Neurodevelopmental Treatment (NDT) Based Assistive Techniques

Question 1

What is NDT historically based on

Answer 1

• Based on achieving the motor development milestones

Question 2

Historical concepts underlying NDT (neuordevelopmental treatment)

Answer 2

• Based on using the developmental postures to improve posture & movement
• Thought to be better to teach the CNS higher levels of motor control in the sequence that it uses for normal motor development in CP and stroke patients
• Influences the CNS through carefully guiding normal movements through “manual therapeutic handling” based on down-up approach and hierarchical model of CNS
• Facilitates desirable reflexes/responses (righting, equilibrium reactions), inhibiting abnormal synergistic reflexes/patterns & counteracting abnormal tone
• Based on the idea that precise ‘manual handling’ would facilitate or inhibit tone

Question 3

Current theoretical approach

Answer 3

• Problem solving based on task orientated functional recovery
• Dynamic movement systems model
• Body, Task, and environment guides CNS to produce movement
• Skilled movement is determined by the specific functional goal
• Task goal, motor learning stage, experience, individual learning strategies, movement synergies, energy, and interest all affect quality of functional activities
• Treatment methods have expanded to involve motor learning principles using ‘task oriented’ practice and feedback patterns

Question 4

Evidence on NDT

Answer 4

• Research evidence is fair
• Lacks high level studies (randomized controlled studies)
• Difficult to determine efficacy

Question 5

Describe our approach on using NDT-based techniques

Answer 5

• Use as ‘assistive techniques’ for patients who need assistance for performing functional tasks (low functional level patients)
• Use manual handling techniques for providing the right sensory experience for functional task to optimize experience dependent neuroplasticiity
• Apply current principles of neuroplasticity & motor learning
• Do not use for purposes of facilitating/inhibiting tone: Use to achieve task specific goals
• Less focus on using for achieving higher levels of developmental postures: Stay focused on the task

Question 6

Intervention parameters for task oriented training

Answer 6

• Practice of impaired components of tasks
• Task modification for progression & regression
• Change BOS, prepositioning, speed changes, amplitude changes, add/remove cognitive demand (dual tasking)
• Environmental modification for progression/regression
• Support surface characteristics
• Perturbations
• Assistance (visual, auditory, manual, or external devices/orthotics)
• Progression using resistance
• Types/progression of practice
• Feedback

Question 7

What differentiates NDT from other interventions

Answer 7

• Precise therapeutic handling differentiates NDT from other interventions

Question 8

Define manual handling

Answer 8

• Handling = manual feedback
• Handling is graded manual input provided by the therapist’s hands at key points of control on the body & should result in better control of posture or movement
• Manual feedback should be gradually reduced/removed as patient gets more independent with tasks

Question 9

Define key points

Answer 9

• The key points (proximal or distal) are the places of physical contact b/w the therapist’s parts of the body or therapy equipment & client’s body

Question 10

Describe proximal key points

Answer 10

• Located closer to the midline
• Shoulder girdle, trunk, pelvis
• Used to influence posture & movement in all 3 planes especially during difficult moments
• Think “proximal stability” per stage of motor control

Question 11

Describe distal key points

Answer 11

• Located away from the midline
• Usually at the upper & lower extremities level
• Used to allow the client to engage in activities with minimal control of the therapist
• Think “distal stability” needed for controlled mobility

Question 12

When & how to apply manual feedback/cues to key points

Answer 12

• Use manual cues to establish BOS or achieve proper postural alignment
• Use manual feedback to provide appropriate cue for movement of body segment, usually by placing hands on the opposite side of the direction of motion
• Apply manual cues with open palms using finger tips if possible
• Start with light contact and gradually increase input as/if needed

Question 13

Describe the sequence of interventions of NDT techniques

Answer 13

• Preparatory activities for body alignment: think preparation phase of Hedman’s temporal framework for tasks
• Selection of the key points for therapeutic handling according to the patient’s posture
• Facilitation of movement by applying graded & varied therapeutic tactile & verbal input

Question 14

Techniques to improve functional mobility

Answer 14

• Proper positioning in supine & side-lying postures counteract abnormal spastic synergies to prevent contractures & pressure sores
• Proper positioning to inhibit tone/spastic synergies pattern: pillows under the hells and each arm for supine; pillows b/w legs, arms, and behind the back for side-lying

Question 15

Tactile cues to assist with bridging

Answer 15

• Light touch or tapping on the weaker side
• Apply task oriented strategies: modify task, environment, or practice in reverse
• Techniques of progression/regression

Question 16

How to improve LE mobility in supine for hip/knee flexion

Answer 16

• Improve hip/knee flexion against synergistic patterns by holding whole foot to inhibit plantar flexion spasticity/clonus: inhibitory technique using deep pressure against foot

