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Chapter 2

Movement Dysfunction

Core Concepts
Chapter 2 focuses on movement dysfunction in individuals with central nervous system
(CNS) neuropathology and on the framework that Neuro-Developmental Treatment
(NDT) uses in its approach to individuals with motor dysfunction. The NDT approach
recognizes that atypical movements in individuals with CNS pathology result from
damage to specific neural tissue; the attempt of other subsystems in the nervous system
to compensate for the initial lesion; the ineffective interactions that result from the
connections of the body systems and environmental factors to a damaged nervous
system; and the inability of the CNS to adapt to environmental opportunities.

An adaptation of the International Classification of Functioning, Disability, and Health


(ICF) model known as the “NDT Enablement Classification of Health and Disability
Model” (NDT Enablement Model) is used to classify and describe posture and
movement problems in individuals with CNS neuropathology. This adapted version of
the ICF is compatible with the NDT problem-solving process originated by Mrs.
Bobath; compatible with the current NDT assumptions and theoretical foundation; and
significant in its inclusion of the effects of the environmental context on the disabling
condition. NDT therapists who work with adults with stroke or cerebral palsy (CP)
recognize that other pathophysiologies can contribute to the impairments and
functional activity limitations of individuals. Growth and development, other unrelated
health conditions, and other system impairments may have direct or indirect influences
on an individual’s functional abilities/limitations.

Next the chapter focuses on dimensions and domains of the NDT Enablement Model.
In the body structures and functions dimension, primary and secondary impairments
are discussed. Impairments may include either positive or negative signs, may occur in
single systems or multiple systems, may be temporary or permanent, and may change
over time.

Unique to the NDT Enablement Model is the motor functions dimension, which
includes the domains of effective and ineffective posture and movement. This domain
links function limitations and underlying systems impairments by describing symptoms
of motor function or dysfunction (e.g., effective/ineffective alignment, weight bearing,
coordination, balance and postural control; the temporal and spatial components of
motor planning; descriptions of tone and movement combinations).

The dimension of individual functions includes the domains of functional activity and
functional activity limitations. Functional activities range from simple tasks to complex
skills and always have a goal or purpose. Functional activity limitations are the extent
to which an individual has difficulties performing a specific task and are generally

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related to a combination of system impairments. Functional activities and functional
activity limitations are grouped into four categories including gross motor control of
body posture and movement in and through space (e.g., crawling, walking);
communications; fine-motor task-directed functions; and social, behavioral and
emotional skills.

The social function dimension includes the domains of participation and participation
restrictions. These domains reflect the nature and extent of an individual’s movement
in life situations and represent the complexity of the interactions of health condition,
impairment, functional activity and context. This dimension suggests to clinicians that
they must look at and address the individual’s needs at the moment as well as his or her
anticipated changing needs in the future.

Contextual factors (i.e., environmental and personal) may facilitate or enhance an


individual’s participation or may act as barriers or hindrances. Environmental factors
include individual personal elements as well as services and systems from within a
larger community. Personal factors relate specifically to the features or background of
an individual that are not part of his or her health condition. Recognition of the
interactions between the individual and contextual factors influencing his or her
performance has been incorporated into current NDT intervention.

Chapter 2 continues with fourteen NDT assumptions of motor dysfunction. Many of


these assumptions focus on impairments and their contribution to movement
dysfunction. In NDT, all impairments that can be constraints on function are included
in the analysis of a client’s functional problems. Through the dimension of motor
functions (i.e., effective/ineffective posture and movement) a stronger connection
between functional activity limitations and system impairments can be made.
Comprehensive discussions of primary, secondary, and multiple system impairments
common to stroke and CP are emphasized.

Discussions on motor function and dysfunction present NDT’s unique emphasis on the
in-depth analysis of postures and movements that link functional activities limitations
with systems impairments. The NDT Enablement Model demonstrates this focus
through its dimension of motor functions, which is composed of the components of
posture and movement, including alignment, weight bearing, balance and postural
control, coordination, muscle and postural tone, and biomechanical and kinesiological
components of movement.

