CLINICAL TOOLS Management of Walking Through the · PDF fileNDTA NETWORK • MARCH/APRIL...

N D T A N E T W O R K • M A R C H / A P R I L 2 0 0 5 • N D T W O R L D W I D E • 2 5

any orthopedic surgical procedures are

designed to enhance the walking ability

of children and adults. Congenital deformities,

developmental abnormalities, acquired

problems such as amputation or trauma, and

degenerative changes all contribute to dimin-

ished gait efficiency. Locomotion is an extremely

complex endeavor with an

interaction between bony

alignment, joint range of

motion, neuromuscular

activity, and the laws of

physics. An understanding

of gait analysis enables the

treating physician to

understand the nature of

the gait problem, gain

insight into the etiology,

and predict possible treatment options. It is

certainly the only way that the technical

outcome of a procedure that is designed to

improve gait can be objectively assessed.

Gait analysis can range from simply observing

a patient’s walk to a fully computerized three-

dimensional motion analysis with energy meas-

urements.

OBSERVATIONAL GAIT ANALYSIS

A complete physical examination with measured

range of motion should be performed on all

Management ofthe Web SpaceTREATMENT ANDSPLINTING INTERVENTION

By Bonnie Boenig, M. Ed, OTR/L

he impact of neurological insult

on the upper extremity often

includes an increase in muscle tightness

distally, particularly in the hand. The

tightness in the hand can be related to

centrally generated tone, posturing dis-

tally in response to demands on postur-

al reactions, or anticipatory response to

task demands. Fisting of the hands may

be characteristically seen, and the degree

of fisting often increases with demands

on posture and active movement. In

treatment, generally speaking, once the

tone-related tension in the hand is

reduced, there is notable weakness and

inactivity in palmar intrinsic muscula-

ture, shortened range of motion in long

finger flexors, and limitations in the

ranges of movement of the thumb

which are reflective of shortened tissue

in the web space.

The posturing that is generally

expressed throughout the whole upper

extremity includes pronation of the

forearm, extremes of flexor or extensor

activity around the elbow, and humer-

al internal rotation. In the hand, there

is a reflection of

Walking Through the Gait LabGAIT ANALYSIS AND DEVELOPMENTAL DISABILITIESBy Hank Chambers, MD

(Excerpted in part from Chambers, HG and Sutherland DH: A Practical Guide to Gait Analysis. Journal of

the American Academy of Orthopedic Surgeons, 10:222-231, 2002).

3

patients who have gait problems. The presence

of muscle and joint contractures, spasticity,

extrapyramidal signs (such as dystonia and

tremor), weakness, motor control problems,

and pain should be determined and charted

in a systematic way. Any abnormal neurological

signs should also be documented as these can

contribute to the gait

abnormalit ies . Radi-

ographic abnormalities

should be documented

inc luding rotat ional

malalignment.

In order to evaluate the

gait of a patient with a

walking problem, one

must sys temat ica l ly

observe the gait. Obser-

vation of the patient walking toward and away

from the observer will enable an understanding

of coronal (or frontal) plane abnormalities

such as trunk sway, pelvic obliquity, hip

adduction/abduction, and possibly rotation.

Each segment (trunk, thigh, leg, and foot)

should be observed coming to and going away

from the evaluator. Abnormalities should then

be charted. The patient will then walk back

and forth with the observer sitting 90 degrees

from the patient. This enables sagittal plane

evaluation such as pelvic (continued on page 18)(continued on page 10)

T H E N E U R O - D E V E L O P M E N T A L T R E A T M E N T A S S O C I A T I O N • M AY / J U N E 2 0 0 5 • VO L U M E 1 2 , I S S U E 3

C L I N I C A L T O O L S

3 President’s Message | 4 NDT Clinician’s Corner | 7 NDT in Australia | 15 Patient Perspective

I N S I D E T H E N E T W O R K :

M

Three-dimensional

motion analysis helps

eliminate some of

the ambiguity

of visual analysis.

