This document summarizes how an instructor teaches the NDT Enablement Classification of Health and Disability model over a seven-month pediatric certification course. The instructor introduces the four-level enablement model on day two and provides examples for each level. Over the next few days, typical and atypical development is presented in the same format as the model for different categories of cerebral palsy. The instructor reinforces use of the model throughout labs, homework, and in teaching students how to assess clients and plan treatment according to the model. The document concludes with an example of how the instructor would use the model to plan a treatment session for a six-year-old girl with cerebral palsy.
This document summarizes how an instructor teaches the NDT Enablement Classification of Health and Disability model over a seven-month pediatric certification course. The instructor introduces the four-level enablement model on day two and provides examples for each level. Over the next few days, typical and atypical development is presented in the same format as the model for different categories of cerebral palsy. The instructor reinforces use of the model throughout labs, homework, and in teaching students how to assess clients and plan treatment according to the model. The document concludes with an example of how the instructor would use the model to plan a treatment session for a six-year-old girl with cerebral palsy.
This document summarizes how an instructor teaches the NDT Enablement Classification of Health and Disability model over a seven-month pediatric certification course. The instructor introduces the four-level enablement model on day two and provides examples for each level. Over the next few days, typical and atypical development is presented in the same format as the model for different categories of cerebral palsy. The instructor reinforces use of the model throughout labs, homework, and in teaching students how to assess clients and plan treatment according to the model. The document concludes with an example of how the instructor would use the model to plan a treatment session for a six-year-old girl with cerebral palsy.
of Health and Disability By Jane Styer-Acevedo, PT In 1998, the Instructors Group (IG) of NDTA adapted the International Classification of Impairments, Disabilities, and andicaps (ICID!") ta#onom$ de%eloped b$ the &orld ealth 'r(ani)ation (1999* currentl$ International Classification of function, IC+* &orld ealth 'r(ani)ation, ",,1)- The IG added a fourth dimension.motor functions.as part of the decision! ma/in( process in NDT to help plan inter%entions directed to specific functional outcomes and ascertain the indi%idual0s participation in societ$ (o1le ",,", p- 8"-) This four!le%el enablement model classifies function and disabilit$ in four dimensions2 a) s$stem inte(rit$3impairments, b) effecti%e3ineffecti%e posture and mo%ement, c) indi%idual functional acti%ities3acti%it$ limitations, and d) participation3participation restrictions in clients 1ith cerebral pals$ or stro/e (o1le, pa(e 8")- This model is used 1hene%er the client is assessed, 1hen the client0s desired functional outcomes are bein( identified, and 1hen the treatment session is planned- It is critical that practitioners be a1are of ho1 their therap$ promotes the ac4uisition of or impro%ement in the client0s current functional s/ills or the return to pre%ious function after ac4uired in5ur$ at all four le%els- The enablement model pro%ides common lan(ua(e for people to share information 1ith and about the client, emphasi)in( the stren(ths and abilities at the %arious le%els of function in an indi%idual0s life- ELEMENTS OF TEACHING I teach pediatric certification for 6, da$s o%er a se%en month period- The first and last 1ee/ends are four da$s, the intensi%e middle section is t1o 1ee/s, and other se(ments are three!da$ 1ee/ends- After