Neurodevelopmental Treatment
Neurodevelopmental treatment (NDT) originally was theorized by Berta and Carl Bobath (Pagliarulo, 2012). Since its inception in the late 1940s, the approach underwent a major shift of focus in the 1990s. Originally the approach focused on patterns of movement. Dysfunction of the movement patterns was thought to be caused by a loss of control from damaged higher centers in the brain. These lesions unleashed abnormal reflex activity. In the 1990s a shift from an orthopedic model to a biomechanical and systems model occurred. Current NDT theory embraces knowledge of motor control and looks at the effects of postural control as a result of interactions between many neurologic and physiologic systems.The overall goal of management and treatment, according to NDT theory and tenets, is to enhance the individual's capacity to function. Intervention involves a hands-on approach when working with individuals with central nervous system insults that create difficulties in controlling movements, with NDT embracing several general treatment principles:
- A child with cerebral palsy must be treated as a whole child with a whole personality.
- A good evaluation or assessment of the child must be completed.
- From the time of initial assessment, treatment programs should be customized to meet the needs of the individual child.
- The child's responses to treatment should be reassessed often.
- Realistic and reachable treatment goals are essential.
- Key points of control are used in treatment. Key points of control are parts of the body, typically proximally, where the therapist can apply light pressure to influence movement through the rest of the body.
- Teamwork is essential and must include the family.
In summary, pediatric NDT is primarily used to treat children with cerebral palsy and other movement disorders. However, aspects of the theory are applicable to many different clinical scenarios.
Proprioceptive Neuromuscular Facilitation
Proprioceptive neuromuscular facilitation (PNF) was developed in the early 1950s by Dr. Herman Kabat and Maggie Knott (Pagliarulo, 2012). The goal of PNF was to strengthen muscles within functional movement patterns rather than straight-plane or anatomic-plane motions. These movement patterns are known as diagonals. Physical therapist Dorothy Voss added many clinically relevant techniques to the PNF patterns. The theoretical basis for PNF rests within the hierarchical model of development. Hence PNF theory is based on the developmental sequence and the sequential mastery of motor milestones.
This is one demonstration of a PNF technique. Be prepared to learn more about PNF in 204 Lab. I recommend for those interested to be mentored by a PF therapist or better, take a class in PNF specific to physical therapy and PNF.
Diagonal patterns can efficiently and effectively address specific problems of musculoskeletal weakness, and PNF is based on the principle that human beings respond in accordance with the demand placed upon the neuromusculoskeletal system. Two diagonals of motion exist for each major part of the body, and each diagonal is made up of two patterns that are antagonistic to each other. Each pattern has a component of flexion or extension. Each diagonal involves movement toward and across the midline or movement across and away from the midline and includes rotation with a flexion or extension pattern. When assessing the patient, PNF treatment protocols will look first at the patient's functional abilities. The identified stronger areas (agonist) will be used within the treatment session to assist the weaker areas (antagonist). Treatment movement patterns must be specific and directed toward a goal. Additionally, activity that will best develop coordination, strength, and endurance is necessary. Stronger body parts assist in strengthening weaker body parts though cooperation of muscle groups to achieve optimal function. For this reason PNF places great emphasis on using maximal resistance tolerated throughout the entire range of motion; by resisting stronger muscles, weaker muscles will receive overflow/reinforcement to help them become stronger and more coordinated. To initiate a movement, PNF technique may call for a stretch of the synergist. This provides the increased proprioceptive stimulation necessary to create a chain of muscle activity from a completely lengthened state to a completely shortened state, where the shortened muscle is the agonist.
In summary the PNF techniques work optimally in individuals with muscle imbalances secondary to spasticity, flaccidity, weakness, or pain. As a patient improves, coordination and balance activities can be added. Treatments tend to be intensive, using the patient's existing capabilities and skills without increasing pain or fatigue. The overall emphasis is on improving the person's function .
Conductive Education
Conductive education was theorized by Andres Peto in 1948 in Budapest, Hungary. It is an integrated system that allows a child with motor dysfunction to learn to move within functional skills. Peto believed that children with motor disorders could learn to move by utilizing their brain's plasticity. He believed that learning movement required practice as well as rhythmic intention, so he based his technique on the educational principles of group learning and motivation .
