Presenter: Lezlie J. Adler MA OTR/L C/NDT Wkendath@msn.com

Therapy in Educational Setting (TIES) Conference

1

Assumptions in Combining the Theories of NDT and SI

•  Accept the WHO Definition of Disability

•  Begin with Functional Goal with the End Goal of Participation

•  Use a Task Analysis Approach to drive Assessment and Intervention

•  Adhere to Current Principles of Neuroplasticity

•  Commit to the Principles of Dynamic System Theory

•  Apply current principles of NDT and SI (SBI)

2

World Health Organization (WHO) International Classification of Functioning,

Disability and Health (ICF)

•  Disability is the variation of human functioning caused by on or a combination of the following: the loss of a body part or function (impairment); difficulties an individual may have in executing activities (activity limitations); and/or problems an individual may experience in involvement in life situations (participation restrictions)

3

What Are Functional Skills ?

Roles and

Participation

4

FUNCTION/ACTIVITY

•  Directly observable milestones or tasks child can do or not do – Functional activity- can roll,

can crawl, can walk up stairs, has a palmar grasp, can eat pureed food, can say word approximations, can put together a 10 piece puzzles,

– Functional limitation- cannot sit alone, cannot get into quadruped, cannot release object in space, cannot bite solid food, cannot say words, can not stand alone

5

PARTICIPATION •  The extent to which an individual

participates within life situations typical for their age. (Includes community, family, work, school, etc.)

–  Participation- can eat in the cafeteria at school, can play with classmates on the playground, can walk to lunchroom with classmates, can participate in school play

–  Participation restriction- unable to carry books at school, unable to communicate needs to the teacher, unable to participate a school assembly

6

Research Principles that help to identifying appropriate

IEP Goals

Goals of Intervention should be driven by the ability to maximize opportunities for participation for the child. A child’s capacity to achieve a goal is driven by:

u Expectations u Values u Self Efficacy u Desire for Competency

7

Task Analysis Essential Components

of the Task

•  Posture and Movement Components

•  Sensory Processing Components

•  Attention, Perception, and Cognitive Components (integration)

8

Task Analysis Interaction between

Three Elements

•  Person performing the task

•  Goal of the task

•  Environment in which the task in being performed

9

Application to Children with Challenges

•  Emergent Abilities

•  Evolution of Essential Components - Function

•  Contextual Applications – Skill/Participation

10

Mobility: maintaining upright/weight shift

transitions on & off, in & out transitions through space

Self Care: hygiene clothing

feeding toileting tool usage

Communication: visual oral gestures

Essentials of Moving from Function ….to Participation

Leisure Time: independent play exercise entertainment

11

12

How can we utilize the core principles of

Handling (NDT) and Sensory

Processing (SI) to maximize functional

outcomes and ultimately participation

for children with developmental

challenges?

Neuroplasticity •  Neuroplasticity can be broadly

defined as the ability of the nervous system to respond to intrinsic and extrinsic stimuli by reorganizing its structure, function and connections; can be described at many levels, from molecular to cellular to systems to behavior; and can occur during development, in response to the environment, in support of learning, in response to disease, or in relation to therapy.

•  “Harnessing neuroplasticity for clinical applications”, Brain (2011)

13

Dr. Michael Merzenich PHD SOFT – Wired

How the New Science of Brain Plasticity Can Change Your Life

“When our bodies sense a sound, a feeling, a sight or a smell, then our eyes or skin sense or ears or nose translate into patterns of electrical impulses and engage the brain. Those electrical impulse patterns travel through the brain on incredibly thin “transmission wires” (axons), and complexly conveyed in the brain from one brain cell to another. As a skill is developed the specific neural routes that account for successfully performing this new skill become stronger, faster, more reliable, and much more specialized to the task.” page 45 “When the brain is “in a learning mode, alert, concentrate and focused –the brain’s plasticity switches are turned “ON” and ready to facilitate change.” page 53 “In the domain of movement, your brain began the process of self – organization in the womb by … mapping representations of sensory information received back from the limbs and trunk. The brain then systematically related that feedback to different patterns of excitation of the muscles that moved your… arms, legs, and other parts. This was accomplished by the operation of competitive plasticity processes that sored out these crucial relationships. As a baby, you had to learn how to move and what consequence each movement would have. You weren’t going to move anywhere until these sensation - to – movement – sensation relationships were reliably recorded, mapped and stored in your brain.” page 60

