INSTRUCTOR SPOTLIGHT: July/August, 2020
Kim Westhoff, OTR/L, C/NDT
Kim is a pediatric occupational therapist (OT) instructor for the NDTA. Her interest in occupational therapy began at an early age. She grew up accompanying her mother to work as an activity director at a nursing home. She loved going to work with her, helping and interacting with the residents. She enjoyed it so much that she spent her summers working in the nursing home both as a certified nursing assistant and in the kitchen, whichever position was open at the time.
Kim grew up on a farm in the country with a love of animals. Her plan was to become a veterinarian, but during her senior year she decided to explore what other careers might be available. During this search she came across occupational therapy. She thought it sounded a lot like what her mom did at the nursing home, and she loved working with the geriatric population. To be sure, she volunteered at a rehabilitation center and fell in love with the work. She applied to OT school and her journey began.
As a young college student, Kim was first exposed to NDT by a guest speaker for one of her classes. This skilled and articulate therapist shared about NDT and how she utilized it to impact her clients and their function. “I remember thinking, ‘Wow! This really makes sense to me and I want to learn more.’ It was early in my education of becoming an OT, but her input and exposure to NDT excited me and planted the seed of desire to learn more about it.” At the end of program, she did her Level II clinical experiences, where she worked in different settings for twelve weeks. Her final clinical was in a pediatric setting, and her supervisor was NDT trained. Her experience with this supervisor further fueled her to learn this advanced, specialized training for the benefit of her patients.
Kim is currently in private practice, serving clients in their natural environments. Approximately 80% of her clients are in early intervention and the remaining 20% range from 3-21 years of age. She treats in different natural environments: homes, private daycares, commercial daycares, preschools, etc. Over the years, she has worked in a variety of settings. Initially, she started out working in a large specialized school that had students both in self-contained classes as well as students in regular education within their local schools. This provided her with the opportunity to work with children 3-21 years of age with a variety of diagnoses and needs. In addition, she did extra work after school hours with children who attended parochial schools but needed occupational therapy services. Since she was a young therapist, she additionally did contract work for a home health agency to gain more experience.
After several years of practice and getting married, she moved to a new city, and so changed work environments. There, she worked in a hospital setting, where her main role was to develop and set up an outpatient program, revise and develop various new follow-up clinics (children traveled to their hospital from all around their rural state), assist in acute care coverage, and establish treatment protocols, as well as covering when needed for in-patient pediatric rehabilitation. Later she went into private practice and opened an outpatient independent clinic (having occupational, physical, and speech therapists on staff) serving children both in the clinic and their natural environments.
Eventually, she left her large practice to become an independent contractor, where she has been practicing for the last twenty years. A few of the peers she interacts and treats with are NDT trained, plus several others who have had various short courses about NDT. When treating with other NDT-trained therapists, she finds it easy to work together because they have the same philosophy, focus, and approach as she does. “Having the luxury of treating with peers who think like you makes it easy to ask questions, look deeper at what is really going on with your patients, and continually analyze what you are seeing. As a result, it is easier to establish goals with both the family and my peers, all to the benefit of the child. I find these patients often demonstrate progress at a faster rate than those who don’t share such a valuable team. I feel these changes are seen due to everyone working on what is the most meaningful, functional skills for that child.
“As OTs, we have always looked at human occupation within functional tasks and delved deeper into the task analysis aspects. Throughout occupational therapy history, we have looked at the individual and sought to find what is meaningful to each person, all while addressing the arm, hand, sensory, and perceptual aspects impacting everyday tasks. OTs include current science concepts within their treatment, and NDT helps give us a frame of reference to further understand and apply these principles of neuroscience, biomechanics, motor development, motor control, and motor learning theories as they impact the posture and movement systems. This ultimately impacts our arm and hand function within daily living activities. Through the eyes of an NDT framework, I can further analyze what I see as an OT and why and what impact it is having to get more specific in my goals for each individual client.”
Naturally, as an OT, Kim feels strongly that the sensory systems have a huge impact on our daily functioning. “Integration of information from our different sensory systems is what enables us to make sense of the world around us and provides us with a way to engage and bond with others. As Jean Ayres first taught us, our nervous system is continually taking in sensory information, interpreting it, and responding to it in order to make an adaptive, meaningful response. This sensory processing is something that goes on continually and simultaneously within our nervous system. Sensory processing begins in utero, where the nervous system first begins to learn and respond to different input. Following birth, our life experiences are impacted by how our sensory systems (sensation) respond to our environment and in turn how we respond (our perceptions) to our environment based on our experiences in life.
“The visual system is one of the sensory systems that as NDT clinicians we can utilize to further enhance our sessions. The visual system provides us with fastest access to our world and functions to provide us with anticipation/adaptations and helps integrate the other sensory systems. Just as motor integration must be functional sensory integration must be functional. As NDT clinicians, we can use our understanding of the posture and movement and utilize what we know about sensory processing to optimize posture and movement performance. Sensation adds intention to the active motor movement.”
Because of all her training, Kim chose to pursue becoming an NDT OT instructor. She enjoys being an instructor because she has a strong passion for NDT and loves sharing with others the things NDT has taught her throughout the years, including the tremendous impact it has had on her clients. As an instructor, she has the privilege of meeting and learning from others throughout the world, all to the benefit of her patients. Teaching provides the opportunity not only to share and learn from others, but it is an avenue to reach and impact so many more clients (in this case, kids). She enjoys the collaboration and team approach that is an important aspect of NDT intervention. Being a part of the NDT Instructor Group enables her to learn from so many wonderful, wise friends and continue to grow both as a clinician and as an instructor.
Kim offers these final thoughts. “I feel overall as an OT I have grown exponentially as a clinician as a direct result of my NDT training and approach. It has taught me to be a keen observer, sensitive to my clients as individuals (long before it became a common thing), and focus on the individual’s needs and meaningful function. My journey within the realm of NDT has brought me the opportunity to learn from many intelligent and fantastic clinicians from all therapy disciplines. There have been so many wonderful teachers and mentors along the way and several that I can now call friends. Most importantly, I have had the joy and privilege to work with so many children and their families. It is truly a gift and a privilege that all these families open their lives to share their children with us. It is an honor to serve them, and it is not something I take lightly. Therefore, I approach all my children with love and an open mind so I can learn from them and better understand how I can have a positive impact on them.