presentin( the current theoretical basis for the NDT approach on the first da$, I introduce the NDT 7nablement 8odel accordin( to the table that is found on pa(e 8" of Neuro- Developmental Treatment Approach, Theoretical Foundations and Principles of Clinical Practice (o1le ",,") on da$ t1o- I pro%ide the basic definitions and e#amples for each of the le%els 1ithin the model and as/ the class for e#amples accordin( to their o1n e#perience- '%er the ne#t three da$s, t$pical de%elopment and the at$pical de%elopment of t1o cate(ories of cerebral pals$ are presented to the class- This %er$ detailed information is presented in the same format as the NDT 7nablement 8odel, meanin( for each (roup of months of t$pical de%elopment and for each cate(or$ of C9, participation abilities and limitations, functional abilities and limitations, posture and mo%ement beha%iors, and sin(le s$stem abilities are presented- Durin( the second se(ment of the course, the remainder of the cate(ories of C9 is co%ered in similar detail- The students hear and see 1hat items belon( in each cate(or$ repeatedl$- o1 to complete an assessment accordin( to the NDT model is co%ered durin( the second da$ of class, accordin( to the (uidelines in o1le0s boo/- This su((ested or(ani)ation uses the le%els of the 7nablement 8odel so the information is co%ered in that %enue as 1ell- I tal/ briefl$ about the use of standardi)ed tests3assessments 1ithin the conte#t of the child0s o%erall assessment- 'ur professions constantl$ need to 4uantif$ and 4ualif$ 1hat 1e are doin( 1ith the child, their pro(ress o%er time, and their eli(ibilit$ for certain pro(rams- :tandardi)ed tests are not co%ered in detail 1ithin the NDT 8odel as the$ are used in an ad5uncti%e manner- I do not consider learnin( the tests as a part of this curriculum and as such, encoura(e all participants to learn the tests that are re4uired b$ their emplo$ers or businesses- Durin( the second se(ment of the course in the alternate format, I brin( an 'T instructor into the course to present ;Tas/ Anal$sis< to the class o%er a t1o!da$ period- &e use the same 1ords $et a(ain- &hen anal$)in( the identified tas/, 1e as/ 1hat are the essential posture and mo%ement beha%iors that are re4uired to perform the tas/ in a t$pical 1a$- Then, after loo/in( at children 1ith sensor$!motor challen(es (neurolo(ical impairment), the students are re4uired to determine the posture and mo%ement beha%iors of the particular child- The$ then identif$ those that limit the child0s abilit$ to complete the tas/ 1hen compared to the essential posture and mo%ement beha%iors 1hen the tas/ is t$picall$ performed- The students are di%ided into (roups for this problem!sol%in( process- 7ach (roup presents its findin(s to the class alon( 1ith its h$potheses of contributin( factors from the s$stems le%el of the neuromuscular, musculos/eletal, and sensor$3perceptual s$stems- The use of the 7nablement 8odel is reinforced dail$ 1ithin the course as the terms are used in labs and practica as 1ell as re4uired in home1or/ assi(nments that are completed bet1een the se(ments of the class- It is 1ithin the assessment, the e#amination, and the e%aluation of the client that this model becomes incredibl$ helpful to the treatin( therapist in plannin( the most effecti%e and efficient treatment session and inter%ention strate(ies to facilitate the client0s successful achie%ement of the identified functional outcome- Therefore, 1hen teachin( this enablement model to a class, I inte(rate the model directl$ into an NDT Treatment 9lannin( &or/sheet that the therapist 1ill use to plan the treatment session- This is accomplished b$ sharin( a client0s assessment and treatment plannin( form 1ith the class- I 1ould li/e to do so here, usin( the table as I ha%e adapted it and a shortened %ersion of the 1or/sheet I use and that 1as ori(inall$ de%eloped b$ :u)anne Da%is, 9T, Coordinatin( Instructor for pediatric NDT- T$picall$ I teach usin( a po1er point presentation into 1hich I ha%e dra1n both m$ adapted %ersion of the NDT na!lement Classification of "ealth and Disa!ility and a t1o!pa(e ;shortened< form (for ease of sharin( the information) of :u)anne Da%is0s ori(inal si#!pa(e 1or/sheet- In this 1a$, I can refer to the documents readil$ to orient the students3therapists- SING THE MODEL The follo1in( information is ta/en from a treatment session planned for and completed 1ith a child named 8adison in Au(ust ",,=- :he is a si#!