive program. Supported by a grant that she applied for from her hospital’s foundation to help offset uncompensated costs, Stacy and her coworkers ran a two-week, 45 minute per discipline per day intensive therapy program that used NDT principles. Using a variety of outcome measures, including the Goal Attainment Scale for pre-test and post-test data, Stacy and her coworkers were able to demonstrate positive changes in their clients following this two-week NDT intensive program.
Stacy feels that NDT helps clinicians evaluate function and impairments and identify realistic goals for each individual client. In her own words, “Using my hands to help facilitate success with an activity is so rewarding, and it’s even more rewarding when you can teach some of these techniques to parents. I believe that a certified NDT therapist has so much potential to exponentially learn and grow as a clinician. Though it’s a journey to become NDT certified, in the end it’s worth every moment.”
Stacy can be reached at firstname.lastname@example.org or email@example.com
INSTRUCTOR SPOTLIGHT: SEPTEMBER/OCTOBER 2018
Pam Mullens, PT, PhD, C/NDT
For this profile I had the privilege of interviewing Dr. Pam Mullens. Pam was one of the founding members of the NDT Instructors Group and of NDTA. She became an NDT instructor for pediatric courses in 1968 and for courses for therapists working with adults with stroke and brain injury in 1972.
Pam began working with children with cerebral palsy in a public school setting. At that time, children with cerebral palsy (CP) were treated with orthopedic methods (bracing, surgery, and exercise) or with strategies previously used for intervention with children with polio. However, intervention was changing due to the influence of innovative therapists working independently of each other in clinical and academic settings. These pioneers observed that children with cerebral palsy and other neurological conditions displayed underlying impairments differing from those of children and adults with orthopedic conditions. Consequently, they were developing intervention to address these differences. Among these leaders were Berta Bobath, Jean Ayres, and Margaret Rood. Interest in this emerging work was so intense that the American Physical Therapy Association held a meeting of university faculty in Chicago to examine these developing approaches (NUSTEP 1966).
It was this atmosphere of excitement, innovation, and change that sparked Pam's interest in NDT. She applied to take the course from the Bobaths in London and was accepted for the summer of 1967. However, another opportunity presented itself. Leila Green, who was among the first therapists from the US to take the Bobath course, invited Dr. and Mrs. Bobath to come to Milwaukee, Wisconsin, in the summer of 1966 to teach a course. Some places in the course were open to therapists from outside of Wisconsin. Pam and another staff member from the school, Nancy Kahn, OTR/L, applied together and were accepted for the course. Thus began a never-ending journey of learning and exploration of the multiple components of the NDT approach.
Following the course, Nancy and Pam returned to the school and began the exciting task of applying what they had learned. One year later, they went together to London for further instruction from the Bobaths. Pam attended the entire course for a second time and Nancy attended a refresher course. In conjunction with the Boyer Clinic in Seattle, they invited Dr. and Mrs. Bobath to come to Seattle to give a full course. In 1968, the Bobaths came and taught the first week of a full pediatric course. Nancy and Pam, together with Suzanne Morris, who taught the speech component, completed teaching the course.
I asked Pam how NDT has shaped her treatment over the years. What original concepts from the Bobaths continue in her practice model? She replied that the NDT course set her on a path of learning that continues today. “One of the basic tenets of the NDT approach is that it is a problem-solving approach. Mrs. Bobath asked these questions during her initial assessment for each child. What can the child do? How does s/he do it, and why? What can s/he not do and why?” She made abundant use of the question why. These questions are still inherent in the NDT Practice Model in the evaluation based on the International Classification of Function, Disability and Health (ICF model) that is used today.