Conductive education is based on four primary principles: a conductor, the group setting, rhythmic intention, and a specific task series for each functional skill. A conductor or a therapist trained in conductive education leads a session. The children attend in a group setting, with a typical ratio of 3 children to 1 adult. Skills are broken down into a series of tasks by the conductor. Children receive individual assistance as needed in order to complete the task at hand. The group of children practices each task until mastered, and then individual tasks are built into mastering skills. Rhythmic intention is the cadence set to time a movement or series of movements. Rhythmic intention allows children to replay the cadence and perform newly learned movements on their own. The cadence helps the child initiate a movement, sequence a movement, and complete the movement. Conductive education focuses on the functional skills a child needs to be optimally independent. This notion is also known as orthofunction. Motor learning and motor control principles come into play, and intensive amounts of practice time are part of conductive education programs.
Conductive education programs use specifically designed equipment that assists the child to perform a movement. Slatted plinths and benches allow the child to grasp between the slats for stability. Additionally, horizontal or vertical posts can be attached to table tops to provide anchors for children to use to stabilize themselves against gravity. Ladder-back standers and ladder-back chairs also provide graspable uprights to use while practicing ambulation. Conductive education programs in the United States are typically 3 to 4 hours per session, with sessions occurring 3 to 5 times per week. Given that generous amount of treatment time, there is wonderful opportunity to practice and use feedback and feed forward mechanisms to master a task and eventually master the skill.
In the United States the trend is to develop transdisciplinary or interdisciplinary teams to provide conductive education programs, using conductors and therapists working together. Some programs also use a hybrid system that allows the child to simultaneously attend their educational program (school) and a conductive education program.
Conductors, who until recently could only receive training in Europe or Hungary, can now earn a teaching certificate with an emphasis on conductive education pedagogy in the United States, and therapists in the United States can receive additional training in the pedagogy of conductive education and be certified as well.
In summary, conductive education is an intensive motor training program that uses motor learning and motor control principles, along with educational learning principles, to teach children with movement disorders to move to their highest potential. This leads to the child being as functional as possible. Conductive education is not appropriate for all children. However, many of the principles and tenets of conductive education can be used successfully with children who may not be eligible for an entire conductive education program.
Strengthening and Stability
Current theories in rehabilitation support the fundamental notion that children with motor impairments must work on strengthening and stability. There is strong evidence in the literature about the importance of strengthening for children with spasticity . Appropriate weight bearing through the long bones helps to maintain bone density and joint structure.
Exercise and strengthening are mandatory for a child with movement disorders to prevent overuse of the strong muscles, atrophy and wasting of weaker muscles, and obesity for children who cannot move as efficiently as their typically developing peers .
Different tools are used to help a child become stronger and more efficient. Appropriate use of a appropriate sized physioballs can be a tool to proximate core muscle strengthening in prone, sidelying, quadruped or supine. Various techniques may be used in addition to any of the other therapeutic techniques when working with a child and/or the child's family.
Therapeutic taping
Therapeutic taping is used to provide support or input to a muscle group. Flexible taping is also known as Kinesio taping, while rigid taping is known as Leukotaping or strapping.
Kinesio taping helps to support weakened muscles or prevent muscle overuse. Kinesio tape is flexible and has elastic properties. To strengthen a weakened muscle, the tape is applied from origin to insertion. To prevent cramping or over contraction of a muscle, tape should be applied from insertion to origin.
Leukotaping (named after Leuko sports tape) is rigid strapping used to support a joint in normal alignment. Muscle facilitation for appropriate firing can be achieved by laying the tape parallel to the muscle fibers. Similarly muscles can be inhibited by laying the tape perpendicular to the muscle fibers. Over time it has been demonstrated that bony remodeling can occur with appropriate and consistent rigid taping.
TheraTogs (2016) is an orthotic product designed to capture the benefits achieved with taping without directly adhering to the skin. The client wears a vest and shorts made of a neoprene-type material. With additional arm and leg cuffs, flexible or rigid straps can be added to the suit to facilitate or inhibit movements. TheraTogs are easy to don and doff, should be worn directly next to the skin, and easily fit under typical street clothes and diapers. The TheraTogs provide consistent input, essentially where a therapist would provide manual input for the child, in the absence of handling the child.
Sensory Integration
Sensory integration therapy assists the child by using controlled sensory input to help children with sensory processing difficulties.It is a theory of brain-behavior relationships.The theory has three major components: normal sensory function, sensory integration dysfunction, and a programmatic guide for using sensory integration techniques. Ayers felt that learning is dependent on the person's ability to take in and process sensory information from the environment and self-movements, then organize behavior and movements in response to these inputs. If an individual has difficulty integrating and processing, the result will be deficits in planning and executing movements and in motor learning. To remedy this dysfunction in motor learning, intervention within a meaningful context must occur to improve the ability of the central nervous system to process and integrate sensory inputs.
In summary, sensory integration treatment encapsulates three areas: the theory, the evaluation, and the treatment. Each is vital in treating the child. A clinician can receive additional training in sensory integration theory and treatments.