In addition to this chapter’s extensive discussion on the complexities of the


relationships between systems impairments and motor function, the distributed neural
model and its foundation for the recovery of function after injury to the CNS are
discussed. The concept that neural damage and recovery can lead to adaptive as well as
maladaptive behaviors is explored. Mechanisms for recovery and compensations, both
neural and non-neural, are discussed in relationship to changes in motor function. A
balance between promoting and supporting recovery, while allowing the use of

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functional compensations for independence in functional activities, is emphasized in
the NDT treatment strategies for individuals with CNS dysfunction.

The chapter concludes with a review of the need for greater research in NDT as a
foundation for evidence-based practice. Use of the NDT Enablement Model as a part of
the NDT framework provides an objective way to examine the effect of NDT on the
variety of dimensions in an individual’s life. Although research that demonstrates the
efficacy of NDT as a treatment approach for children and adults with CNS dysfunction
is limited, clinical studies by clinicians are strongly encouraged to systematically
evaluate current NDT principles and intervention methods as a means of establishing
evidence-based practice.

Key Terminology

International Classification of Functioning Topographic distribution of movement


Disability and Health (ICF) Impairments
NDT Enablement Model Co-activation
Primary impairments Muscle synergies
Secondary impairments Temporal impairments
Multiple system impairments Reaction times
Positive signs of neuropathology Sequencing impairments
Negative signs of neuropathology Insufficient force generation
Pathophysiology of the health condition Anticipatory postural control
Selective control Hypokinesia
Isolated movements Fractionated movements
Functional activity Sensory processing
Functional activity limitations Motor planning
Compensations Edema
Effective posture and movement Alignment
Ineffective posture and movement Weight bearing
Participation Muscle tone
Participation restrictions Abnormal muscle tone
Ischemic strokes Postural tone
Hemorrhagic strokes Postural control
Cerebral palsy Abnormal postural control
Spasticity Scaling
Hypertonicity Coordination
Dyskinesia Recovery
Athetosis Distributive Neural Model
Rigidity Diaschisis
Tremor Neural Shock
Ataxia Evidence-based practice
Hypotonia Sackett’s Level of Evidence

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Learning Modules40

Unit 2.1: NDT Enablement Model


(pp. 83-100)

Objectives
At the conclusion of this unit, the reader will be able to:

1. Categorize clinical examples of dimensions and domains within the NDT


Enablement Model

2. Describe the common clinical characteristics of cerebral palsy or stroke

3. Identify, compare, and contrast primary and secondary impairments

4. Discuss the relationship of impairments to the development of ineffective postures


and movements

5. Discriminate positive from negative signs of neuropathology

6. Identify contextual factors and describe how they influence the dimensions within
the NDT Enablement Model

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Learning Activity 2.1.1 (pp. 83-85)

Match the following list of clinical examples to the appropriate dimension or domain
within the NDT Enablement Model.

Dimension and Domain Clinical Example

a. Body system structural integrity _______ Intact sensation

b. Impairments _______ Asymmetry in standing

c. Effective posture and movement _______ Able to play with friends on


playground at recess

d. Ineffective posture and movement _______ Good sitting balance

e. Functional activity _______ Able to isolate wrist and


finger extension

f. Functional activity limitation _______ Dresses self independently

g. Participation _______ Cannot go to daughter’s


house to babysit
because new wheelchair
does not fit in car

h. Participation restriction _______ Needs help to put on AFO

_______ Poor trunk control

_______ Cannot independently do


grocery shopping for
family
_______ Decreased strength

_______ Chews and swallows ham


sandwich without choking

_______ Slow labored movement

_______ Excessive cocontraction

_______ Cannot lift arm overhead


past 90 degrees

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Learning Activity 2.1.2 (pp. 85-90)

Answer either 2.1.2A or 2.1.2B

2.1.2A There are two mechanisms resulting in stroke, ____________ and


___________. Describe the characteristic clinical picture with which these individuals
present, including common functional activity limitations and system impairments.