14

Theoretical Frameworks and their Emphasis to Attain

Function •  Neuro Developmental

Treatment – Typical Development, Changes

in Motor Performance, and Motor Control as they impact function

•  Sensory Integration – Processing of Sensation as it

impacts adaptive responses

15

Dynamic Systems Theory Current research emphasizes that

interacting systems work together to explaining how humans

accomplish functional tasks

Regulating System

Function- Skill

Commanding System

Comparing System

Environmental System

Neuromuscular

System

Sensorimotor System

Bernstein Heroza Thelen

Musculoskeletal

System

16

Critical Thinking from Assessment to Treatment

Goal Selection: Function to Participation

Task Analysis Typical Performance Parameters

Strategy Selection

Evaluate Results (Post Test)

Treatment Implementation:

17

Observation and Documentation (Pre Test)

Form a Hypothesis: Identify and Prioritize System Impairments & Strengths

Independence Function

Independence is the achievement of a skill because it is important to the individual. It does not delineate quality. The quality of performance only has to be satisfactory to the individual. Independence requires no prompts for performance.

Function can be superimposed on another individual. It does not have to be self-motivated. It always involves an element of dependence because the individual may not perceive relevance, and will need a prompt for performance.

Skill

Performances are variable and adapted to different contexts. Involves anticipation, active problem solving, and the ability to error detect and correct with in the performance.

18

Moving from function to Participation

19

IEP Goals identify

Functional Outcomes by including

• PERSON (who) • PERFORMANCE (what they will do and how they will do it) • PLACE (where the behavior will be performed) • CONDITIONS/HELP (any physical, verbal, environmental assistance) • MEASUREMENT (performance criteria…what determines accomplishment)

and identifying incremental steps

and expected time parameters to accomplishment

Functional Assessment….Participation

u  Identify a Participation Area u  Identify a Functional/IEP Goal u  Essential Musculoskeletal /Neuromuscular Requirements (typical posture and movement behaviors + what you see) u  Essential Sensorimotor Capacities (specific sensations needed +what you see generated) u  Essential Perceptual Strategies

(what is needed and gaps you see during performance) ð Regulation (attention) ð Commanding (perception) ð Comparing Systems (cognition)

u  Environmental Considerations (where) u  Practice Parameters (stage and best method of learning) u  Intervention Plan

ð Preparation ð Simulation ð Practice ð Carry Over ð Infused into Home or Embedded into the classroom

20

NDT

SI

Unique and Common Theoretical Foundations NDT and

SI that contribute to handling and sensory processing intervention

strategies

21

•  NDT is a holistic and interdisciplinary clinical practice

model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. Using the ICF model, the therapist applies a problem-solving approach to assess activity and participation to identify and prioritize relevant integrities and impairments as a basis for the establishment of achievable outcomes with clients and caregivers. An in-depth understanding of typical and atypical development, and expertise in analysis of postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activation of optimal sensorimotor processing, task performance, and skill acquisition for achievement of participation in meaningful activities.

Cayo C, Diamond M, Bovre T, et al. The NDT/Bobath (Neuro-Developmental Treatment/Bobath) Approach. NDTA Network. 2015;22(2):1.

The Neuro-Developmental Treatment Definition

22

NDT is a Practice Model Emphasizing these

TREATMENT PRINCIPLES

u Functional Goal directed activity that is relevant to the child, from which they can receive external knowledge (results), internal feedback (performance), and prepare for the next activity (feed forward).

u Judicious Use of Handling including key points of contact, to maximize skeletal alignment and activation of postural muscle system, limiting the need to increase muscle stiffness and fix the skeleton to perform the functional

u Offer critical information essential to the functional goal: to guide behavior, biomechanical, kinesiologic, sensory, and cognitive responses

u Treatment must be active, involving problem

solving, performing, practicing, and problem solving with in a goal oriented task new opportunities to posture and move, in order to develop new functional motor programs

u Functional goals establish new posture and

movement patterns, the nervous system responds, utilizes, and stores relevant information

23

Typical Movement Principles

•  Flexion > extension > lateral control > rotation •  Elongation > activation •  Re-emergence of primitive skills prior to efficient

movement •  Typical movement is the control and coordination

needed for function

•  Postural muscle activity •  Movement muscle activity •  Movement requires stability and mobility •  Proprioception >Deep pressure > Light pressure •  Organization of function

• Postural Control Requires : Dynamic stability with points of control Symmetrical extension/flexion Lateral flexion Initiation from upper or lower body Rotation Counter-rotation 24

Essentials of Typical Development •  Head:

–  ability to control neck in midranges of flexion + extension leading to rotation