“I also feel strongly that I would not be the clinician I am today or be able to be an effective instructor if it were not for the love and support that I have from my husband. He is supportive, encouraging, and willing to be a single parent when I am gone traveling for my teaching and during the many hours of phone conferences or virtual platforms working on different aspects within the NDTA Instructor Group.”
INSTRUCTOR SPOTLIGHT: May-June, 2020
Lezlie Adler, MA, OTR, FMOTA, C/NDT
Lezlie is an internationally recognized and respected clinician and consultant with extensive and broad experience in medical, educational, and community-based settings. As a pediatric occupational therapist, she has practiced in schools, hospitals, outpatient clinics, homes, community organizations, and nursing homes for children. Since 1976, she has conducted over 500 seminars throughout the United States, Europe, Asia, Australia, New Zealand, South America, Central America, Canada, and the United Arab Emirates on a large variety of topics related to children and families with an emphasis on Neuro-Developmental Treatment, emphasizing upper extremity and hand function, daily living skills, play, and sensory integration.
Like many therapists, it took Lezlie a while to find her niche. She states, “I had a few false starts as an occupational therapist before I found an area of specialty that was a perfect fit. Once I began focusing on children and young adults with neuromuscular challenges, I realized my only clinical skill was making them laugh.” This began her career in pediatric occupational therapy and led her to NDT. “I felt frustrated and desperate when I heard other therapists talking about the Bobaths. Sitting in an auditorium with an intimate crowd of 300 other therapists, I watched and listened to Karl and Berta Bobath talk and demonstrate a therapeutic approach to help children with cerebral palsy and adults with hemiplegia. Inspired, I quit my job, applied for a certification course in pediatrics, and took a loan to pay for this eight-week adventure. Over 20 years later when my caseload changed to include adults, I managed to complete a NDTA certification course dedicated to adults with hemiplegia and head trauma.”
Lezlie found she “was zealous about the Neuro-Developmental Treatment clinical practice model. I had some skills and if something wasn’t helping a client, I had ways to rethink how I should alter my intervention. Clients weren’t just laughing; they were acquiring skills. In the early 1980s there was a paucity of occupational therapy pediatric instructors to meet the demands for courses. The NDTA Instructors Group took an innovative step and sent out an invitation to all the OTs that had been certified in pediatrics to attend a weekend of instruction and evaluation to fast track becoming an OT Instructor. My memory recalls about 50 people accepting the invitation, with clinicians with far more clinical, teaching, and research notoriety than I had attending. Three of us were anointed. I was the only one that persevered. Thank you to the many Coordinator-Instructors, Occupational Therapy, Physical Therapy, and Speech Therapy NDTA Instructors who mentored, challenged, and guided me as I developed the skills to practice and teach.”
Lezlie has taught and inspired numerous OTs throughout her distinguished career. She has expertise in several clinical areas. When asked why she encourages therapists to seek training and certification in NDT she states, “When you teach you are forced to learn. Inherently, if you are
- a lifelong learner
- committed to your discipline and area of practice area beyond them being ‘a job’
- have a desire to be surrounded by clinicians that are current, questioning, and committed to offering the highest quality of life for individuals who are challenged
- willing to change
then utilizing the NDT Practice Model is an absolute essential component as part of your clinical toolbox. It not only gives you clinical skills but will change the way you think.”
The theme of this edition of Network is the relationship of sensation to motor control. This is a topic that falls within Lezlie’s areas of expertise. In asking her to discuss this topic she highlighted what she feels is most important in this relationship. “Clinicians are in the business of creating the opportunity for change for our clients. Research in neuroplasticity is clear; the brain does not have a specific box for sensory, motor, and cognition. The redundant functions of the central nervous system make it imperative that we look at maximizing how we can alter the nervous system connectivity to facilitate new learning from the ‘outside.’ Every goal a client and family identify requires the clinician to identify the essential motor, sensory, and cognitive components that are needed for performance and compare those with the integrities and impairments present in the client.
“A multi-system assessment is integral to the NDT Model. If during assessment you note that a child’s head drops forward into gravity and only briefly extends the head against gravity with predictable asymmetrical hyperextension, it is imperative to look at hypothesizing why from many different systems. Is there an impairment in the musculoskeletal system related to the range of motion available in any part of the spine? Is there an impairment in timing that makes it difficult for the child to initiate postural muscle activity? Is there an impairment in the sensory systems that limits the individual’s opportunity to use his or her eyes to orient the head in a symmetrical vertical position? Is there an impairment in understanding postural verses movement proprioception as a vehicle for understanding the head’s position in space? Examples of a hypothesis could be developed for every system that may contribute to the posture and movement behavior observed. Prioritizing the systems is next. Prioritizing includes thinking about which system may turn the lights on in the nervous system – make the most sense to the client. If a therapist prioritized the sensory systems and decided to emphasize the capacity of the client to self-generate linear vestibular and postural proprioceptive input, the handling strategies selected would emphasize sustained cervical extension with capital flexion, holding the held erect against gravity, and moving first in small ranges to look at an object, increasing to larger ranges in a variety of planes to look at objects in the environment. There is no one way to light up the nervous system to learn. Neuro-Developmental Treatment believes that connectivity in one system enhances other systems and solidifies learning. It is essential to have a multi-systemic approach to impacting execution so that we can identify the most effective way to help our clients change.”
Finally, I asked Lezlie what she likes best about teaching and being an NDT instructor. She feels it gives her the opportunity to enable others to be their best selves. “Clinicians become more confident and competent in their capacity to help their clients. Families gain information and learn new ways of embedding therapy in everyday life. Children and adults acquire new abilities and those changes mean a more inclusive quality of life. Being an NDT Instructor has given me much more personally than I have ever given others.”
In addition to being an NDT instructor, Lezlie sits on the NDTA Board of Directors as a member at large and on the Board’s Membership Development Committee. Within the organization’s Instructor Group, she is the pediatric OT representative to the Candidate Review Committee.
INSTRUCTOR SPOTLIGHT: March/April, 2020
Karen Guha, PT, C/NDT
Karen Guha is a Canadian-trained physiotherapist and NDT Coordinator-Instructor who has worked in both Canada and the United States since graduating in 1996. She is the mother of two wonderful daughters and a wife to a husband who has been very supportive of her career goals. She loves team sports but has an affinity for running with her two dogs, something she does every day.