Common Functional Activity Limitations:

System Impairments:

2.1.2B Describe the common clinical characteristics associated with each of the
following types of cerebral palsy (CP).

Type of Cerebral Palsy Ineffective Posture and Impairment


Movement
Spastic or Hypertonic

Dyskinesia

Ataxia

Hypotonia

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Learning Activity 2.1.3 (pp. 90-93)

Select one item from the list of ineffective postures and movements provided below.
Describe three different impairments that could cause the problem. For each of the
impairments, clarify how this might occur.

1. Asymmetrical step length in walking


2. Decreased scapular stability during reaching activities
3. Inability to chew and swallow mixed textured food

Learning Activity 2.1.4 (pp. 90-100)

Using the definitions provided within this chapter, match the following Key Terms to
their Definitions.

Key Terms Definitions


A Positive signs of neuropathology Problems that are directly attributed
_____ to the brain pathophysiology.

B Negative signs of neuropathology Problems that do not occur directly


_____ from the original pathophysiology,
but result from the brain lesion
interacting over time with other
body systems and environmental
contexts.

C Primary impairment Problems that constrain posture and


_____ movement because of their absence
as a result of neuropathology (e.g.,
insufficient force generation).

D Secondary impairments Problems in body systems that are


_____ present and excessive and not
expected in the typical population.

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Learning Activity 2.1.5 (p. 91)

After reading the following pediatric and adult case studies, list five potential primary
and secondary impairments.

2.1.5A Pediatric Case Study

Joey is a four-year-old boy who lives with his mom, dad, and older sister. He was born
at 29 weeks gestation and remained in NICU for 8 weeks. While in the NICU, Joey
experienced a Grade III interventricular hemorrhage and required nasogastric tube
feeds and mechanical ventilation for three weeks, resulting in a diagnosis of broncho-
pulmonary dysplasia. The high levels of oxygen resulted in retinopathy of prematurity.
He has a diagnosis of cerebral palsy, spastic quadriplegia. He has been receiving
therapy since hospital discharge.

Joey’s head control remained limited. If Joey’s head falls forward, he has difficulty
lifting it up. If he is able to lift his head up, it is laterally flexed to the right with
decreased range of motion (ROM) to the left. Oral intake is limited to pureed foods. He
wears a bib to keep his chest dry due to issues in saliva management. He will attempt
to reach and interact with a toy, resulting in increased stiffness characterized by upper
extremities (UE) flexion with humeral extension and internal rotation. When Joey
reaches, his lower extremities (LE) move into extension with internal rotation.

He attends preschool for half a day, five days a week, and enjoys socializing with peers
in the classroom. Any activity is exciting, which results in increased stiffness, pushing
into extension with asymmetry. Joey engages in visual activities for only brief periods,
as he requires large visual targets. He attends the preschool program in the morning, as
he requires a three hour nap every afternoon due to fatigue.

When placed on the floor in prone, Joey becomes distressed and hyperextends his head
and neck, lumbar spine, and LEs, resulting in an asymmetrical position that causes his
body to flip over into supine. In supine, Joey is unable to move. His mom comments
that she is unable to separate his legs to change his diaper in this position. Attempts to
change the supine posture result in extension of his neck extensors, spine, UEs, and
LEs. His rib cage is flat in contour and elevated with limited space or movement. His
respiratory pattern is shallow with belly expansion. Joey prefers to sit on his parents’
lap or in his adaptive seating system, which he has outgrown. His trunk posture in the
seating system presents a pelvic asymmetry, with muscle shortening on the left more
than right; LE internal rotation with extension and adduction, lateral trunk flexion to
the left, and UE extension. Joey’s orthopedist is monitoring his right hip subluxation.
Joey loves to sit and watch his sister swing outside but becomes emotionally upset
when he is moved. He does like riding in the car, seated in his car seat, which has
allowed his parents to take vacations to visit family.

