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CLINICIAN'S CORNER

Transformation
A Clinician's Mind and a Patient's Body in the
World of NDT


There is no reward greater as therapists than observing and successfully facilitating development in a young patient who has been given a dismal prognosis. Witnessing a parent's fears and disappointments transform into tears of joy are what keeps us determined to facilitate functional outcomes for the people we work with, despite the hard physical and emotional work.

Jack came to me in April, 2010, with his original diagnosis of torticollis and communicating hydrocephalus. He was born thirteen weeks prematurely. His parents were concerned that he did not tolerate prone and that his head was positioned in left rotation and right lateral flexion relative to his shunt. He had a very traumatic first year, undergoing countless surgeries, including several shunt revisions. At the time of the initial evaluation, he was wearing a cranial molding orthosis during most of his waking hours in order to decrease his plagiocephaly. Jack also demonstrated a slight hand preference – while he mostly used his left upper extremity (UE) for reaching and fine motor tasks, he was able to utilize the right UE with cuing. I was cognizant that his diagnosis of hydrocephalus is often associated with neurodevelopmental challenges, but his range of motion (ROM) in all extremities was within normal limits, and at the time, abnormal tone was not notable. Jack had slightly decreased active movement in his right lower extremity, but I observed his muscle strength to be at least 3/5 throughout both lower extremities (LEs). Reciprocal kicking of the LEs was slightly decreased, but intermittent, and at the time of the evaluation, Jack had a strong preference for lying in supine. The plagiocephaly I observed was likely a result of his lack of strength and lack of motivation to abandon his supine positioning.

From the moment I evaluated him, I was determined to "cure" Jack's torticollis and improve his functional limitations. My focus was simply stretching and strengthening the involved cervical musculature while keeping in mind my goals of symmetrical and age appropriate developmental milestones. I fervently worked on ROM and insisted that his mom follow a stringent home program.


Jack at 19 months (16 months, corrected), beginning to sit independently. He is still
challenged by an imbalance of strength of
his cervical muscles.

In October, Jack's mother arrived at therapy in a fury of grief. Jack had been examined by a physical medicine and rehabilitation physician who had diagnosed him with triplegic cerebral palsy. She had in her hand prescriptions for a stander and bilateral solid ankle orthoses. She was surprised and devastated to learn that the smiling, happy baby whom she thought would have a few minor challenges had been given a prognosis characteristic of a severe physical disability.

Just like Jack's entrance into this world, my depth of clinical thinking before my NDT certificate course was premature, to say the least. I had been a pediatric physical therapist for almost eleven years, employed at the same outpatient hospital satellite clinic since my graduation. I had fallen in love with pediatrics during my clinical rotation in graduate school, and felt so very fortunate to be hired on at a premier hospital working with a population with whom I felt so passionate.

I had waited for nearly a decade for the NDT certificate course to come to Detroit, or at least somewhere local, in order for my commute not to interfere with balancing my role as a mother, clinician, and student. I had several colleagues who explained NDT education as the "pinnacle" of their career, one that exceeded the amount of knowledge they acquired in graduate school, and also a course where invaluable hands-on experience was guided by expert instructors. The unparalleled value of learning and practicing simultaneously and repeatedly throughout the eight-week course is an amazing method of instilling this theoretical framework into clinical practice. There is simply no better way to enhance one's skills.

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Until I became a student of NDT and Jane Styer-Acevedo, I took for granted any variability that may be present in the NDT course. I had assumed that all courses were taught in the exact same manner. While I am very certain that all of the courses do have a similar format, and are all taught by talented and knowledgeable instructors, Jane had a unique way of sharing her understanding of this problem-solving approach, and fostering and facilitating each and every student's growth in a very personal and dynamic manner. She is a brilliant clinician, remarkable teacher, and a true gift to all of her students. Jane's influence has guided me to think critically and coherently, connecting cause and effect while I assess each patient and organize my treatment strategies.

When goals are not met, it is now so natural to simply "break down" posture and movement into system impairments, and then naturally and directly identify what needs to be addressed. NDT has taught me to prioritize effectively, and how to truly treat the "whole patient," considering all contextual factors when creating goals. NDT makes so much sense. The Bobaths' theory has continued to evolve and holds such practical applications; each patient becomes a "puzzle," and it is our job as therapists to fit the pieces together. Jane's passion for NDT was, and is, contagious; she created within us a community of passionate students who were all anxious to discover the interminable positive results of applying NDT to all of our patients, both throughout the course and in the clinic.