$ear!old (irl 1ith a dia(nosis of cerebral pals$ of the spastic athetoid classification- I prefer to loo/ at the ;bi( picture< first and be(in m$ assessment and plannin( at the le%el of participation- I ;peel the onion< to see 1hat the cause mi(ht be for an$ area in 1hich 8adison has difficult$- If I can still as/ ;1h$,< I /no1 there must be a deeper reason for the limitation- As I introduce each of the four le%els of the model, I define the le%el and complete the information for 8adison (in italics) as follo1s2 Fo!ndation of T"eatment #lan$ #a"tici%ation$ the nature and e#tent of a person0s in%ol%ement in life situations Ad&e"tisement$ Clic' belo( fo" la"ge" ad) Attends #inder$arten daily n$a$es in play %ith playmates at home Attends church services %ith family &nteracts %ith lar$e e'tended family at family $atherin$s #a"tici%ation "est"iction$ an$ problem an indi%idual ma$ ha%e in the manner or e#tent of in%ol%ement in life situation- (e)uires physical assist for mo!ility on play$round at school and in the community Cannot en$a$e in play %ith playmates %ithout assistance or set-up Cannot *oin her classmates in $oin$ places %here her +C,stroller,%al#er cannot $o People outside of the family cannot understand her ver!al communication F!nction$ directl$ obser%able acti%ities- 9erformance of a tas/ or action b$ the indi%idual Transitions floor to lon$ sittin$ and plays in sittin$ for -.-/0 minutes Pulls up to #neelin$ on furniture Transitions couch to #neelin$ on floor via tummy or !ac# (olls !ac# to !elly and !elly to !ac# Self feeds usin$ utensils and drin#s %ith a cup usin$ / hands Commando cra%ls len$th of t%o rooms Creeps in )uadruped 1-2 3steps4 %ith assist of - to maintain position and !alance +al#s /05 %ith physical assist at trun# and hips +al#s %ith Pacer inconsistently in classroom and at home $iven ver!al cues Communication6 initiates conversation %ith friends and family Calls out loudly !et%een rooms for assistance Tal#s %ith youn$er !rother and family,friends 7olume and len$th of utterance increase in the pool F!nctional limitations$ difficult$ or inabilit$ an indi%idual ma$ ha%e in performin( a tas/ or function (e)uires physical assistance for any vertical mo!ility Dependent on manual +C,stroller for mo!ility and mana$ement (e)uires supervision for po%er +C mo!ility Dependent in all dressin$, toiletin$, and !athin$ nvironmental and personal conte'tual factors6 En&i"onmental$ the ph$sical, social, and attitudinal en%ironment in 1hich people li%e and function (e#ternal)2 facilitators and barriers #e"sonal$ +eatures of the indi%idual that are not part of a health condition or functional state (internal)2 facilitators and barriers #ositi&e and Negati&e Conte*t!al Facto"s$ o Supportive e'tended family o asily frustrated %hen communication is not understood o &nsurance covera$e availa!le o "as tantrums %hen frustrated o Social $irl o &nconsistent 8P therapy covera$e +) F!nctional o!tcome$ &rite the desired functional outcome- >emember it must be functional and meanin(ful to the client, his or her famil$, and3or the care(i%ers- 'utcomes must be challen(in( $et meanin(ful to the client so that the$ are moti%ated to participate in the session and e%en ta/e the lead or share the lead durin( the session as possible- The time frame must be clearl$ stated and understood- T$picall$, this anal$tical process is used for e%er$ treatment session- &ith $ears