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Model Teaching

Teaching the NDT Enablement Classification


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<