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Primary Impairments Secondary Impairments

2.1.5B Adult Case Study

Mike is a 59-year old married man with two college-aged daughters. He is employed
by the state as the Northern Director of Audits. He supervises a staff of 50, which
requires him to travel. His diagnosis is right ICH with left hemiplegia. He has been
receiving outpatient therapy services since discharge a month ago.

He presents with decreased range of motion (ROM) in his left ankle, decreased sensory
awareness of his left arm and leg, and delayed ability to swallow. He verbally
communicates and has a tendency to talk on and on even when no one is listening. His
OT is concerned about his two-finger-width shoulder subluxation and anterior shoulder
pain. Mike is able to sit on a mat table without assistance. He is able to pivot transfer,
but only with assistance, as his left side becomes stiff, with flexor posturing in his UE
and extension in his more involved lower extremity. He demonstrates impulsivity in all
functional mobility activities. He is dependent on a wheelchair for mobility, although
he is very motivated to stand and walk. Visually, he is able to focus on the right side
but has a visual field cut on the left. He is right handed and eats with utensils using his
right hand, as his left arm is pulled next to his trunk. He continues to have severe pain
and edema in his left UE. He is unable to dress himself, and when he attempts to do so,
loses his balance and falls back into trunk flexion. He requires assistance for all
activities of daily living and has recently begun taking medication for depression.

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Primary Impairments Secondary Impairments

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Learning Activity 2.1.6 (pp. 46-49; 90-93)

Match the following terms with their respective definitions.

TERMS DEFINITIONS
A Base of support The distribution of the body weight at rest
in relation to the support surface and in
anticipation

B Balance The fundamental arrangement of body


segments relative to each other with
reference to the force of gravity; the base of
support as needed to anticipate and organize
the movements needed for the nature of the
task

C Weight shifting Controlling the body’s position in space for


the purposes of stability against the force of
gravity and orientation of the body
segments to each other in task-specific
relationships; requires the integration of the
sensory information to assess the position
and motion of the body in space and the
motor mechanisms to generate forces for
controlling the body position and to prepare
for reactive forces of movement

D Alignment The mechanical forces that affect muscles


and joints at rest or while in motion;
includes range of motion, muscle strength,
skeletal and articular structures and force
and length of the muscle-tendon unit.

E weight bearing Consists of proactive postural orientation,


steady-state or postural stability and
reactive postural adjustments to stabilize the
body against the force of gravity

F Biomechanical components of movement The ability to change the distribution of the


body weight relative to the support surface
and in anticipation of movement

G Postural control The quality of temporal-spatial execution of


a task, (e.g., accuracy, reliability, efficiency,
quickness and adaptability)

H Coordination All points of the body in contact with


surfaces, and the area of the surfaces
between points

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Learning Activity 2.1.7 (pp. 91-92)

Identify each neuromuscular system impairment as a positive or a negative sign. Use


‘P’ for a positive sign and ‘N’ for a negative sign.

______ Insufficient force generation (weakness)

______ Timing and sequencing (temporal and sequencing impairments)

______ Hypokinesia (poverty of movement)

______ Spasticity

______ Excessive overflow of intralimb and interlimb contractions

______ Impaired anticipatory postural control

______ Impaired motor execution (impaired modulation/scaling of


forces)

______ Loss of fractionated or dissociated movements

______ Impaired muscle activation (excessive co-activation, impaired


muscle synergies)

Learning Activity 2.1.8 (pp. 96-99)

For the following case presentation, identify the relevant contextual factors that may
impact progress in therapy.

You have been treating 17-year-old Joel for one month in your outpatient clinic. He
was in a motor vehicle accident that resulted in a traumatic brain injury four months
ago. Prior to the accident, he struggled at school and had failed the ninth grade. His 19-
year-old brother brings him regularly to therapy, but prefers not to remain for the
sessions. Both parents work full time and speak only Spanish, although both boys
speak English. Joel was given a manual wheelchair that does not fit him. A new one
has been ordered but will not arrive for two months. With the assistance of a therapist,
he can walk short distances using a walker with a forearm support on the right to
accommodate the forearm fracture. It is unclear if he walks at home. He is still
receiving homebound education three times a week. It is unclear when he will return to
school and if special education will be required. He makes inappropriate sexual
comments and uses frequent expletives. When engaged in an activity, he works hard
and follows directions.