Jack is now standing at a support surface
independently. We are working on lateral weight shifts and cruising with facilitation, often using his lower extremities as key points of control.



I am so grateful for all of the knowledge and confidence I have gained through my NDT course, but there are a few areas I want to highlight and emphasize, as they have completely transformed my thought process, and hence, my assessment techniques and treatment plans. I now feel confident in my ability to identify directly and prioritize the impairments that result in abnormal posture and movement. I am also able to facilitate good alignment in my patients using effective preparatory techniques. Finally, I am able to utilize powerful treatment strategies that facilitate the patient to use the base of support (BOS) for active stability.

The NDT Enablement Model has provided for me a most valuable framework to prioritize my patients' functional limitations and how to address them. Prior to NDT, I attributed Jack's list of problems to his hypotonicity and lack of strength and cervical ROM. Following my NDT education, I am able to observe Jack in a variety of postures, many of which are appropriate for his family's goals, and I use a critical eye to observe not only his head, but the position of his scapulae, UEs, pelvis, and LEs, which all contribute to his lack of sitting balance and dislike for prone positioning.

When I first performed the intake during Jack's evaluation, my problem list consisted of abnormalities I thought I could "fix" regardless of Jack's family's main concerns. I had always been taught to treat the root or the cause of the problem and to use the developmental sequence of a typically developing baby as a guide for positioning and facilitating movement. Because Jack was not tolerating prone, regardless of his age and lack of sitting balance, I wanted to stretch his "tight" cervical muscles and then begin facilitating movement with prone as my goal.

Having an NDT trained mind now, I am driven to identify all of the components necessary to develop a movement required for function. Since NDT education, I am able to see and analyze Jack's limitations in a more global view. And ironically, the position of his head and cervical spine appears to be more toward midline, and is less of a concern, when working on sitting balance and mobility, both goals his family had expressed early on in treatment.

An important and invaluable tool that has transformed my clinical analysis is the ability to separate and identify single system impairments that contribute to a patient's various abnormal posture and movement behaviors. This skill requires a very organized thought process, but is most appreciated when establishing goals and creating a treatment plan. Previously, I had considered weakness only as a lack of muscle strength; my treatment plan would then include concentric and eccentric strengthening activities and exercises.


The ball has been a wonderful tool for
facilitating transitions into sitting. Jack responds so well when provided input down into his BOS, but patience is a necessity.



After NDT, I am able to divide Jack's system impairments into neuromuscular, musculoskeletal, and sensory-perceptual categories. Jack's lack of sitting balance is not simply a result of "low tone" and weak proximal muscles. I am now able to direct my treatment toward improving his ability to sustain postural muscle activation by using gravity and facilitation of movement to work on this neuromuscular impairment. Jack can activate his abdominal muscles using quick, phasic bursts. He does, however, require significant work on sustaining activation, grading and coordinating muscle activity for static and dynamic balance, as well as for coordination of extremities for mobility.

Now that Jack is standing with support and transitioning to stand with assistance, I am able to observe his decreased pelvic-femoral mobility, which may also be attributed to his small repertoire of posture and movement behaviors. This is one of the many musculoskeletal impairments that contributes to some of his abnormal postures and movements. Muscle strength and muscle endurance have also been identified as factors that require guided treatment planning.

Finally, Jack's sensory-perceptual experience as a 19-month-old with limited mobility, was yet another factor that challenged his postural control and balance. I now know how poverty of movement can adversely affect a child's postural proprioception, altering and decreasing the amount of sensation needed to generate the correct posture and movement for transitions. Jack's tactile awareness was also impaired; he did not tolerate weight bearing through his LEs in supported standing and preferred to maintain a closed-fist position with both hands in prone and supported sitting. Whether this was due to lack of experience or a neurological response, I now knew it was something I needed to address in my treatment strategies.

