Clinician’s Corner

Playing with Postural Control

By Katie Shepard, PT, DPT, C/NDT

During this past year, I had the opportunity to take the NDT certificate course. I have had mentors who
were NDT trained and had been told that it would change everything and was worth it. Nodding my
head, I do not think I realized then how it would impact me as a therapist going forward. It changed my
perspective on movement, facilitation, and play, and I believe the biggest benefit is the progress the
patients make.

When I started seeing kids with a new perspective, I began to notice the subtle details about alignment
and the foundation of postural control. I learned how to better structure my treatment sessions to
maximize functional outcomes, and I learned the importance of postural control within the treatment
session with purposeful movement.

After finishing the course last year, I evaluated a patient with a diagnosis of chromosomal disorder and
some neurological involvement. He demonstrated poor trunk control, low tone, and poor movement
patterns. He is built short and stocky and moves as a block only in the sagittal plane. He needed
assistance for all activities of daily living, including rolling and sitting, with maximal assistance needed to
stand.

I focused my treatment session at

the beginning on improving
mobility at his trunk, rib cage, and
hips and improving movement of
his trunk in relation to his base of
support and in various planes of
movement. Some of his biggest
impairments were lack of mobility
at his hips and trunk leading to
poor posture, including posterior
pelvic tilt, thoracic kyphosis, and
rounded shoulders. I started my
sessions by sitting him on the swing
to increase arousal through
vestibular input, or I gave
proprioceptive input on a therapy
ball.

Because of the lack of mobility in

his chest, I would increase range
through anterior chest expansion techniques and ribcage mobility to increase intercostal space. Then I
would move on to facilitating mobility at the trunk and hips through lateral and anterior/posterior
Clinician’s Corner
Playing with Postural Control
By Katie Shepard, PT, DPT, C/NDT

weight shifts on a therapy ball or anterior weight shifts on an inclined bolster or rotation with extension
over a bolster.

Other activities that I incorporated during many sessions included thoracic extension by reaching
overhead while I facilitated shoulder external rotation and worked on rotation with extension over the
bolster.

As he improved with trunk control and with his sitting balance, he became more alert and engaged.
There are various hypotheses to explain this relationship between postural control and engagement. It
could be the increased vestibular and proprioceptive input, along with a more mobile and stable trunk,
that allowed him to interact and engage with his environment more readily. He was also practicing these
skills at home, including skills that we had not focused on in his therapy sessions, thereby reinforcing the
new motor learning.

Several times, his caregiver reported that he had started rolling on his own before it was observed in an
intervention session. One time, his caregiver said that he would pull to stand if you just held his hands,
which was not an activity that we were working on, and sure enough, he was able to assist with a pull to
stand. That was the moment there where it started to connect. As he started to move more, he wanted
Clinician’s Corner
Playing with Postural Control
By Katie Shepard, PT, DPT, C/NDT

to interact more and play in his environment. I also hypothesize that once he was able to engage and
stabilize his center of mass, he was able to create mobility distally.

I realized the importance of improving postural control because it was the foundation for the
building blocks of movement. For my patient, as he gained more control and stability at his trunk, he
was able to move more distally at his extremities, leading to more exploration of his environment, which
in turn caused him to move and explore.

He once was a child that saw his world on his back and only interacted with his environment from
supine or sitting on a family member’s lap. Now he is starting to initiate the ability to explore on his own
and become more independent. Improving the core and postural control leads functional movement
and becoming independent. Optimizing movement patterns with postural control are the building
blocks for functional movements and helping our patients achieve their goals.

■ Katie Shepard, PT, DPT, C/NDT, is the Physical Therapy Supervisor at Reach Therapy in Houston, Texas.
She can be reached at kshepard@reachtherapycenter.com