For the past 20 years, Karen has worked in the Neuro Rehabilitation Clinic of Grand River Hospital in Kitchener, Ontario, Canada. The clinic is a publicly funded, multidisciplinary, out-patient clinic attended by individuals who have suffered a stroke, brain injury, or spinal cord injury. She also works in a private practice out-patient setting at Back Works Spinal and Sports Rehabilitation in Waterloo, where she sees individuals after they have exhausted their limited publicly funded therapy. Her caseload at Back Works includes individuals who have suffered a stroke as well as other neurological diagnoses such as multiple sclerosis and Parkinson’s disease. Her involvement in both of these settings gives her an opportunity to follow and help individuals achieve their rehabilitation goals through their evolving recovery.
“When I was a teenager, I had no idea what I wanted to be when I grew up. However, my basketball coach in high school suggested I consider looking at physiotherapy as a profession. He knew I was academically inclined as an Ontario Scholar and also athletic, so he thought physiotherapy was a good match. I investigated physiotherapy and had a cooperative education placement in high school to learn more about it and get the required experience for admission. I applied at several universities but accepted the offer of admission to the University of Toronto, Faculty of Medicine, Department of Physical Therapy, in 1992.
“I graduated from the University of Toronto with honors and Bachelor of Science in Physical Therapy in 1996. I immigrated to the US soon after with my husband, where I was first introduced to NDT. I had been working on a stroke unit and quickly realized I needed to improve my knowledge and skills to help my patients achieve their desired recovery and return to an active life. My hospital sponsored me to take an introductory NDT course, which inspired me to accept the challenge of the NDT certification course within that same year. The principles of NDT resonated with me because of the connections it made to all systems in the body – neural, musculoskeletal, and cardiovascular – its focus on function, and its patient-centered approach. I continued to take more NDT courses because NDT provided me with the knowledge and tools to create the pathway for my clients to achieve their rehab goals like no other approach. So, in 2002, I started the process to become an NDT instructor, becoming a PT instructor in 2007 and then a Coordinator-Instructor in 2011. My motivation to become an instructor was to share my knowledge and passion for NDT. I am convinced NDT gives us the skill set to maximize our client’s potential for recovery.
“The NDT instructors who trained and mentored me inspired me to believe recovery was possible for my clients and provided me with a pathway for my clients. I was inspired by them to be a better therapist and to strive to try to do what they could accomplish with clients. Ultimately, this led to becoming an instructor myself. I am truly humbled and grateful for all those instructors who have participated in my journey.
“Teaching gives me a platform to share my passion for NDT with others. I love to collaborate with other therapists and help them to gain skills so we as a therapy community can help our client’s meet their goals.
“I truly believe my clients challenge me to be a better therapist. They expect more in their recovery, with evolving goals after each success, which required me to gain more knowledge and skills so I can assist them to achieve those goals. Without these challenges, I am not sure that I would be an NDT instructor now. As we age, we often develop other health issues, but my clients may be more likely to develop issues if their mobility is compromised. This creates even greater challenges on their functional abilities. Regardless of changing health issues, as my clients age, they usually struggle to maintain their mobility at the same level.”
Karen states, “NDT gives a purpose to every treatment session through working towards a functional goal(s) that is important to the client and gives a framework for how to accomplish this. Prior to practicing NDT, my therapy sessions incorporated a bunch of therapy stuff and exercises, but with no functional outcome. My clients wanted to return to functional activities like walking, doing activities of daily living and leisure interests, but I had no idea how to help them. If my therapy session was successful, I felt lucky that I guessed the right thing, versus understanding the end therapy goal and choosing strategies and set-ups that work towards that goal. Every client is an individual with his or her own goals and impairments that interfere with function, so problem solving is critical to NDT.” Karen finds that knowledge and skills using the NDT Practice Model meet the needs of her clients recovering from a neurological injury because therapy sessions and holistic management take a lot of focused practice, and that practice needs to continue over the client’s lifetime.
INSTRUCTOR SPOTLIGHT: January/February, 2020
Gail Ritchie, PT, DPT, C/NDT
Gail Ritchie is an occupational therapist (OT) instructor within the NDTA organization. She currently practices as an independent, pediatric therapy practitioner, offering a range of therapies based on the culmination of skills and expertise attained over the last 35 years. She presents workshops both nationally and internationally and has been a certified NDTA instructor since 1996.
Gail first became exposed to NDT in 1982 at her first job as an occupational therapist in an early invention program that was participating in a federally funded project for cerebral palsy at the Curative Rehabilitation Center in Milwaukee, Wisconsin. The NDT instructors at that time were Rona Alexander, CCC-SLP, PhD, Barb Cupps, PT, Regi Boehme, OTR, and Linda Kliebhan, PT. “Their gifts at teaching NDT and the patient treatment demonstrations planted the NDT passion seed in me.” This led Gail to taking her initial NDT course in 1986 in Augusta, Georgia, with Judi Bierman, PT, Sarah Forsythe, OT, and Mary Meek, SLP. Gail stated, “It was a life-changing experience for me both professionally and personally. The energy, compassion, and dedication from my instructors for the patients and to our class learning was amazing. During that time, I thought that maybe becoming an instructor would be something I would want to pursue.
I was given the opportunity to be a lab assistant for Boehme Workshops in 1989. This organization was providing continuing education with the underlying theme of the NDT Approach. Being a lab assistant gave me the ability to assist novice therapists learning how to facilitate movement from an NDT perspective while at the same time learning how to provide feedback from a positive point of view. Regi was the main instructor, who, over time, was my mentor, teacher, and eventually my friend. She influenced my career as an OT, giving me the guidance and encouragement to become an OT instructor.”
Over the last 27 years, Gail has had the opportunity to work in a variety of pediatric settings that have had numerous physical therapists, speech therapists, and occupational therapists who were NDT certified as well a other clinical specialties such as myofascial release, craniosacral therapy, and Sensory Integration. She found the gift of being in these types of settings expanded the interaction among the therapists, thus enhancing everyone’s skill set to become the best in their profession to help the patients they were treating. The clinical conversations were always challenging and enlightening.
Because of these valuable experiences, she has found that “the problem-solving approach used in an NDT session gives any therapist the ability to ask the questions of how and why a person with a central nervous system dysfunction moves the way they do. Asking these questions during the assessment leads the therapist to select, sequence, and execute treatment strategies based the specific functional outcome in the plan. As Regi used to say, ‘If it works it’s treatment, if it does not then it is assessment!’ So, we are never wrong. We just have to continue to ask ourselves the question why to figure out the problem.
