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NDTfinal
NDTfinal
NDTfinal
Agenda
Defining NDT Origins and key concepts of theoretical approach Assessment and intervention Evidence of efficacy Strengths and limitations Recommendations for clinical practice
NDT
Advanced hands-on approach to the examination and treatment of individuals with disturbances of function, movement and postural control due to a lesion of the central nervous system (CNS) Used primarily with children who have cerebral palsy (CP) and adults with cerebral vascular accidents (CVA) Practiced by OT, PT, SLP who completed advanced training in NDT
3. 4.
Decreasing muscle tone through the use of reflex inhibiting postures Incorporation of hierarchical motor sequences into therapy, with one activity following another during facilitation (head control, rolling, sitting, quadruped, kneeling) Facilitation of automatic movement sequences as opposed to isolated developmental skills Currently, it is recognized the need to direct the treatment towards specific functional situations
Muscle and postural tone determine the quality Task goals, experience, individual learning strategies, movement synergies, energy and of the patterns of posture and movement used interests all affect the quality of the final action in functional activities
NDT Assumptions
1. Impaired patterns of postural control and movement coordination are the primary
problem of motor coordination are treated by directly addressing neuromotor and postural control abnormalities in a task specific context
3. Sensorimotor impairments affect the whole individual the persons function, place
across the life span provides the framework for assessing function and planning intervention.
5. NDT clinicians focus on changing movement strategies as a means to achieve the
best energy-efficient performance for the individual within the context of the age appropriate tasks and in anticipation of future functional tasks.
6. Movement is linked to sensory processing 7. Intervention strategies involve the individuals active initiation and participation,
Key Concepts
I. Normal development Principles of normal development Cephalocaudal, proximal-distal, gross to fine Sensory-motor-sensory feedback system Components of normal development a. interplay between stability and mobility b. effects of postural reflex mechanism on movement postural tone muscle tone reciprocal innervation - interplay between agonist and antagonist muscles during coordinated muscle movement righting and equilibrium reactions Righting reactions - restore and maintain the vertical position of the head in space, the alignment of the head and trunk and trunk and limbs Equilibrium reaction - serve to maintain or regain balance during a shift in the center of gravity the ability dissociate movements development of postural control in the three planes of space Sequences of motor development II. Abnormal development III. Sensory input as a means of bringing about change
Initial contact
Data collection
Evaluation Analysis
Intervention plan
Examination
NDT Focus: to identify constrains that limit the clients ability to perform functional activities. Components: Present and anticipated functional skills or limitation of skills Posture and movement components and compensatory strategies Anatomical and physiological status of those systems that contribute to functional limitations
Examination (contd)
Functional Skills
Gross and fine motor control, communication, and control of behavior and emotions
Functional abilities and limitations Potential to change function Clusters of function and activity limitations Relationship between participation and activity level Assistive devices, splinting and orthothics
Examination (contd)
Observation of posture, movement and compensatory strategies
Spontaneous posture and movement Typical and atypical posture and movement Compensatory movement strategies Alignment, weight bearing, balance, coordination, muscle and postural tone, and movement components
Examination (contd)
Individual systems related to function
Neuromuscular system Musculoskeletal system Sensory, perceptual, cognitive systems Regulatory system (arousal, attention, emotional and behavioral responses) Limbic system (emotions, fear, pain) Respiratory, cardiovascular system Integumentary system (skin)
Examination (contd)
Measurement Tools
Norm-referenced tests (WeeFIM, AIMS, The School Functional Assessment) Criterion-referenced tests (COPM) Non-standardized tests (compare the performance at the beginning and at the end of the session)
Evaluation
The therapist observes, describes and formulates hypothesis, linking treatment planning with outcomes.
Clients internal and external resources Functional limitations and participation restrictions The relationship between posture and movement components Hypotheses regarding impact of impairments on daily life function Potential to change Intervention plan developed
NDT Intervention
NDT Focus: what differentiates NDT intervention from other approaches is the precise therapeutic handling, including facilitation and inhibition, used to provide sensoriomotor cues that facilitates change in function ( Howle, 2004). Handling is graded input provided by the therapists hands at key points of control on the childs body. and results in active control or movement (Kramer, 1993, p. 78).
Principles of Intervention
1. Establish a treatment plan with anticipated outcomes that include specific, observable functions within a specific time frame under specific environmental conditions. 2. Therapy utilizes clients strengths, recognizes that each individual has competencies and disabilities. 3. Set anticipated outcomes and impairment goals in partnership with the family, the client, and the interdisciplinary team. 4. Treatment strategies often include preparation and simulation of critical foundational elements (task components) as well as practice of the whole task. 5. NDT intervention includes planning and solving motor problems. 6. Repetition is an important component in motor learning. 7. Create an environment that is conducive to cooperative participation and support of the clients efforts. 8. Knowledge of the development of posture and movement components is use in designing treatment strategies. 9. A single treatment session progresses from activities in which the client is most capable to activities that are more challenging. 10. NDT intervention methods include modifying the task, or the environment, and take into account the current level of the clients performance and capacity for function. 11. Individual treatment sessions are designed to evaluate the effectiveness of treatment with the session. 12. Families receive information regarding the clients problems and management of those problems, as they are able to understand and assimilate the information. 13. In an NDT approach, suggestions to the family are as practical as possible. 14. NDT recommends an interdisciplinary model of service. 15. Coordinate with the goals and activities of all other medical, therapeutic, social, and educational disciplines to ensure a life-span approach to solving the clients problems.