The question why led to an understanding of the body system impairments and contextual factors contributing to the activity limitations. Understanding the factors underlying each individual’s functional deficits and selecting appropriate intervention is a process requiring never-ending learning and experience. Pam felt that many factors helped in this process. Beginning her work with children with cerebral palsy at school age was helpful in understanding the progression of impairments that became stronger over time and eventually produced loss of function. When her work situation changed from the school to a preschool setting, she saw these same impairments (such as protraction of the shoulders) but at a lesser intensity. Work with infants gave deeper insight in to the development of normal and abnormal movement and its effect on the development of functional activity.
Pam stated that she was fortunate to study the NDT approach to treatment of infants with Dr. Elspeth Kong and Mary Quinton, FCSP, from Switzerland. Their teaching of normal and abnormal development helped develop her understanding of the earliest beginnings of cerebral palsy and the refinement of treatment strategies needed to promote normal development and prevent the development of inefficient movement strategies. Pam's experience in working with a number of individuals with CP from infancy to adulthood has sparked her interest in a lifespan approach to the treatment of individuals with CP. She now teaches courses on this topic.
In response to the question of what advice she would give to a younger clinician working with people with stroke or with children or adults with CP to improve their skills, her reply was, “If you have not taken the NDT course, take it. People often tell young therapists that they do not need to take the course. I have not taken another course that teaches such a thorough understanding of the development of secondary impairments and analysis of normal and abnormal movement development. The NDT Practice Model shows the processes of problem solving that lead to the selection of effective treatment strategies. In addition, the NDT course provides opportunities to treat children or adults under the supervision of skilled instructors, to discuss the effectiveness of your intervention, and to receive guidance in the sequencing and progression of treatment. This is a learning experience not to be missed.
“In addition, I would suggest working with children of all ages. Cerebral palsy is not a static condition. The manifestations change over the lifespan and intervention includes strategies for improvement of function and also the prevention of secondary impairments that may produce activity limitations over time. If you have not observed older children and adults, it is hard to see the importance of addressing mild and apparently insignificant impairments in infants and very young children that may become limiting factors over time. It is not easy for therapists working in birth-three programs to see older children, but it is an important component of learning. Choose a work environment where all staff are eager and encouraged to learn and where continuing education is encouraged and supported.”
On the personal side, Pam talked about how she developed an interest in physical therapy. Through piano lessons! Pam was in her final year of high school and was considering a choice of career paths. Her piano teacher had suggested that she pursue a career in music and attend the Royal Academy of Music in London. However, in conversation at the end of a piano lesson, the teacher told her that during World War 1 she had worked as a nurse in the Red Cross and had received training in massage and remedial exercise. She described her work with soldiers with hand injuries and other musculoskeletal injuries and the success she had in working with these patients. Pam was very interested and asked her to tell more about her experience with this work. As a result, Pam began researching a career in physical therapy. She went to the physical therapy department at a local hospital, talked with physical therapists, read books on the topic, and decided to go to PT School.
Pam said that she had a number of mentors in addition to the Bobaths. One of her instructors in PT School, Deena Gardner, taught kinesiology and analysis of movement. Another mentor with whom she had only a brief contact was Elizabeth Zausmer. Although she saw Ms. Zausmer only briefly at a course on the treatment of people with polio, the memory of her instruction is still very clear in her mind. She performed a muscle test on a very young infant by testing reflexes and postural reactions. Pam was amazed and intrigued by this and by Ms. Zausmer's ability to detect abnormal responses caused by muscle weakness. This sparked her interest in working with children. At that time, she was working in a hospital setting mostly with adults.
Other mentors included Dr. Kong and Ms. Quinton, whose influence has already been mentioned. People who helped improve her treatment skills included therapists from Switzerland who came to Seattle and shared their expertise and their friendship with the NDT group in Seattle. She also said that other instructors with whom she taught increased her understanding of NDT, and then she acknowledged the many children and adults and their families with whom she has worked whose input increased her learning and her ability to apply and to teach NDT.
Jacqueline Grimenstein, PT, C/NDT, CKTP, who interviewed Dr. Mullens, can be reached at firstname.lastname@example.org