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1. Place at least one contextual factor from the case presentation in each of the boxes
below.

Facilitator Hindrance/Barrier

Personal

Environmental

2. Explain how each factor may influence therapy and how you might address each
factor during the therapy session.

Factor How addressed in therapy

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UNIT 2.2: NDT Assumptions of Motor Dysfunction
(pp. 99-140)

Objectives
At the conclusion of this unit, the reader will be able to:

1. Identify the 14 assumptions of motor dysfunction within the NDT Enablement


Model

2. Distinguish between key terms used to describe posture and movement


dysfunctions

3. Describe how impairments of posture and movement contribute to the


development of movement dysfunction

4. Differentiate between impairments and ineffective postures and movements

5. Describe the clinical interrelationship of primary and secondary impairments to


motor dysfunction and functional limitations

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Learning Activity 2.2.1 (pp. 99-100)

The following statements reflect the 14 assumptions of motor dysfunction in the NDT
approach. Identify which ones are true and which ones are false with a ‘T’ or an ‘F’. If
the statement is false, correct it.

Movement dysfunction can emerge from specific disease processes.

All disease processes will lead to primary impairments.

Secondary impairments emerge from the interaction within body systems and
can result in movement dysfunction.

An individual’s desire to solve motor problems in all that is needed for motor
function.

Secondary impairments may further complicate the individual’s functional


abilities and lead to disability in life roles.

Impairments do not interfere with an individual’s ability to have many


movement strategies.

Motor dysfunction affects the whole person.

Secondary impairments occur at the activity level in the enablement model.

Primary impairments refer to the negative signs of underlying neuropathology.

Knowledge of typical function across the life-span is important in determining


the level of participation expected from a client.

Therapists need only to use a problem-solving approach in their evaluation of


clients, integrating information from standardized and norm-referenced tests,
knowledge of the pathology and medical reports.
Impairments can not be changed with experience or environment toward
conditions.

The sensory and motor impairments that individuals with CNS dysfunction
demonstrate are somewhat predictable but will affect each individual’s ability
to carry out life functions differently.
Our clinical observations of effect and ineffective posture and movement
strategies help us link the individual’s impairments and functional abilities.

The timing of the initiation of intervention is not important to the optimal


outcome.

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Learning Activity 2.2.2 (pp. 101-138)

The list below contains examples of both system impairments and ineffective postures
and movements. Identify the system impairments with an ‘I’ and the ineffective
postures and movement statements with a ‘PM’.

Loss of proprioception on the left with hemiplegia

Lower rib flaring with sternal retraction

Decreased perceptual awareness of midline

Trendelenburg of left hip

Visual neglect

Decreased hamstring length

Weakness of respiratory muscles

Breath holding

Inability to initiate activity in the muscles around the shoulder girdle

Knee hyperextension

Weakness of hip abductors

Can’t weight shift forward

Visual cortical blindness

Asymmetrical alignment of the trunk

Tightness of pectoral muscles

Flexion synergy in UEs during gait

Decreased level of alertness

Decreased balance

Decreased cardiovascular endurance

Use of phasic bursts of postural muscles to overcome interia

Decreased ability to grade activity between the flexors and extensors around the knee

Abducted scapula

Forward head posture

Decreased ability to sustain activity in deep thoracic extensor muscles

Weakness of cheek and lip musculature

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Learning Activity 2.2.3 (pp. 101-121)

Pediatric example: Use the pictures on pages 271 and 272 of the text, figures 4.1, 4.3,
and 4.4.

Adult example: Use the pictures on page 292 of the text, figures 4.37 and 4.38.