I believe that the NDT Approach gives a therapist an avenue of how to choose the appropriate adjuncts that will enhance a therapy session as well as provide ongoing support for the client. Understanding the vestibular system and its relationship to postural control can definitely make a significant difference within a treatment session and across time. The vestibular system is one of the sensory systems that has a direct influence on movement, balance, and emotional regulation. One critical aspect of the vestibular system is the coordination of the position of the head and movement of the eyes when we are moving or static. When we have alignment of our head over the base of support, the vestibular system provides us with postural equilibrium, balance, and spatial orientation. When incorporating vestibular activities into the treatment session, it is critical to address the alignment of the trunk over the base of support. The base of support for the head and neck is the shoulder girdle and ribcage. When there is malalignment in the trunk and pelvis, this affects the alignment of the head and neck. The vestibular system, which is housed in the cranium, is then malaligned, which can result in inadequate processing of vestibular stimuli, resulting in poor balance, poor selective control of the eyes, and poor awareness of the body in space. Incorporating adjuncts such as a towel roll for supporting alignment of the cervical spine or compression garments that enhance postural alignment may be beneficial in supporting both the sensory and musculoskeletal systems to improve function and help clients reach their full potential.”
Gail participated in the development of the book Neuro-Development Approach: Theoretical Foundations and Principles of Clinical Practice and the study guide for it. She is currently on the Theory and Curriculum Committees for the NDTA. She serves as a mentor and inspiration to the numerous OTs who are touched by her experience and teaching.
INSTRUCTOR SPOTLIGHT: November-December, 2019
Colleen Carey PT, DPT, C/NDT
Colleen is a Coordinator-Instructor for NDTA. She has served over the past several years on the NDTA Executive Committee of the Instructor’s Group as both Vice Chair and Pediatric Working Group Chair. She is the owner and director of Children’s Therapy Center in Ambler, PA. Through her center, outpatient treatment is offered as well as contract services for direct occupational and physical therapy in early intervention, preschool intervention, and public schools. In addition to administrative responsibilities, Colleen provides direct patient care.
When asked about her career and the role NDT has played in shaping her practice, Colleen stated, “I was introduced to the idea of rehabilitation by my older sister. She was an occupational therapist working with clients who had stroke or traumatic brain injuries. I shadowed her one summer and thought, ‘This is kinda cool.’ I could see myself working in that setting. But as the youngest sibling, I wanted my own identity. I reasoned that if I went into physical therapy, I would be able to work in rehabilitation, but in a unique way from my sister.
“In college, I was exposed to neurologic pediatric conditions. I felt drawn to this population and pursued my first job in a children’s rehabilitation hospital. I worked with a strong clinical staff who mentored me and shared their insights in the NDT approach. I was so fortunate that this hospital supported me traveling to Georgia for eight weeks to complete my pediatric certification course with Judi Bierman. I eagerly returned to my work at the hospital in the cerebral palsy clinic, the gait lab, and my caseload with both inpatient and outpatient populations. The problem- solving approach of NDT was a perfect match with the complex children that I worked with, and I found that the emphasis on functional outcomes meant that the children I treated made better progress.
“My husband and I relocated shortly after the NDT course to the Philadelphia area. I interviewed at Children’s Rehabilitation Hospital with Jane Styer-Acevado and was hired on staff. She was a wonderful mentor to me as a young therapist and shared with me her knowledge of NDT. We worked together in the NICU at Jefferson and with outpatients at the rehabilitation hospital. Although I studied a variety of other treatment models, I felt as though NDT was interwoven in every assessment, treatment session, and clinical recommendation that I made. I also worked in an early intervention program in an inner city, Camden, NJ, before I opened my private practice. I continue to act as director of the center but consider my main job providing direct treatment to children with neuromotor impairments.
“When I moved to Philadelphia following my initial NDT certification course, I was intensely focused on gaining as much knowledge as I could about typical development, gait, orthoses, and all the other aspects of working with a child with cerebral palsy. I was so excited when we hooked up with the internet in 1991 that I searched cerebral palsy treatment. There were 1000 hits which only took 30 minutes to load!
“Alas, there had to be a better way to soak up all the knowledge about cerebral palsy. I began to plan and organize weekend seminars at a local site on various topics related to NDT. In 2004, Lois Bly was teaching in Allentown, PA. She asked me if I was available to assist in the lab sections of the course. During those eight weeks, I was convinced that becoming an instructor was the perfect way to quench my thirst. I would have the opportunity to work with amazing NDT instructors to share ideas and perspectives on treatment. Working with this group, I knew that I would be connected with the most current scientific information about the treatment of children with cerebral palsy.
“Teaching the NDT certificate course is so much work. It includes preparation of lectures, reading and updating literature related to cerebral palsy, grading homework, creating assessments, and more. And yet, every time I am involved in teaching the certificate course, I find new energy. The passion and enthusiasm I had as a young clinician in the certificate course is rekindled as I watch other clinicians undergo transformation. It is a journey of knowledge that will forever change them as clinicians. I feel so honored to be a part of that process and overwhelmed with emotion every time the course comes to an end. Like the song from the Broadway play Wicked goes, ‘Because I knew you, I am changed for good!’
“If I consider how NDT has shaped the way I treat patients to maximize their potential, I would say that NDT has shaped who I am as a therapist in every way. It is the lens through which I see a child. NDT has allowed me to consider the whole child – looking at who the child is, how he or she relates to family members, and what dreams mean for each child moving through this world. NDT is the cornerstone of my clinical philosophy from the moment that I talk with the child (or their family) about the reason they are coming for PT to the time that I develop a treatment strategy to enable the child to reach his or her functional goal.”