of e#perience and man$ repetitions, this process can be done 1ithout 1ritin( the information on the 1or/sheet but b$ a mental anal$sis- ,) Session f!nctional o!tcome$ 9adison %ill %al# /0 feet to%ards the s%in$ set %hile in her Pacer, do%n the drive%ay incline, head in midline %ith her shoulders over her hips, feet at hip %idth and not scissorin$, foot flat at heel stri#e %earin$ her dynamic an#le-foot orthosis :DAF8s;, hip a!ove the ipsilateral foot at push off, %hile !oth hands hold the Pacer handles for sta!ility, or either hand is held !y an adult for t%o of three trials< #ost!"e and Mo&ement -eha&io"s .#/M-s0$ directl$ obser%able and a result of the interaction of man$ s$stems- I identif$ t1o to four 9?8@s that are critical to the successful completion of the identified functional outcome- The interaction of the s$stems includes the indi%idual, the tas/ itself, and the en%ironment- The rele%ant en%ironment includes the surroundin(s, famil$, culture, and care team- Ineffecti%e 9?8@s can include ali(nment, 1ei(ht bearin(, balance and postural control, coordination, muscle and postural tone, and biomechanical and /inesiolo(ical components of mo%ement- ere are the t1o 9?8@s that 1ere identified for 8adison as re(ards the identified functional outcome- 1) #ost!"e and Mo&ement -eha&io" 21 At heel stri#e, lum!ar spine is in hypere'tension %ith anteriorly tilted pelvis, hip in a!duction, e'cess fle'ion and e'ternal rotation %ith #nee e'tension and an#le plantarfle'ion, ri$ht = left< 3) #ost!"e and Mo&ement -eha&io" 2 3 Bilateral upper e'tremities $enerally in scapular adduction and elevation, ri$ht humeral e'tension %ith internal rotation and adduction, el!o% and %rist e'tension %ith a fist> the left upper e'tremity is in humeral e'tension %ith e'ternal rotation and el!o% fle'ion, forearm pronation %ith %rist fle'ion and fin$er e'tension< Single system4Integ"ity -ody f!nction$ the ph$siolo(ical or ps$cholo(ical functions of the bod$ s$stem -ody st"!ct!"e$ the anatomical parts of the bod$ such as or(ans, limbs and their components Single system im%ai"ment$ 9roblems in bod$ function or structure as a si(nificant de%iation or loss- :in(le s$stem impairments occur 1ithin the indi%idual s$stem or structure- 8ulti!s$stem impairments occur as a result of s$stem interaction (i-e-2 tone, balance)- Temporar$ or permanent, the$ are sub5ect to chan(e o%er time and can include the follo1in( s$stems2 neuromuscular, musculos/eletal, sensor$3perceptual, respirator$, cardio%ascular, inte(umentar$, (astrointestinal, ps$cho3emotional, co(niti%e, endocrine, (enitourinar$, and reproducti%e- Ad&e"tisement$ Clic' belo( fo" the f!ll sched!le of 355, City 6ids Co!"ses) In presentin( the bod$!s$stems le%el of the content, I stron(l$ recommend practicin( the obser%ational s/ills re4uired to identif$ the %arious component parts of the different s$stems- This is done %ia slides, %ideotape presentation, 1or/in( 1ith a %ariet$ of partners in lab, and durin( assessment and treatment demonstrations b$ the %arious instructors in the class- +or e#ample, 1hen an instructor states that the hip abductors and adductors are not coacti%e, it ma$ be pointed out in a slide or durin( a treatment demonstration that in the stance phase of (ait, the le( is postured in too much abduction or too much adduction as compared to t$pical (ait 1here the le( should be under the hip 5oint- If the hip musculature 1ere sufficientl$ coacti%e, the le( 1ould be in neutral abduction3adduction to sli(ht adduction durin( stance phase of (ait- Another e#ample mi(ht be the inabilit$ to sustain acti%it$ of the postural s$stem- 'bser%ations that can lead one to this s$stem impairment in a standin( posture mi(ht be the pel%is restin( in an anterior tilt, the poorl$ ali(ned spinal column, and an anteriorl$ positioned head and nec/ that de%elops in a short period of time from 1hen the child 1as demonstratin( a 1ell ali(ned head and