–  extension traveling down spine… –  arms first experiences with support, –  visual localization and tracking in all 3 planes.. eyes are

pathfinders •  Upper Trunk:

–  arms push into the surface –  increased thoracic extension and activation of oblique's drive

descent of the rib cage –  increased activation of the shoulder girdle complex and trunk

facilitates weight shifting in the arms and to the palms hands

•  Lower Trunk: –  increased muscular control connecting the rib cage to the

pelvis provides stability for COM –  activation of the abdominal musculature and deep trunk

extensors –  lumbar positioning changes from flexion to extension…

facilitating hip extension, combination of trunk flexion and extension with rotation

•  Pelvic Girdle and legs: –  legs stable base of support for body movement and

controlled mobility of a stable trunk, wide base provides initial stability

–  controlled trunk flexion, extension and rotation facilitates a narrow base of support,

–  alternating use of the pelvic girdle and legs function for dynamic support and mobility

–  feet used for stability, mobility and propulsion

25

Essential Handling Concepts

Facilitation/ Inhibition

Preparation: Preparation addresses the critical impairments in any system that must be specifically addressed before an individual is ready to move. Facilitation and Inhibition: Keeping undesired responses and movements at bay while activating postural readiness, postural anticipation and control, postural accompaniments, and efficient movement components for new motor patterns. Simulation: Imitate functional goal in a variety of activities that are similar to the functional goal and involve components gained, practice components. Functional Goal: practice the function

Preparation Simulation

26

Function

Key Concepts of Handling

Ø  What movement, component(s), or quality of movement do you want …….FUNCTION Ø  Choice of facilitation: passive/assisted/active Ø  How you hold/contact/pressure Ø  Where you hold/key points of contact (joint or muscle – proximal or distal, single key vs. combinations) Ø  How much you hold (decreasing sensation & support, increasing activation) Ø  Manipulating the direction of force to activate the base of support (ground reaction force) Ø  Direction of movement /degrees of freedom /range of movement Ø  Amount/speed/duration/frequency of stimulus given Ø  Rhythm of movement (person, activity, context) Ø  Repetition/sequence/variation of movement/problem solving/risk Ø  Integrating volition/purpose/meaning (goal directed posture and movement) Ø  Emphasizing sensation Ø  Therapist’s expectations, movement, & activity: lead, follow, guide, terminate Ø  Environmental manipulation

27

SIGN Sensory Integration Global Network •  Sensory integration theory proposes

that sensory integration is a neurobiological process that organizes sensation from one’s own body and from the environment and makes it possible to use the body effectively within the environment. The spatial and temporal aspects of inputs from different sensory modalities are interpreted, associated, and unified. Sensory integration is information processing...Praxis and perception are both end products of sensory integration... Practic ability includes knowing what to do as well as how to do it.

28

Interventions for Sensory Features

AJOT Sept/Oct 2015

Two primary categories of intervention: 1.  Ayres Sensory Integration

(ASI) 2.  Sensory Based Interventions

(SBI)

29

Sensory Based Interventions (SBI’s)

•  “Typically occur in the child’s natural environment and consist of applying adult-directed sensory modalities to the child with the aim of producing a short term effect on self regulation, attention or behavioral organization.”

•  “Common individual SBI’s include weighted vests, brushing, bouncing on a ball, and adaptive seating devices that allow motion”…single sensory and multisensory interventions that do not adhere to ASI Fidelity criteria.

•  SBI’s may be “provided in a systematic manner throughout the child’s day or at as needed in response to the child’s self regulation and are often combined into what is termed a “sensory diet”.” 30

Neuro physiological Processes

supporting the ability to integrate sensation and drive sensory based intervention

Ø Sensory Processing: CNS and PNS ability manage incoming information from peripheral sensory systems. Includes: registration, modulation, integration, and organization of multiple sensory stimuli.

Ø Sensory Threshold: PNS = minimum intensity of the stimulus necessary to produce excitation and inhibition. CNS = process of reaching a threshold leading to the transmission of the electrical or chemical signal.

Ø Sensory Detection: CNS records sensory

information at multiple levels affecting ongoing neural activity.

Ø  Intersensory Integration: multisensory neurons receive input from more that one sensory system, the summing is reflected in the response.