As therapists, we always strive for success for our clients’ participation in their families and society in both big and small gains. Colleen was asked to cite an example of this with one of her many patients. Her client’s success is an inspiration and goal for all of us. “Last year as everyone was making New Year’s resolutions, I was asked to think over the past year about a child with whom I made an impact and how could I use that experience to shape a work resolution for the following year. I meet so many children over the course of a year, some for a short period of time, some children whom I have known for years. Who would stand out to me as a PT in making an impact in his or her life? A family who cried with you when they received the diagnosis of cerebral palsy, a child who was placed on hospice at birth and was now starting school, a child who took their first steps when they were never supposed to be able to walk? There are so many success stories with the children that I work with. I chose for my New Years’ experience a child who is ambulatory with cerebral palsy. She was referred to me about a year after undergoing multilevel orthopedic surgeries on both lower extremities. She was 10 years old and going through a challenging time. She had become well-aware of her physical limitations; she was burnt out on the endless physical therapy sessions following her surgery, and everyone was focused on her knee recurvatum and how bracing could improve the knee alignment. She did not want a better brace for her knee; she wanted no brace and cute sneakers like everyone else in her class. Putting on a holistic framework, I considered all that the family was sharing regarding their hopes as well as their frustrations. We began to work in therapy on improving strength and control of the leg with the recurvatum. Within our sessions, she worked hard out of her bracing on improving her ankle mobility, motor control, and strength. We set goals together of stepping up a curb without arm assistance, running, and maintaining static balance while lifting and placing various weight items. Six months later, knowing that motivation would come from participation with her typical friends, I suggested that she join Girls on the Run, a group that aims to help girls develop self-respect and healthy lifestyles through interactive lessons and running games. It ends with a community 5K run. I was so moved the day that her mother sent me a video of the 5K run. There was my client, with a tulle skirt, leggings, and running shoes. She ran about 20 feet and then would walk for several feet. She continued to walk and run for the entire 5K. As she approached the finish line, all the other girls were milling around after completing their run. As they saw her round the corner, they ran back to her and jogged alongside as she ran the final 50 feet of the course. I feel so lucky to have been involved in her journey. My resolution: find a way for the child to participate in a real-life way that brings motivation!”
INSTRUCTOR SPOTLIGHT: September/October, 2019
Jodi Renard, PT, DPT, C/NDT
Jodi Renard is an instructor for the “NDTA Contemporary Practice Model™ Certificate Course in the Management of Adults with Stroke and Brain Injury.” She currently works as a physical therapist for a large hospital system in Ohio, providing specialized neurological outpatient physical therapy (PT) alongside a team of speech and occupational therapists.
Her desire to become a physical therapist started young when she had the opportunity to experience many different clinical settings as a volunteer during high school. She started her PT career by spending her first year of practice in pediatrics working in outpatient and school settings, which exposed her to the use of NDT. She also kept her hand in the adult world working extra hours on weekends. Jodi was given the opportunity to change jobs to an acute inpatient rehabilitation setting with OhioHealth and left the pediatric world at that time. She was fortunate enough to be exposed to many NDT courses, as Marie Simeo, PT, MS, Coordinator Instructor, also worked within the same hospital system. Within three years of graduating, she took the NDT certification course. She also worked with other amazing therapists that were NDT trained, helping her develop as a clinician. Jodi transitioned to outpatient care in 2004 and has continued her clinical work there solely. She has been given the opportunity to serve as the acquired brain injury PT program coordinator for outpatient services for her hospital system for the past two plus years, although her love and primary job is with the clients.
When asked how she became interested in becoming an NDT instructor Jodi stated, “Marie Simeo, PT, MS, gave me the opportunity to serve as a lab assistance for many introductory courses. I loved these opportunities and realized that each time I attended the courses, I would not only get to develop my handling skills but would also learn another clinical pearl. I was driven by the opportunity to help my patients get better. As I began the instructor process, I always had the mindset that each time I would teach or take an advanced course, I was becoming a better therapist with the sole intent to benefit my patients. I consider myself a life-long learner, and teaching gives me this opportunity as I need to stay on top of the evidence available. I am driven to problem-solve with peers regarding our patients. I truly believe that the NDT problem-solving and movement analysis approach can change a therapist’s perspective, and a therapist is given the ability to link impairments with distinct treatment strategies to address those impairments.”
Jodi has found using the NDT Practice Model to be of great benefit to her clients. “NDT has allowed me to start my assessment with my patients who have sustained a stroke, head injury, or other acquired brain injuries from the moment I say hello. The movement strategies they chose as they start to move gives me a head start on what impairments I may need to address. The handling skills that I have gained from my NDT training have given me ‘another set of eyes’ to be able to feel their alignment and movement and then be able to predict their movement, aid in correcting their alignment, and help facilitate muscular activation and timing. I believe that if we allow compensation, we block motor learning, and in the adult world, most functional activities are actual re-learning since we have already experienced moving around our world. NDT has given me the skills to limit compensation and given me the knowledge to teach efficient motor sequencing to my patients to successfully move again for the purpose of re-engaging in activities that are important to each individual. You wouldn’t believe the number of individuals that want to mow their lawn again!”
Clients who have suffered a stroke, traumatic brain injury, or other type of neurologic insult often face ongoing challenges as they recover, age, and learn to adapt to their limitations. Taking this into consideration Jodi states, “As I get further into my career, I have had the opportunity to follow many patients over many years. As we age, our bodies change, and we experience new challenges. It is even more so with patients that have sustained a stroke or traumatic brain injury. Many patients have residual deficits that leave them vulnerable to orthopedic dysfunction and pain. Spasticity changes as they move through the recovery phases, and they generally need a therapist to navigate medical consultations, prevent secondary impairments, and help them with any orthosis needs. Activity levels can change, and deconditioning can be detrimental to functional mobility and community access. I generally check in with a patient annually to determine any new needs.”
“Treating, teaching, and collaborating with colleagues makes for a rewarding career that benefits ourselves, our clients, and fellow therapists with whom we have the privilege of interacting.” .
INSTRUCTOR SPOTLIGHT: MAY/JUNE, 2019
Kris Gellert, OTR/L, C/NDT
Kris is an occupational therapy instructor in the treatment of adults with stroke and other neurological disorders. She was introduced to NDT in college and then had the very good fortune to work in a free-standing rehabilitation hospital where several therapists were NDT trained. She quickly saw that the NDT-trained therapists were very focused, and they got great results with their patients.
“I wanted to do what they did,” Kris states. “However, it wasn’t until I took what is now the NDTA Adult Certificate Course that I had a more comprehensive thought process to guide my assessment and interventions with patients. My treatments became much more focused. Through NDT training, I learned about how movement evolves. Having an in-depth knowledge of typical movement patterns and an understanding of what may occur after a neurological insult or injury has profoundly changed my practice as an occupational therapist (OT).”