Question 17

Describe placing/loading affected LE to counteract spastic synergistic patterns in supine

Answer 17

• Inhibitory technique against spastic synergies, WBing would additionally inhibit spasticity

Question 18

Describe improving UE mobility by counteracting spastic patterns in side-lying

Answer 18

• Scapular protraction using handshake hold with the other hand

Question 19

Describe self mobilization activities using double arm elevation

Answer 19

• Involved UE in anti-spastic posture, manual assistance ti keep scapular protracted, pt holding steady, then increase intensity (active flexion/extension then against resistance, add another load by flexing hip/knees)

Question 20

Key point of control to improve lumbar extension versus thoracic extension

Answer 20

• Lumbar extension: forward and up; correct sensory cueing direction
• Thoracic extension: forward and down; correct sensory cueing direction; below the clavicles

Question 21

Describe how to achieve thoracolumbar extension versus flexion

Answer 21

• Extension: anterior pelvic tilt; key points from the side approach & front approach
• Flexion: posterior pelvic tilt; key point on abdominals from the side approach

Question 22

Describe the approach used for achieving a neutral pelvis

Answer 22

• Side approach and front approach using 4 fingers and ‘pinky finger’ technique

Question 23

Additional manual feedback jey points for positioning UE and trunk in seated posture

Answer 23

• Need to position the affected UE using WBing
• If elbow extension & trunk extension needs manual feedback, can use side approach
• If trunk needs feedback for extension & lateral flexion can use the side-sitting approach

Question 24

Describe functional tasks in seated posture & ideas about progression

Answer 24

• Add functional tasks using this posture (once stability has been achieved, add controlled mobility): with UE shoulder flex/ext or abd, with weight shifts
• Progression/regression ideas: make it more intense by manipulating BOS, add double arm exercise, add weight in hand
  Add functional tasks using this posture (once stability has been achieved,
  add controlled mobility) – with UE shoulder flex/ext or abd
• Change BOS – crossed leg, sit on dynadisc
• Close eyes
• Internal perturbations – shake head
• External perturbations – push
• Add resistance – weights on hands, push towards the tilted side

Question 25

Key points of control for flexion momentum (initiation phase) for a sit to stand

Answer 25

• Side approach (paretic side for safety), front approach (good for protecting affected UE)

Question 26

Key points of control during momentum transfer/lift (execution phase) for a sit to stand

Answer 26

• Take care of the knee
• Therapist on the paretic side: one key point below clavicles and other behind paraspinals, part practice, practice in reverse

Question 27

Other key points to provide manual feedback for a sit to stand

Answer 27

• Therapist sitting in front: both manual cases on side of trunk
• Therapist on paretic side: one manual cue on thigh and other on paraspinals
• Therapist on paretic side: one manual cue on thigh and other positioning the paretic arm appropriately
• Therapist on paretic side: one manual cue below clavicle and other on paraspinals, therapist leg controlling the knee forward movement
• Therapist in front: both manual cues on side of trunk, therapist leg guarding the knee, good for transferring to another seat

Question 28

Describe a sit to stand

Answer 28

• Maintain hip forward flexed & trunk extended posture while coming down
• Don’t let patient touch the edge of seat prematurely, let patient squat to reach for armrests during descent naturally

Question 29

Describe a squat pivot transfer

Answer 29

• Initial conditions: seat height (from and to), w/c preparation
• Patient preparation: BOS at EOB, feet placement staggered, hands placement for creating ‘pre-twist’
• Therapist preparation: hands placement (key points of control), feet placement, sit away from patient in a diagonal fashion
• Initiation/forward flexion: have patient move forward with hip flex/trunk extended position
• Execution/momentum-transfer: trunk rotation cue with hands and therapist knee during pivoting (allow tibial forward movement)
• Termination: avoid flopping down

Question 30

Describe pre-gait activities for standing postural control

Answer 30

• Patients might show knee extension spastic pattern or buckling, pelvic extraction, with weight shifted away from affected side
• Therapist on affected side
• Protect affected UE with sling if needed
• Increase WBing on affected LE
• Protract the affected pelvis: elbow technique (elbow on pelvis and other hand on chest)
• Keep the pelvis protracted with knee extended (elbow on pelvis and other hand on knee)
• Controlling pelvis protraction, knee extension while increasing weight shift on affected LE
• Trunk control may need additional key points for trunk control (other key point under clavicles)

Question 31

Describe the ‘Hip-flck’ method

Answer 31

• Therapist standing behind patient
• Key points on patient’s affected pelvis and on unaffected pelvis/shoulder
• Provide ‘flick’ cue using hand during start of swing phase on retracted pelvis
• Go with patient’s rhythm