Ø  Sensory Discrimination: distinguishing and organizing the temporal and spatial characteristics of sensory stimuli. 31

Vestibular Ocular Spinal Triangle Josephine Moore PhD OTR

Sensory Synergy

32

Role of the Vestibular System in Postural Control

•  Sensation and Perception of Position and Motion

•  Orients the Head and Body to Vertical

•  Controls Position of the Body’s Center of Mass

•  Stabilizes the Head During Movement

33

Vestibular Receptors

Otolithic Organs

Semicircular Canals

Receptor Macula of Utricle/saccule

Cupula (within ampulla)

Orientation Utricle: horizontal Saccule: vertical

Perpendicular Planes

Stimulus Type

Linear accel/ Deceleration Including gravity

Angular acc/ deceleration

Stimulus Velocity

Slow or static Fast Movement (>2deg/sec)

Response Tonic Phasic 34

n  Definition: Information arising from the body, especially muscle, ligament and tendon receptors associated with a change in joint position (spindles) indicating the position of a body part, body parts to each other, or a body part in relation to a surface (location)

n  Receptors respond most to active movement

n  Greatest generation when muscles contract

against resistance n  Function

Ø  Multifaceted system that influences behavior regulation and motor control

Ø  Affects rate and timing of movements, regulation of muscle force (task specific) and muscle stretch, ability to motor plan, maintain fluidity of movement, calibrate actions in space, interpret feedback from action, stabilize joints, and orient body segments.

Proprioception

35

Posture and Movement System Model

Judith Bierman DPT C/NDT

•  Sensory and Neuromuscular systems that are controlled by complementary subsystems, one for posture and one for movement

•  Posture and Movement are integrated systems, yet –  They are separate systems with

separate characteristics –  Can be studied separately –  Can be damaged separately –  Require different strategies for

intervention 36

Function Requires both the appropriate action of Postural + Movement

Systems and the Perception of their action

•  POSTURAL SYSTEM

•  Dynamically holds body up against gravity

•  Protects joint integrity

•  Provides preparatory set for movement

•  Provides counterbalance for center of mass

•  MOVEMENT SYSTEM

•  Provides range and speed of motor acts

•  Translates large body segments in space

•  Overcomes inertia

37

Architecture and Rules of Engagement

•  Short, broad, angular, deep muscles that cross few joints

•  Activate: skeletal alignment, activate first, work symmetrically, not responsive to thinking, function to hold and move in small ranges, respond to more resistance

•  Long, parallel, distal, superficial, cross many joints

•  Activate: skeletal alignment, after postural muscles, keep moving in larger ranges, respond to light resistance

38

Postural Muscles

Movement Muscles

•  Alerting System for Survival •  Spatiotemporal Adaptation,

Orientation, and Navigation •  Anticipation •  Adaptation •  Learning, Memory, Recall,

and Integration

39

Parallel and Distributed Visual Processing Systems

•  Information carried by the geniculo- cortical pathway is segregated into parallel processing channels –  The “dorsal stream” carries

information to the parietal lobe for the information of WHERE SOMETHING IS LOCATED

–  The “ventral stream” provides information allowing us to recognize WHAT SOMETHING IS

Kingsley, RE (1996). Concise Text of Neuroscience. (p. 410). Williams & Wilkins: Baltimore.

40

Using Vision for Postural Control Rose Marie Rine PT PhD

1.  Retinal and non retinal information (eye position and head)

2.  Movement of the environment vs.

individual’s movement (am I moving or is the environment moving)

3.  Central or peripheral flow (peripheral

flow most important for postural control……visual flow)

4.  Symmetrical eye alignment, convergence, opto kinetic reflex, smooth pursuits, saccades)

41

n  Detection and transmission of sensations via the skin

n  Types: ð Touch: ð Pressure ð Vibration ð Temperature ð Pain

n  Two elements: n  Registration: basic initial sensory processing (awareness) without ascription of meaning n  Perception: understand, interpret or give meaning i.e. internal representation (location, timing, modality specific characteristics)

Exteroception

42

ð Touch: sensation generally results from

stimulation of tactile receptors in the skin ð  Receptors detect subtle changes on

skin surface ð  Via hair displacement ð  Fast response ð  Diffuse sensation

ð Pressure: Results from deformation of deeper tissue ð  Receptors deep under skin surface ð  Slow responses -- cortical analysis ð  Discrete sensation

ð Vibration: Rapid signal as object moves

across skin, rapidly adapting receptor

ð Temperature

ð Pain

Exteroception

43

Variables of Intervention

ü Choice of Sensory System ü Combination of Sensory Systems ü Intensity of Sensory Input ü Frequency of Sensory Input ü Duration of Sensory Input ü Rhythm of Sensory Input ü Timing of Sensory Input

44

Motor Learning Guiding Principles

•  direct result of practice and experience

•  can not be observed directly, processes are internal, must infer learning occurred on the basis of observed changes in behavior

•  produces relatively permanent changes in the capability for skilled behavior (Motor Performance is a relatively short term change.)