Intervention (contd)
Sequence of Intervention
Preparatory activities for passive movement or body alignment Selection of the key points for therapeutic handling according to the childs postural tone Facilitation of active or automatic movement patterns by applying graded and varied therapeutic input
Intervention (contd)
The key points (proximal or distal) are the places of physical contact between the therapists parts of the body or therapy equipment and clients body. (Boehme, 1988) Proximal key points: Located closer to the source of the problem, usually at the head, trunk, or large joints Used to influence posture and movement in all three planes (sagittal, frontal, and transverse), especially during difficult moments
Intervention (contd)
Distal key points:
Located away from the source of the problem, usually at the upper and lower extremities level Used to allow the client to engage in activities with minimal control of the therapist
Intervention (contd)
Facilitation is the process of intervention which uses the improved muscle tone in goal-directed activity. Facilitation techniques involve stimulation of the muscle activity to produce a desired motor response. It is related with the functional goal that needs to be achieved.
(Boehme, 1988, p. 3)
Guides the childs posture or movement during the activity Techniques: tapping and intermittent compression to provide proprioceptive and tactile stimulation
Intervention (contd)
Inhibition is the process of intervention that reduces dysfunctional muscle tone.
(Boehme, 1988, p. 3)
Reduces the intensity of spasticity Reduces the effect of fluctuating muscle tone Improves the range and variety of movements Not used with hypotonicity Techniques: traction and light joint compression It is used in combination with facilitation
Intervention (contd)
Weight bearing and weight shifting promote:
Postural alignment Childs movements Proximal stability
Efficacy (contd)
Children who received NDT performed slightly better than control or comparison groups (Ottenbacher, et al., 1986) Children with cerebral palsy
6 studies reported benefit vs. 4 studies reported no benefit (Brown & Burns, 2001) 1 study reported benefit vs. 5 reported no benefit (Brown & Burns, 2001)
Efficacy (contd)
From 101 studies identified 21 met inclusion criteria Overall results did not show an advantage for NDT intervention over the alternative to which it was compared No consistent evidence that NDT changed abnormal motor responses, slowed or prevented contractures, or that it facilitated more normal motor development or functional motor activities
( AACPDM, 2001)
Efficacy (contd)
More intensive therapy did not confer a greater benefit 4 of the 21 studies were coded as Level I (definitive) evidence and 10 were Level II (tentative) evidence
( AACPDM, 2001)
Efficacy (contd)
Factors that may account for research results
1. 2. 3. 4.
Sample size Heterogeneous samples Participants not randomly selected Participants assigned to either a treatment group or a nontreatment groups without using an adequate blinding process
Efficacy (contd)
5. Different assessment tools used to collect the data in each study 6. Whether many of the measures used are valid and/or sensitive enough to detect change 7. Variation in outcomes being measured 8. Variation in treatment therapy and duration of interventions
Efficacy (contd)
Issues are methodological ones Absence of evidence of effectiveness should not be construed as proof that NDT treatment is not effective, may just reflect more meaningful research is needed a limited number of high quality NDT research efficacy studies have been published (Brown & Burns, 2001)
References
Boehme, R. (1988). Improving upper body control. An approach to assessment and treatment of tonal dysfunction. Tucson, AZ: Therapy Skill Builder. Brown, G. T., & Burns, S. A. (2001). The efficacy of neurodevelopmental treatment in paediatrics: A systematic Review. British Journal of Occupational Therapy, 64(5), 235- 244. Butler, C. & Darrah, J. (2001). Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence report. Developmental Medicine and Child Neurology, 43, 778-790. Howle, J.M. (2004). Neuro-develompmental treatment approach. Theoretical foundations and principles of clinical practice. Laguna Beach, CA: NDTA. Ottenbacher, K. J., Biocca, Z., DeCremer, G., Jedpvec. K. B., & Johnson, M. B. (1986). Quantitative analysis of the effectiveness of paediatric therapy: emphases on the neurodevelopmental treatment approach. Physical Therapy, 66, 1095-1101. Schoen, S. & Anderson, J. (1993). Neurodevelopmental treatment frame of reference (pp. 74- 86; pp. 49- 69). In P. Kramer & J. Hinojosa (Eds.) Frames of Reference for Pediatric Occupational Therapy. Baltimore, MD: Williams & Wilkins.