T

2 • N D T A N E T W O R K • M A Y / J U N E 2 0 0 5 • C L I N I C A L T O O L S

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R E G I O N A L C H A I R P E R S O N S

N D T A B O A R D O F D I R E C T O R S

Views expressed in the NDTA Network are those of the authors and are not attributed to the NDTA, the Director of Publications or the Editor, unless expressly stated.The NDTA does not endorse any instructors, courses, educational opportunities, employment classifieds, products or services mentioned in the NDTA Network. Copyright 2001 by the Neuro-Developmental Treatment Association. Materials may not be reproduced without written permission from the Editor.

IG EXECUTIVE COMMITTEEChair: Cathy Hazzard Chair Elect: Gay GirolamiVice Chair:Teddy ParkinsonTreasurer: Sherry W.Arndt Secretary:Teresa GutierrezPeds Subcommittee Chair: Kacy HertzAH Subcommittee Chair: Cathy RunyanCI Working Group Chair: Karen BruntonOT Working Group Chair: Lezlie AdlerPT Working Group Chair:

Susan Breznak-HoneychurchSLP Working Group Chair: Gay Lloyd PinderCI Representative: Judi BiermanOT Representative: Mechthild RastPT Representative: Monica DiamondSLP Representative: Rona AlexanderNominating Committee Chair: Mona Miley, OT

IG STANDING COMMITTEESBonnie Boenig, Grievance Committee ChairTom Diamond, Peer Review Committee ChairJudith C. Bierman and Lois L. Bly,Theoretical

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A B O U T T H E N D T A N E T W O R K M E S S A G E F R O M T H E P R E S I D E N T

he web taping and gait analysis articles in

this issue are examples of clinically sophis-

ticated tools for improving the care we give our

clients. They put me in mind of one tool we may

sometimes forget: the ability to communicate

with our clients.

Communication. Sounds so simple. Webster

defines communication as “sharing information,

a sense of mutual understanding and sympathy,

conveying feelings, and being connected to

another person.” I am beginning to understand

more fully how truly complicated the commu-

nication process is and the important responsi-

bility that we all face as we meet the challenges

involved in communicating with our clients.

Therapy sessions involve ongoing communi-

cation between the therapist, the client, and

family member/caregiver and all involve time,

effort, diligence, and a commitment from all

parties in order to be effective.

As therapists, we use whatever it takes to

convey our message—explaining directions and

information in detail, as simply as possible, and

if necessary, providing sensory/motor cues.

Successful rehabilitation depends upon clients

understanding the information we share and

being able to follow through with the functional

activities and exercises that we determine are

appropriate and necessary for recovery. Their

keen awareness of the personal relevance and

importance of these tasks is critical. Our clients

must believe that we care about them as indi-

viduals as much as they believe that we have the

knowledge and skill to aid their recovery. They

need to know that we are truly interested in them

and value their feelings and the feedback that

they share with us.

But although we have endless tools available

to assist us in our communications with others,

such as face-to-face

conversation, telephone,

written word, type,

gesture, facial expressions,

and body language, many

of our clients are not so

fortunate. For them, the

skills we take for granted are often significantly

delayed or absent.Yet from the beginning of their

rehabilitation and recovery process, we bombard

them with new and unfamiliar information that

they are immediately expected to grasp, assim-

ilate, and attempt to utilize for improving their

functional and independent performance. Never

mind that they are also dealing with weakness,

balance issues, spasticity, etc.

Their caregivers, too, are overwhelmed with a

myriad of responsibilities, worries, and fears

related to the care of a loved one. No wonder we

have to repeat the same things over and over

again for them to understand and integrate the

information! It can be frustrating for us as ther-

apists to do so. On the other hand, in trying to

survive one day at a time, our clients and their

caregivers can only absorb so much information

at one time.

I plan to spend a bit more time listening to

my clients and working on mutual understanding

and empathy. Perhaps that will be a form of

communication that they really can “hear.” Might

be good for all of us.

Wendy Drake-Kline

NDTA President

Wendy Drake-Kline

T

The Commitment to Communication

any clinicians seem to have little desire

to study treatment theory, preferring

to use their time learning hands-on tech-

niques. But techniques are only tools; under-

standing theory can provide possible expla-

nations for the expected impact of therapy

and can offer suggestions for the selection of

therapy tools and handling strategies.