45

Motor Learning Treatment Implications •  Preparation:

–  Set the goal for session, including actions –  Give clear instructions (verbal or physical)

•  Person

–  Reciprocity and shared control –  Do not work to fatigue, provide a rest period to

avoid deterioration –  “Work on the edges”

•  Environment –  Choose or adapt to the individual –  Change in context provides variability

•  Task Parameters –  Intervention directed toward functional task –  Assess Complexity of the task

•  Part or whole practice/Serial/Complex Task

•  Practice Schedule –  Acquisition/Refinement/Retention

•  Reinforcement: –  What and how –  Random

46

Treatment Variables Laboratory

Driving Treatment Strategies

Handling

Use of Self

Equipment

Environment

Practice Sens

atio

n

47

Treatment Strategies

Handling

Ø  Task Analysis - Identify critical Posture and Movement Strategies to Emphasize Ø  Choice of facilitation – Alignment over, Activate the BOS, Direction of Pressure, Choice of Postural or Movement Muscle Synergies, Specific Type of Muscle Contraction Ø  Direction of movement - Degrees of Freedom, Range of Movement, Coming to Upright Ø  Where you hold - Key point (s) of contact , single key vs. combinations, stay or move Ø  How you hold - Level of Touch, Area of Contact Ø  How much you hold - Mobility or Stability, When and How you Decrease, Maximize Sensation by Increasing Activation Ø  Repetition and Variation - Facilitation of Posture and Movement Behavior (speed, frequency, duration, rhythmicity), Activity, and Context, Speed, Frequency Ø  Response Time - How Long to Wait

48

Treatment Strategies

Sensation

Ø  Choice of Sensory System Ø  Combination of Sensory Systems Ø  Intensity of Sensory Input Ø  Frequency of Sensory Input Ø  Duration of Sensory Input Ø  Rhythm of Sensory Input Ø  Timing of Sensory Input Ø  Scaffolding

Ø  complexity Ø  challenge Ø  context Ø  interaction

49

Treatment Strategies

Use Of Self

Ø  Feelings - Intentions Ø  Trust and Safety Ø  Expectations - Encouragement Ø  Interaction Ø  Contact Ø  Position Ø  Movement Ø  Activity Level Ø  Rhythmicity of Actions Ø  Non verbal Communication/Feedback Ø  Verbal Communication/Feedback Ø  Therapeutic Surface Ø  Novel or Routine Behavior Ø  Limit Setting - Boundaries

50

Treatment Strategies

Use of Equipment

ü  Stable Surface ü  Unstable Surface ü  Inherent Resistance ü  Alternative Uses ü  Novelty ü  Familiarity ü  Inherent Support ü  Inherent Limitations ü  Substitution ü  Qualities (affordability/independent use) ü  Sensory Properties ü  Motoric Demands ü  Cognitive/Perceptual Demands ü  Relationship to Functional Task

51

Treatment Strategies

Managing The Environment

v  Physical Space v  Visual Space v  Auditory Space v  Structure: Flexibility - Adaptability v  Physical Characteristics

v height v weight v angle v surface texture v resistance v space v location v …..

v  Management vs. Problem Solving v  Work Alone or in a Group v  Method of Instruction (physical, verbal, visual, auditory) v  Complexity vs. Simplicity v  Risk vs. Safety (real vs. perceived challenge) v  Volition: Contextual or Non Contextual v  Rhythm: Organized, Chaotic, Calming 52

Treatment Strategies

Use of Practice/Learning

Ü  Schedules (when) Ü  Frequency (how often) Ü  Context (same vs. varied, setting) Ü  Variety of Practice (similar or different) Ü  Feedback (extrinsic or intrinsic) Ü  Feedback (what and how) Ü  Feedback vs. Feed forward (problem solving or anticipation) Ü  How to Practice (executive vs. physical guidance) Ü  Type (whole vs. part) Ü  Outcomes (predictable or unpredictable)

53

“Combining” NDT and SI Therapeutic

Frameworks ü Based On a Belief That Many

Systems Contribute to Developing Function then Skill

ü Requires Critical Thinking ü Based on a Functional Goal

Enabling Participation ü Develop a Hypothesis….Test

It….Revise It ü Modify Treatment Strategies

Based on Results ü Every Child Has the Potential for

Change

54