Early in her career when Kris worked in the freestanding rehabilitation hospital, she worked predominately on the stroke and then the brain injury team. Also, Monica Diamond, PT, was on that team as the clinical educator. Her influence was strong in this setting and in their region. She taught an NDT course every year in their facility and trained several staff each time. Because of this, there was a strong NDT presence in the early part of Kris’ career. “When I left that facility and moved across the country to North Carolina, I missed that unifying presence and invited Monica to come and teach a certificate course for my team in NC. Because I was helping to coordinate the course, I learned a great deal about what is involved to run a course, and she allowed me to join in as much as my schedule would allow. I knew that NDT training was a game changer for me, and I had the unique opportunity to view a course from a different perspective. I was hooked, and I began seeking information to become an instructor.
“I love being an instructor, even though it means traveling away from my family and my home and talking in front of people – I am an extreme introvert. I have enjoyed the opportunity to teach and learn from my colleagues and visit places I may not have otherwise seen. I learn something every single time that I teach. Patients have taught me a ton, and my peers are incredibly knowledgeable and eager to continue to grow. I am very fortunate to work side by side with some of the greatest clinicians I can imagine.
“Mostly though, I feel a tremendous sense of pride when I see clinicians who are taking the certificate course change. It is awe inspiring – every time. Therapists come to these courses often because they wish to be better – to help their patients improve. They are so often transformed. I selfishly love to be a part of that process.
“Some therapists may initially resist trying something new because it is frightening to let go of something familiar. I try to stress that giving up or challenging some of our old habits is the only way for us to grow. I think most people who commit time and money to take the NDTA Certificate course are allowing themselves to be vulnerable and to grow so that they can help their patients get optimal results quicker.
“I am an adult course occupational therapy instructor, but I have worked with children with neuromuscular dysfunction throughout my career. I think having a good understanding of how movement develops and evolves, as well as how to engage people of any age, helps me to be a good clinician.
“I really like making a difference. I, like many of you reading this, became a therapist because I wanted to help people. Having NDT training has helped me connect to people of all ages and work with them to improve their participation in a meaningful life, whatever that may mean to them individually.”
As an instructor Kris tries to encourage other OTs to become NDT certified. When asked why she thinks this is beneficial to other OTs she states, “Katy Kerris, an adult course occupational therapy instructor from Alaska, and I did a presentation to the NDTA Instructor’s Group last year, and we depicted occupational therapy and NDT as the perfect pairing, like wine and cheese. I believe this is true.
“NDT is a fabulous tool for any OT who is working with patients who have had a neurological insult. Occupational therapy professionals are committed to finding ways to help their patients achieve the highest possible level of meaningful function and participation in life. The NDT approach is also designed to help patients achieve highest level of participation in life roles. With NDT, though, the OT really learns to understand how the body moves and what can go wrong after a stroke or brain injury. My training in school did not include looking at the whole body, and this is crucial for helping people to move to attain functional goals.
“Having NDT training has really helped me be more holistic in my approach to care. As an OT, this is essential. I use the thought process and clinical problem solving with all my patients, not just those with neurologic dysfunction. I use my problem solving with several of my orthopedic type patients to determine how their movement repertoires may be leading to the problems that they are trying to remedy. I treat musicians who have developed painful upper extremity conditions due to lousy posture during practice and performances. Often correcting the foundation and adjusting the posture can alleviate many symptoms.”
Kris has found that she is able to take her knowledge and treatment skills and apply them to her current practice at a large health center in their outpatient neurological rehabilitation clinic in Greensboro, NC. Within that health system and in the outpatient clinic, there are other NDT certified therapists, and Kris finds it is a pleasure to work with like-minded clinicians. In addition to teaching across the country, she has had the opportunity to teach for her health system on several different occasions, which she finds to be fun. She states, “I like to think of myself as a lifelong learner, and I get tremendous joy from seeing that in my colleagues. It’s great to learn new information together, and then problem solve on how to better assess and provide treatment to those we serve. I really enjoy a collaborative approach to patient care, and when I work with other disciplines, our goals and our paths to reach those goals may differ, but our thought process is similar, despite our discipline. It’s as though we are talking the same language.”
Part of working as a therapist is dealing with the challenges our patients present and helping them deal with the challenges they face living with a disability, whether it is from birth or acquired. The theme of this Network deals with adjusting to the unexpected. In discussing this with Kris she said, “I think so many of the patients we serve have shown true strength and grace in their ability to adjust to the unexpected. I now work in an outpatient clinic, so for many of my patients, this is the end of the line in terms of therapy. Our goals are geared to help them no longer live as patients who have been sick, but to help them get back into their lives, having lunch with friends, babysitting the grandchildren, returning to meaningful work or volunteer activities, etc.
“One story that comes to mind is about a young professional woman who I met shortly after her surgery to remove a large cancerous brain tumor. She started out as a shadow of her former self, but absolutely knew who she wanted to be. She teased that she was wanting to be the 2.0 version of herself. She came to us with significant hemiplegia on her dominant side, very strong visual and vestibular dysfunction, poor appetite, weakness/deconditioning, and diminished cognitive abilities, especially executive functioning. She was unable to be left alone and her parents were unable to work, as they needed to be with her all the time. I will never forget her walking in wearing sunglasses to dim the light, wrapped in a scarf blanket because she was always cold, and wearing a mask over her face to avoid any chance of germs. She needed to hold her mother’s hand because she was not able to safely take even one step unassisted. She was so frail and so frightened, so unsteady, and so determined that she would overcome her current state. Once her team had assessed her and worked to gain her trust, we started to see her true spirit come through. We worked steadily toward her long-term goals of being able to be left alone and take care of her basic needs, including dressing up for church, preparing a simple meal, and returning to her service work in the community.
“She met and exceeded all her goals, and on her last day of therapy, she proudly strutted out in 3-inch-high heels on her way out to lunch with her boyfriend! She stays in touch, and I was just invited to her bell ringing service celebrating her cancer-free year. She was such an inspiration to her team, and I am so proud that I got to be a part of her recovery.”
In addition to being an occupational therapy instructor, Kris sits on the NDTA Board of Directors, the Executive Committee of the Instructors Group, and several other committees of the Board and Instructor’s Group.