The following is a clinician’s interpretation

of treatment theories based upon infor-

mation in Janet Howle’s book Neuro-Devel-

opmental Treatment Approach: Theoretical

Foundations and Principles of Clinical Practice

(2002). These synopses are intended to

provide a brief working knowledge of the

basic theories and are followed by a treatment

model. The practice of NDT is currently

based on an Interactive Systems Model,

which accepts that each system is dependent

upon the integrity of another. The Dynamic

System Theory and the Neuronal Group

Selection Theory, discussed below, are the

basis for this model.

SYSTEMS THEORY/DYNAMIC SYSTEMS APPROACH

Names to know: Nicoli Bernstein, physiol-

ogist (1967) applied the principles of

dynamic systems to the understanding of

human behavior. A number of theorists have

expanded the systems theory, including:

Darrah & Bartlett, Heriza, Kelso, Kugler,

Kelso & Turvey, Perry, Thelen.

Definitions of Key Terms:

Degrees of freedom: Elements of movement

are assembled into functional patterns.

Coordinative Structure: Two or more inde-

pendent parts (muscles or joints ) combine

to perform as one functional unit or synergy.

Functional linkages between groups of

muscles simplifies motor control.

Self organization: Interacting systems,

through repetition and practice, can organize

themselves and create motor patterns out

of this continual activity as discussed in

“Clinical implications of a dynamical

systems theory,” Neurology Report, 22,4-10

by S.B. Perry, 1998).

Rate-limiting factors: Each subsystem

develops at its own rate, but is constrained

(or supported) by physical and environ-

mental factors.

Transitions: Motor behavior is made up of a

series of states of stability, instability,and

phase shifts. During development, motor

behaviors can either become more stable or

destabilize.

Most change can occur during periods of

de-stabilization.

Theory basics:

• Biological systems, like other physical

systems, are complex, multidimensional,

cooperative systems in which no one

subsystem has priority for organizing

the behavior of the subsystem (Howle

2002, pg. 17).

• As a new movement sequence is learned,

the learner attempts to limit the number

of muscles and joints to an excessive

degree, providing mechanical stability.

As learning takes place, the mechanical

constraints are less used, and there is a

freer use of a combination of neural and

musculo-skeletal constraints that allow

for greater motion,variability, and a

higher level of success.

• Movement and changes in movement

patterns generated by various systems

are organized by the interactions of

multiple components of cooperating

systems, such as body weight, muscle

strength, joint configuration, postural

support, mood, attention, specific envi-

ronmental conditions (such as inertia

and gravity), and patterns of neural

firing (Howle 2002, pg. 20).

Clinical Application: Because the impair-

ments underlying functional limitations are

considered rate-limiting factors, treatment

designed to reduce the impact of these factors

will improve function.A clinician’s definition

of constraints to movement can include bony

restrictions, limited flexibility in soft tissue

and fascia, and constraints created by faulty

timing and lack of coordinative firing of

muscles attempting to work cooperatively

together. According to this theory, as new

skills are integrated and become more auto-

matic and less cognitively driven, we should

expect to see more ease of movement and

ability to refine skill. Within the context of

developmental sequence, or when learning

motor behaviors under the conditions of

neuromotor deficit or insult, certain periods

of time are more supportive of having new

skills emerge. Our therapeutic intervention

can actually create periods of “chaos” by

inhibiting compensatory or habitual patterns

of movement; during these opportune times,

the client is more likely to make a shift in

motor behavior.

NEURONAL GROUP SELECTIONTHEORY (NGST)

Names to know: Edelman (1987) and Sporns

(1994) have offered a balance between matu-

ration and interactive physical systems.

Theory Basics:

• Neuronal groups are arranged in neural

Theory Basics Refine Clinical PracticeBy Bonnie Boenig, M.Ed, OTR/L


C L I N I C I A N ’ S C O R N E R

M


maps in segregated areas of the brain;

however long-reaching reciprocal connec-

tions between groups integrate activities

of multiple sensory and motor areas of

the brain.

• Each person has individualized neural maps

as a result of unique motor experiences.