trun/- These and similar clinical si(ns are pointed out to the class fre4uentl$ so that the$ learn 1hat the terms mean and ho1 to utili)e them 1ith the children that the$ see in practicum be(innin( in the second se(ment of the course- The follo1in( is the anal$sis of the s$stems for posture and mo%ement beha%iors A1 and A"2 1) #ost!"e and Mo&ement -eha&io" 21 At heel stri#e, lum!ar spine is in hypere'tension %ith anteriorly tilted pelvis, hip in a!duction, e'cess fle'ion and e'ternal rotation %ith #nee e'tension and an#le plantarfle'ion, ri$ht = left< Ne!"om!sc!la" System 21 coactivation of a!dominal and $luteal muscles coactivation of hip a!ductors and adductors a!ility to sustain activation of the postural system moderate hypotonia of trun# a!ility to sustain activation of the a!dominals a!ility to terminate activity in lum!ar e'tensors, iliopsoas, )uadriceps, plantarfle'ors a!ility to terminate activity in latissimus dorsi reciprocal inhi!ition of )uadriceps and hamstrin$s Poor timin$ and coordination M!sc!los'eletal System 21 %ea#ness of hip e'tensors, )uadriceps, dorsifle'ors and plantarfle'ors %ea#ness of a!dominals !ilateral hamstrin$s limited to .0? popliteal an$le dorsifle'ion limited to .? !ilaterally flared ri! ca$e :no s#eletal anomalies,deformities; Senso"y4#e"ce%t!al System 21 &mpaired proprioceptive a%areness of trun# and le$s Poor tactile a%areness of le$s Poor #inesthetic a%areness 3) #ost!"e and Mo&ement -eha&io" 2 3 Bilateral upper e'tremities $enerally in scapular adduction and elevation, ri$ht humeral e'tension %ith internal rotation and adduction, el!o% and %rist e'tension %ith a fist> the left upper e'tremity is in humeral e'tension %ith e'ternal rotation and el!o% fle'ion, forearm pronation %ith %rist fle'ion and fin$er e'tension< Ne!"om!sc!la" System 23 coactivation of a!dominal and $luteal muscles a!ility to sustain activation of the postural system moderate hypotonia of trun# a!ility to sustain activation of the a!dominals a!ility to terminate activity in latissimus dorsi, ( = @ a!ility to terminate activity in lum!ar e'tensors, iliopsoas, a!ility to terminate activity in ( triceps and @ !iceps, ( %rist e't and @ %rist fle#ors M!sc!los'eletal System 23 %ea#ness of a!dominals, scapular depressors, and triceps dissociation of scapulae and humerii flared ri! ca$e Shortened latissimus dorsi :see decreased shoulder fle'ion; :no s#eletal anomalies,deformities; Senso"y4#e"ce%t!al System 23 &mpaired proprioceptive a%areness of trun# and arms tactile a%areness of arms and hands Poor #inesthetic a%areness After completin( the anal$tical process to determine the impairments for each of the t1o posture and mo%ement beha%iors that I identified, I continue 1ith the NDT Treatment 9lannin( &or/sheet (please refer to fi(ure 1) to simpl$ identif$ those impairments that occur more than one time in the anal$tical process- The$ are listed in no apparent order- 7e%eated Im%ai"ments$ Bist those impairments that are mentioned in more than one 9osture and 8o%ement @eha%ior Decreased coactivation of a!dominal and $luteal muscles Decreased a!ility to sustain activation of the postural system +ea#ness of a!dominals Poor #inesthetic and tactile a%areness Decreased a!ility to terminate activity in latissimus dorsi &mpaired proprioceptive a%areness of trun# Decreased a!ility to terminate activity in lum!ar e'tensors and iliopsoas Decreased a!ility to sustain activation of the a!dominals 9oderate hypotonia of trun# Clic' fo" la"ge" detail) #"io"iti8e No1, usin( clinical 5ud(ment, prioriti)e the top fi%e or si# impairments that $ou ha%e listed abo%e, accordin( to the identified functional outcome- There is no recipe for this process- It relies hea%il$ on $our o1n 5ud(ment and e#perience 1ith pre%ious children 1ith neurolo(ical impairments and 1hat impairments 1ere /e$ to their success in particular functional s/ills- This list 1ill be different for e%er$ client and possibl$ for e%er$ functional outcome- +or 8adison and her identified functional outcome2 Decreased a!ility to sustain activation of the postural system Decreased coactivation of a!dominal and $luteal muscles 9oderate hypotonia of trun# Decreased a!ility to terminate activity in latissimus dorsi Decreased a!ility to sustain activation of the a!dominals Decreased a!ility to terminate activity in lum!ar e'tensors and iliopsoas +ea#ness of a!dominals &mpaired proprioceptive a%areness of trun# T"eatment #lanning a%in( done a stellar 5ob of anal$)in( $our client0s abilities and limitations, $ou are no1 read$ to mo%e into the treatment plannin( phase- +ollo1in( the NDT Treatment 9lannin( &or/sheet, list 'ther Considerations- The follo1in( ma$ positi%el$ or ne(ati%el$ impact the treatment session2 client0s preferences, client0s disli/es, conte#tual factors, positi%e and ne(ati%e- 8adison0s considerations that ma$ positi%el$ impact the successful completion of the outcome2 @oves to play @oves to !e outdoors n*oys readin$ !oo#s and %ritin$ %ith crayons 8adison0s considerations that ma$ ne(ati%el$ impact the successful completion of the outcome2 Prefers 3!ein$ in control4 at all times Brother 3helps4,does a $reat deal for 9adison %henever they are to$ether No1 $ou are read$ to de%elop the treatment plan that $ou 1ill use to facilitate the achie%ement of the outcome 1ith the client- &hat is the functional outcomeC Consider the prioriti)ed impairments and the chan(e that $ou anticipate for each impairment- >emember that treatin( multiple impairments 1ith a sin(le strate($ is time efficient and can be 4uite effecti%e- @elo1, $ou 1ill see a table that lists the t1o 9osture and 8o%ement @eha%iors and the t1o most important impairments that 1ere re%ealed from the prioriti)ation process- I ha%e listed onl$ t1o sample treatment strate(ies for each impairment and the e#pected chan(e from treatment of those impairments- This is b$ no means an e#hausti%e list, simpl$ a samplin( of 1hat one mi(ht choose to use as treatment strate(ies for these t1o impairments onl$- Dou 1ill need to list treatment strate(ies for each impairment that $ou ha%e prioriti)ed- Dou need to plan accordin(l$ to ensure that the se4uence of the strate(ies pro%ide for a smooth and successful treatment session- Clic' fo" la"ge" detail) The treatment session has no1 been planned and is read$ for e#ecution 1ith the clientE a%e fun and en5o$ the session 1ith $our clientE SESSION 7E9IE: 'nce the session is complete, $ou need to re%ie1 1hat actuall$ too/ place and determine 1hether the sustained impro%ed ali(nment in trun/ and limbs and the neutral ali(nment of the pel%is carried o%er to the attainment of the functional (oal- If not, 1h$ notC &hat 1ere the barriers to successC o1 mi(ht $ou ;t1ea/< the ne#t session so that the client mi(ht achie%e the outcomeC 9erhaps $ou need to 1or/ on the same outcome and chan(e some of the treatment strate(ies or the order of the treatment strate(ies- 9erhaps $ou 1ill chan(e the outcome and therefore, the strate(ies ma$ chan(e accordin( to the ne1 prioriti)ed list of impairments that result from the anal$tical process for the ne1 outcome- Dou can re%ie1 the table and the NDT Treatment 9lannin( &or/sheet (do1nload here as 9D+) to be sure that $ou did not miss an important component of the anal$tical process- Feepin( this table and3or 1or/sheet in $our ;mind0s e$e< 1hile assessin( $our client 1ill help to focus $our obser%ations and therefore $our plannin(- Dou 1ill be able to pro%ide more efficient and effecti%e treatment sessions for $our clients to1ards more functional life s/ills 1ith the possibilit$3probabilit$ of participatin( in their preferred life acti%ities- No1, (o and ha%e funE Jane Styer-Acevedo, PT, is a pediatric NDT Coordinator-&nstructor and a Physical Therapist for AenCrest Services in Philadelphia and Dela%are Counties in Pennsylvania< She can !e reached at *sacevedoBrcn<com<