INSTRUCTOR SPOTLIGHT: MARCH/APRIL, 2019
Monica Diamond, PT, MS, NCS, C/NDT
Monica is an NDT instructor who teaches the “NDT/Bobath Certificate and Advanced Courses in the Management of Adults with Stroke and Brain Injury” course and other short courses on the treatment of adults with acquired disabilities. In her early years as a physical therapist, she was fortunate to work in a facility that greatly valued education and training. Monica was encouraged to be trained in NDT and then to work toward becoming an instructor. She had wonderful opportunities to pass along what she was learning to the rest of the staff during in-services and during the certificate courses that they sponsored regularly. She found the benefits to their patients were huge, as was the enthusiasm of the staff at seeing their patients make progress.
Monica currently works in an outpatient neurorehabilitation program associated with an inpatient program at Ascension Sacred Heart Hospital in Milwaukee with a great group of colleagues. Of her worksite she states, “We also have a dedicated Brain Injury Day Program that provides services to individuals who have just been discharged from inpatient rehabilitation or who spent some time at a residential rehabilitation facility prior to being ready for the outpatient program. Although things have been reorganized and changed over my many years at this facility, it’s still my patients and co-workers that make me want to come to work each day.”
Returning to work and the community following stroke or brain injury presents numerous challenges. When asked about the challenges Monica sees she stated, “We are fortunate to work closely as a team. Depending on the patient’s needs, the team may include PT, OT, SLP, psychology, therapeutic recreation, nursing, and vocational rehabilitation, as well as the physician. We also have availability of orthopedic PT, work conditioning, and other services within our system.
“There are so many variables to be considered when helping someone decide whether or not to return to work. Often, the question needs to be investigated with a wider focus – considering the individuals’ interests, family involvement and support, their current and potential abilities and limitations (physical, cognitive, behavioral), as well as their ability to sustain attention and physically tolerate specific situations. Our team works together and shares progress, questions and considerations, observations, etc. As a group we may recommend part time work, investigation of volunteer involvement, or focus on a hobby or leisure activity. After investigating the job duties, and depending on the situation, we may provide guidelines to the physician who writes the work release, specifying the number of hours to be worked per day, particular limitations (sitting, standing, lifting, etc.), environmental constraints, and other factors that we feel are most likely to make the individual’s return to work be successful.
“It’s important to know the employer’s willingness to work with the individual – someone who returns to work too early may be denied the opportunity to continue due to his or her limitations or may become discouraged and decide not to continue to work. Safety is a huge consideration, especially since so many of our patients demonstrate cognitive and behavioral limitations. Within our Brain Injury Day Program, patients are encouraged to work on attention, social skills, and group activities that will prepare them for success in the workplace or wherever they choose to find meaning in their lives. Junior, a recent patient, experienced a stroke with left hemiplegia, but was amazingly motivated to return to work in the Facilities Management Department at Miller Park (Milwaukee Brewers Stadium). Fortunately, as we continued to challenge him, we noted that his cognition and judgement appeared to be good, so we were able to challenge him with higher level activities and continued to instruct him in what to work on at home (usually this involved more of what not to do). We continued to evaluate his balance, coordination, and endurance for the activities he hoped to progress to at home and eventually at work. We used a combination of simulations (as much as was possible in the clinic, eventually including climbing ladders, and reaching overhead to perform two-handed tasks as though working on the HVAC system) as well as careful progression of home activities. He successfully returned to work and now welcomes current day program participants during their yearly outing to a Brewers game.”
In addition to the physical challenges of returning to work or the community, we discussed how Monica and her team deal with not only the physical needs, but the social challenges of getting back into activities people may have participated in before their stroke or accident. “Some of my greatest rewards as a PT have involved working with people who were getting back to their life. One of my greatest inspirations is Marilyn. I met her when we were both really young – I was probably a few years out of PT school and she was a new graduate registered nurse, a couple of years younger than me, injured in a hit and run accident on her way home from the night shift at a local hospital. We worked together for many weeks and for many different admissions, since she was back in the hospital repeatedly for surgeries to correct her problems. She had a primary brain injury with significant ataxia, but also many fractures and other orthopedic issues
“She introduces herself on the phone and on Christmas cards as your favorite patient but also reminds me that she used to be my favorite guinea pig! At the time I was treating her, I was doing my NDT training and attending a lot of continuing education courses. She would greet me on Monday morning and ask, ‘So what did you learn this weekend?’ and we would explore my new knowledge together.
“Marilyn taught me that recovery is not quick. Due to her many surgeries and recoveries, and to the fact that she could no longer do hands-on nursing, she was not able to return to work for many years, but always planned to continue. Today she walks slowly and stiffly and lives alone but is able to drive and manage her own affairs. She reports difficulty with some cognitive tasks, but has developed and can describe, strategies she uses to stay on track. She is amazing! She has family support but also functions as a strong support to family members, which included caring for her parents as they aged.
“Marilyn returned to work eight years after her accident and has been working since. She is a phone triage nurse, and due to difficulty she has in getting going in the morning, she prefers to work the shift that starts at 3:00 PM. She recently celebrated 25 years at her job and has joked with me that even though she is near retirement age, she needs to pick up all the extra shifts she can, since she ‘missed out on eight years of earning.’ She is a great communicator, and in spite of difficulties controlling her voice, she is on the phone all day at work. We are in touch at least 2-3 times a year, so we can get together and catch up on our latest activities.”
Being able to work with and continue to follow patients over longer periods of time can help us learn valuable lessons that we carry through our career and life. Some of the lessons Monica learned from working with Marilyn include:
- Recovery may take a lot longer than we expect due to medical, emotional, and other issues. It takes a long time to get going if you have challenges, and sometimes a period of adjustment is OK.
- People may need to consider many options – sometimes these are related to their before injury lifestyles, but not always. We can help explore options, as well as the possible challenges. We can also help develop solutions.
- We are in a great position to be cheerleaders: encouraging, problem solving, or gently nudging.
Monica utilizes all this knowledge and experiential learning to assist the students in her NDT classes to learn and grow. When asked what she likes best about being an NDT instructor Monica states, “I love the teamwork that goes along with teaching and learning, working with other instructors to assist course participants to help their patients to do things they could not do and sometimes could not even imagine doing. I am fortunate to teach with a great team. We consider our chance to teach together as the ultimate in advanced continuing education. We challenge ourselves and each other in our teaching successes and challenges, as well as in patient treatment and problem-solving during demonstrations and patient practicums. It’s always exciting to watch therapists learn how effective they can be in helping patients achieve their goals. I feel that by training others, I have a wonderful opportunity to help so many more individuals conquer their challenges.”