At this point, I was able to recognize that limited ROM of cervical movement (musculoskeletal system) was not the most important system that needed to be addressed in order for Jack to reach his functional outcomes. Now that I had identified his abnormal posture and movement behaviors, I had recognized the need to consider Jack's functional limitations, participation restrictions, and contextual factors. Jack is very motivated and very intelligent; he communicates well with his very supportive and loving family, as well as with his therapists. He is beginning to verbalize and has a quickly growing vocabulary. He now loves to be placed in a supported standing position at a small tabletop and is able to play independently there for five minutes. Once he can activate his BOS, Jack is quite capable of cruising with a little bit of facilitation. Jack's family is thrilled that he is not a candidate for a prone stander after all.

Postural alignment for Jack was an issue, not only because of the position of his head relative to his body, but in prone, his weight was shifted in a cephalic direction and in sitting, his posterior pelvic tilt brought his BOS posteriorly. In order to activate and work off his BOS, Jack needed help with alignment. Once he was in good alignment, it was easier to activate his BOS. For example, Jack did not know how to activate his gluteal muscles in sitting. I had been so focused on his trunk, but through my NDT practical experience and labs, I learned the need for coactivation of the gluteals and abdominals in order to activate the BOS in sitting. Now I was ready to facilitate normal posture and movement for Jack.


The NDT Enablement Model has provided for me a
most valuable framework to prioritize my patients' functional
limitations and how address them.

Jack responded immediately to my facilitation. I had always wanted to achieve the ability to facilitate movement without "moving" the patient. This was another of the most valuable tools I received from my NDT training. I knew Jack could learn to initiate movement by generating weight shifts and activating his BOS. All of the work I had practiced in my NDT course with patients, fellow students, and instructors using various key points gave me the requisite tools to problem solve with greater insight and success. Suddenly, I was finding my hands on muscle groups, not bony prominences. A simple light touch was now all that was needed for Jack to align his center of mass (COM) over his BOS, and now he is now capable of sitting independently for at least ten seconds.

I finally discovered where to target my treatment because I had identified specific postures Jack couldn't maintain and movement transitions he couldn't make. My goals became specific and functional and were very appropriate within Jack's contextual factors. The NDT approach involves constantly reassessing treatment strategies and outcomes. I am now setting specific goals for Jack. This is empowering for both Jack and his family, knowing that progress never ceases. Writing and re-writing goals is challenging, but I have learned to focus on only a couple of posture and movement behaviors, and after identifying system impairments, I am able to quickly focus on just a few goals that are achievable and very appropriate for Jack and his family.

My new variety of treatment strategies has undoubtedly grown, and their effectiveness is quite evident after plenty of practice. I am aware of, and have incorporated into my practice, many preparatory techniques that are invaluable when used before implementing my treatment. Increasing pelvic femoral mobility, gaining ribcage mobility, and elongating some of the shortened muscles Jack uses ineffectively to gain stability and mobility have all assisted me in working toward our functional goals. During treatment, Jack loves to bounce on the ball, and since NDT, I am able to focus on getting him to sustain activation of postural muscles – gluteals, abdominals, and spinal extensors – while I continue to keep an eye on the position of his head and neck over his BOS. He is able to coactivate muscle groups now, and motor learning has played a role in his adapting new patterns of movement into his repertoire.

NDT has also improved my ability to WAIT for Jack's motor response. Previously, if I facilitated a movement, I was impatient, and eventually created the movement for the patient. Jack is able to generate his own movements, sometimes not as quickly as I would anticipate, but eventually with the right handling techniques, he can initiate his own weight shift. This active initiation provides the right sensory feedback and motor learning experience required for him to continue to move in an energy efficient manner with good postural alignment.

Jack's functional progress improves with every visit. His family was first devastated to learn of his cerebral palsy diagnosis. Now they are observing a remarkable shift in his motor behavior. He is independent and even happier as he becomes more mobile and is able to work against gravity. He is proud of his own success, and so am I. My simultaneous transformation in clinical thinking has fostered his motor development, and I am so very grateful for my NDT education. I will continue to be amazed by Jack's progress, as the principles of NDT guide my treatment.


Stacy Zousmer, MPT, is a pediatric physical therapist at Beaumont Hospital's Center for Children's Rehabilitation in West Bloomfield, Michigan. She can be reached at 248-855-4480 or stacy.zousmer@beaumonthospitals.com.

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