2.2.3A Analyze the pictures referred to above. Identify the effective and ineffective
postures.

Effective Posture Ineffective Posture

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2.2.3B Based on your analysis above, hypothesize the system strengths and the system
impairments that may explain the postures observed.

System Strengths Possible System Impairments

2.2.3C From your analysis, identify three of this patient’s possible functional activities
and functional activity limitations. Be specific.

Functional Activities Functional Activity Limitations

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UNIT 2.3: Process of Recovery and Compensation
(pp. 140-148)

Objectives
At the conclusion of this unit, the reader will be able to:

1. Identify the current theoretical neural control model used within NDT
approach

2. Identify the sequelae associated with the recovery of the central nervous
system following an insult

3. Define recovery and compensation

4. List non-neural factors that can influence the process of recovery

5. Compare and contrast the processes of recovery and compensation

Learning Activity 2.3.1 (pp. 140-141)

Fill in the blank:

1. NDT has adapted to a _____________ _____________ of the CNS versus the


old hierarchical model. This helps to explain two phenomena in the recovery
of the individuals with CNS damage.

2. Which two of the following statements represent the two phenomena in the
recovery of individuals with CNS damage?

a. Neural damage and recovery can lead to both adaptive and maladaptive
behaviors.

b. Men recover their motor abilities easier than women do.

c. An individual’s prior activity level and skill has very little to do with
his/her recovery.

d. There is variability in functional activity limitations among individuals


despite similar factors (e.g., site and extent of lesion).

e. Damage to the cortex of the brain can have a greater functional impact than
damage to the basal ganglia.

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Learning Activity 2.3.2 (pp. 140-141)

1. Define Recovery.

2. Define Compensation.

Learning Activity 2.3.3 (pp. 143-148)

Research in recovery has shown that the brain has great capacity to change. No single
mechanism accounts for the return of function following injury. There seems to be a
variety of neural and non-neural factors that collectively, could account for recovery.

List the non-neural factors that can contribute to brain recovery.

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Learning Activity 2.3.4 (pp. 140-148)

Both recovery and compensation are examples of CNS plasticity. One causes positive,
functional recovery and the other causes negative, maladaptive movement.

Sort the following list of conditions, which could contribute to positive, functional
recovery and negative, maladaptive movement, by placing a P for positive plasticity or
a N for negative plasticity next to each condition.

_______ Receives minimal amount of therapy

_______ Practicing within functional activities that are challenging

_______ Family unable to assist with home program

_______ Pre-existing co-morbidities

_______ Receiving coordinated interdisciplinary team interventions

_______ Use of adapted equipment that allows the client to use inefficient movement
strategies

_______ Structured practice opportunities throughout the daily routing

_______ Active support/dynamic weight bearing through the more involved limbs

_______ Facilitation strategies to activate the muscles in the more involved limbs

_______ The caregiver continuing to assist with parts of functional tasks

_______ Achieving active optimal alignments in functional activities

_______ Assistive devices prescribed early in the intervention process

_______ Highly motivated client

_______ Learning one-handed strategies

_______ Passage of extended period of time since the CNS damage

_______ Allowing the client to make movement mistakes

_______ Limiting the practice of inefficient movements

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UNIT 2.4: Research and Evidence-Based Practice
(pp. 148-156)

Objectives
At the conclusion of this unit, the reader will be able to:

1. Discuss the challenges in documenting the effectiveness of NDT


2. Describe how NDTA™ Inc. has addressed the need to establish evidence

Learning Activity 2.4.1 (pp. 148-155)

In today’s climate of accountability, we must justify what we do. We begin with


objective observations and then submit what we believe about out observations to the
rigors of experimental research in order to know which interventions work, for whom,
and under what conditions.
Documenting effectiveness is difficult because of the complex problems and the
heterogeneity characterizing this population and the professionals involved in their
care.

Discuss some of these challenges.

Learning Activity 2.4.2 (p. 156)

List the steps the NDTA™ Inc. has taken to work towards evidence-based practice.

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