Monica would like to thank the many patients who have shared so much with her over the years. Many thanks also to the many members of the NDTA Instructors Group from whom she has learned so much.
INSTRUCTOR SPOTLIGHT: JANUARY/FEBRUARY 2019
Helen "Timmie" Wallace, PT, C/NDT
I have had the privilege of teaching with Timmie on several occasions across the world. She is a seasoned clinician with a wealth of knowledge about NDT and treating children. She was fortunate to do her initial NDT training directly with Mrs. Bobath. When she was a physical therapy student, she heard about the Bobaths in her therapeutic exercise course. She knew she wanted to work with children, so this approach intrigued her. She explored her options and chose a clinical experience at a children’s residential hospital that had a physical therapy supervisor who was Bobath-trained and included NDT in her clinic. As it happened, the Bobaths visited that hospital during the time Timmie was there, and she was totally hooked after watching Mrs. Bobath work with the children.
When asked what made her take the step to become an instructor Timmie replied, “This was by mistake. I had the opportunity to have a second course (once part of the criteria for becoming an NDT instructor), took the course, was asked to assist in other courses, realized I could reach more kids and families if I taught other therapists – and the rest is history! I really appreciated the opportunity to share this wonderful approach with other therapists and learned more and more about teaching as I assisted many amazing instructors.”
Teaching and treating children have been passions for Timmie throughout her career. Over her career she has worked in all aspects of treatment settings. She currently provides home-based services to the birth to three population. Her love of the children and desire for them to achieve more is evident every time you see her treat a child. She has a fun way of relating to children of all ages and getting them on board with therapy through creative, fun activities. She is currently a sole practitioner but has worked in settings with other NDT-trained therapists in the past. When we talked about the advantage of working in those settings, Timmie stated, “In other eras, I have worked with therapists following the same philosophy / basic premises and concepts as NDT / Bobath. This makes communication easier and the total approach, to me, has greater impact on positive results for child and family.”
With her passion for teaching she has had the opportunity to train therapists all over the world regarding the benefits of using the NDT/Bobath treatment model. When looking at what she likes therapists to learn from this approach, she cites the areas of typical development and postural control as two of the most important aspects in helping children develop good movement patterns to improve functional outcomes. She states, “Understanding the refinements of typical movement development and the importance of postural control and postural stability in the role of function are areas all therapists need to know better. Using this base for establishing treatment objectives and strategies is one of the best (for me the best!) ways to observe functional gains in children with chronic conditions, as we are able to see the gains and not get held down by inabilities. Knowing how it all fits together challenges us to always look for the child’s abilities.” As we look at the importance of the role of postural control Timmie has found that “Postural control is more than a role; it is one of the primary bases for functional skill development. Postural control is not just the neuromotor or musculoskeletal systems. It incorporates the sensory systems, the digestive and respiratory systems, communication, and all body systems that we are challenged to address. Postural control puts the onus on alignment, which includes weight bearing, weight shifting, vestibular responses, strength, tone, influences of gravity, motivation, visual and hearing and tactile senses, as well as the understanding and integration of the feedback this provides in order to use this information to perform / perfect (through feed forward) the activity/skill. The NDT approach brings postural control into function by helping to provide a strong base for skill development. I believe this is as Mrs. Bobath originally intended us to understand.”
Whether teaching with Timmie or taking a course from her, her passion for both treating and teaching is evident. She is certified as an instructor in pediatrics and has taken the course on the treatment of adults with neurologic impairments. She has spent her career in pediatrics but found that being certified in the adult side of NDT has taught her that it is important that all of us (instructors) take the opportunity to have the other course so that we can better understand where we have come from and where we are going – that we understand the lifespan. She finds that sharing valuable information with other therapists and helping therapists realize the abilities of the kids as our teachers provides her the most joy in being an instructor. As an instructor she states, “I get to be a catalyst in this interchange between therapist and child. Watching the families become so connected to the therapists as the therapists learn ways to provide the basis for function is also a gift for me.”
Because Timmie has had the opportunity to teach around the world, I asked her what she has found to be the benefits of treating in a variety of cultures. She states, “Sharing the information with more people and learning how NDT fits with various cultures. In some situations, this is the first exposure the therapists have to this approach, and the word spreads very quickly that NDT really can make a difference. Another aspect is that families (parents and caregivers) often have not understood that there are great possibilities that their children can improve in their skills, and the intensity of this course is a real eye-opener for the families and the children.”
MEMBER SPOTLIGHT: NOVEMBER/DECEMBER 2018
Debra Kray, PT, C/NDT
The NDTA 2018 conference was a huge success thanks to NDT practitioners like Debra Kray, who has served on the Conference Planning Committee for the past four years. Having practiced for 32 years, Debra currently resides in Los Angeles, California. She works for the state’s Westside Regional Center in the birth-3-year-old early intervention program as both a treating therapist and as a consultant. She recalls being fortunate to work as a student intern at a hospital with Randy Jacobson, PT, who was NDT-trained. At graduation, Debra secured a job at that same hospital and was able to be guided in treatment ideas and continuing education course recommendations by Randy.
In 1987, Debra was able to take the five-day “Components of Movement” course taught by Lois Bly, which gave her an excellent introduction to NDT-oriented movement analysis. She then followed this with several other shorter courses with a variety of instructors, giving her well-rounded exposure to NDT treatment strategies. But she reports that she wanted to further understand strategies and how to determine when to use them. In 1999, Debra was able to take her certification course with Lauren Beeler and Mary Hallway.
Debra defines NDT as a philosophy that she has been able to keep in the forefront, applying its movement analysis and problem solving strategies in all the job settings where she has worked. She found this to be most important when her family had moved to another state where the awareness of NDT was quite limited. Being in this type of work environment forced her to become more self-reliant.
Debra recalls an 18-month-old child she treated there shortly after starting. She focused on improving postural control in standing and during walking because these were both age appropriate and important to the family. Her favorite treatment memory is of a fall afternoon when she and the child walked outside crunching leaves. She utilized home programs and community involvement to help the family understand the child’s functional possibilities and to become comfortable with their “differently-abled child.” When asked what advice Debra had for any therapist inquiring about NDT she stated, “It just makes sense! NDT certification is a journey that does require a strong commitment of time, energy, and finances, but the value of learning will continue long after your training is complete.”