• The development or recovery from brain

damage is aided during activities that occur

in functionally or developmentally appro-

priate environmental contexts and the

individual generates movement to meet

the demands of the task.

Clinical Application: This theory supports the

necessity for including functional tasks during

treatment and using environmental set-up and

handling strategies to assist in providing

effective, precise feedback information.

Clinical judgment is the clinician’s ability

to analyze movement and decipher clues

based upon an understanding of the human

body and accepted theories of motor

behavior, and then to choose the appropriate

combinations of strategies. The best outcomes

in therapy result from having a toolbox of

strategies and techniques, a strong working

knowledge of the structure and systems of

the human body, and an understanding of

the scientific bases of human movement. A

sound theoretical foundation is a beacon to

the appropriate choice of therapeutic

approach, a guide for making shifts in the

therapy plan, and the cornerstone to

achieving optimal functional outcomes. ■

Bonnie Boenig is an NDTA occupational

therapy instructor and a clinical specialist for

Lifeworks of Southwest General Health Center

in Middleburg Heights, Ohio. Bonnie’s private

practice includes short term intensive therapy,

teaching short courses, and providing

customized staff and parent-training programs

for facilities that specialize in pediatric therapy.

She can be reached at [email protected].

MAY 20-22Neurophysical Principles and NDTA

Location: NTS Therapy (Houston)3250 WilliamsburgMissouri City, TX 77049Instructor: Judi Bierman, PT_______________________________________

JUNE 17-19, 2005Functional Activities in Standing and Gait: AnNDT Perspective for Adults with Hemiplegia

Location: Miami Valley HospitalOne Wyoming St., Dayton, OH 45409Instructor: Marie Simeo, PT_______________________________________

JULY 15-17, 2005Practical Applications for Treating Children withNeuromotor Impairments–An NDT/BobathPerspective

Location: KIDSCenter982 Eastern Parkway, Louisville, KY 40217Instructor: Wendy Drake-Kline, OT_______________________________________

JULY 29-31, 2005Problem Solving for Function: An NDT/BobathPediatric Handling Intensive Course

Location: American International College1000 State St., Springfield, MA 01109Instructor: Barb Hodge, PT_______________________________________

AUGUST 27-28 (TWO DAYS ONLY)Topic To Be Announced

Location: Parkview Health System2200 Randallia Dr., Ft. Wayne, IN 46805Instructor: To be announced

SEPT. 23-25, 2005Creative Routes to Outcomes

Location: Erie County Medical Center462 Grider St., Buffalo NY 14215Instructor: Kay Folmar, PT_______________________________________

OCTOBER 14-16, 2005Moving Into NDT/Bobath for SLP’s: AnIntroduction to Neurodevelopmental Treatment

Location: Erie County Medical Center462 Grider St., Buffalo NY 14215Instructor: Therese McDermott, SLP_______________________________________

OCTOBER 21-23, 2005Creative Routes to Outcomes

Location: Genesys Regional Medical CenterOne Genesys Parkway, Grand Blanc, MI 48439Instructor: Kay Folmar, PT_______________________________________

OCTOBER 28-30, 2005Managing Adults with Hemiplegia:An NDT/Bobath Perspective

Location: Estes Park Conference Ctr.101 S. St. Vrain Ave.,Estes Park, CO 80517Instructor: Kay Folmar, PT_______________________________________

NOVEMBER 11-13, 2005Treatment of Children & NeurologicalDisorders: An NDT/Bobath Perspective

Location: Aberdeen Hospital835 East River Rd., New GlasgowNS B2H 5C8 CanadaInstructor: Marcia Stamer, PT

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Register on the web at www.ndta.org or fax your form into theNational NDTA office at 949/376-3456

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THE RELATIONSHIP OF HAMSTRING SPASTICITY & CONTRACTURE TO GAIT IMPAIRMENT IN CHILDRENWITH SPASTIC DIPLEGIA. Glock E., Yoloho E., Physical Therapy Program, Young University, Pungo VA.

PURPOSES: The purposes of this research were to determine the: 1) reliability of hamstring spasticity meas-urements; 2) reliability of popliteal angle measurements; 3) relationship of hamstring spasticity to step length,stride length & gait velocity; 4) relationship of hamstring contracture to step length, stride length & gaitvelocity. SUBJECTS: Eleven children (8M/3F) with spastic diplegia (ages 3-15 yrs) were studied. Allwalked independently with or without appliances. METHODS: Two raters twice graded hamstring spas-ticity in both legs of subjects using the modified Ashworth scale while subjects simulated the Terminal Swing(TSw) Phase position in standing. Raters twice goniometrically measured subjects popliteal angles in thesupine position. Each subject walked 20í with inked shoe pads to determine stride & step length distances.Gait velocity was determined using a stopwatch. DATA ANALYSIS: Intraclass correlation coefficients (ICC)and percent of agreement (0-100%) were used to determine the reliability of intrarater & interater meas-urements of spasticity and popliteal angles. Speanean rank correlation coefficient was used to assess therelationship between spasticity & gait, and between hamstring contracture & gait. RESULTS: Intratesterreliability for hamstring spasticity measurement was fair (.487) to good (.941); intertester reliability waspoor (.242) to fair (.613); the percent of agreement ranged from 0% - 10%. The reliability of poplitealangle measurements was good (.884) to high (.962). Negative correlation between hamstring spasticity& gait measurements was poor (.305) to fair (.431) on the right side, and moderate (.564) to good (.877)on the left side. The Pearson product moment correlation coefficients between hamstrings range (poplitealangle) & gait were moderate (.685) to good (.840). Correlation of hamstring range with Terminal SwingPhase gait was significant at the .05 level. CONCLUSIONS: The reliability of spasticity measurements wasvariable, and the relationship of spasticity to gait was equivocal with respect to the right and left sides. Mea-surements of hamstring range were reliable, and there was a significant relationship between hamstringrange of motion and swing-phase gait. RELEVANCE: Reliable examination procedures are required to as-sess patient impairments and their impact on functional movement. Assessment of the efficacy of treat-ment on patient functional outcomes requires the heath care provider to analyze the relationship betweenmeasured impairments and measured functional performance. ACKNOWLEDGEMENT: This researchwas supported by Grant No 652 awarded by Young University, Pungo, VA.

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SUBMISSION DEADLINE:JULY 31, 2005

C A L L F O R P O S T E R S


‘m pleased to be able to share with

Network readers the Neuro-develop-

mental Treatment (NDT)–based therapy

we provide in our KIDS+ program, which

we run through our therapy practice,

Children’s Therapy Services, in Geelong,

southern Australia.

My initial ideas for KIDS+ resulted from

observations and learning at the various

facilities I attended in the United States

while training to become an NDTA OT

Instructor. I worked with a number of

extraordinary therapists and my obser-

vation of the power of NDT was reinforced

through the remarkable results achieved

by my mentor and friend, Regi Boehme, in

her sessions with children both in the U.S.

and as she travelled and taught in Australia.

I was inspired, to say the least, and worked

towards the creation of the KIDS+ program

together with my physiotherapist practice

partner and later our associate speech

pathologist. This article is based upon a

publicity document written for pediatri-

cians in our region.

The KIDS+ program provides specialized

therapy programs for children (0-18 yrs

old) with neuro-developmental disabilities,

including children with cerebral palsy, brain

injury, and stroke. The overall objective is

to increase the participation of these

children in daily life, including their roles in

family and societal settings such as

preschool and school (ICF 2001).

We started KIDS+ at Children’s Therapy

Services in 1997. It incorporates PT, OT, and

SLP. The program was initiated in response

to parents’ wish for a more intensive, regular

therapy service, due to the diminishing

frequency of pediatric therapy available for

these children in our region.

The program is essentially a number of

‘mini’ intensive group-therapy sessions. Each

of three children has a therapist – PT, OT,

or SLP (or co-treatment by two therapists)—

for each session. They therefore receive the

individual goal-based therapy they require,

while also receiving some of the positive

attributes of a group setting, such as simi-

larly aged children joining in for play and

socialization and parent-to-parent contact

and support available within each session.

PROGRAM STRUCTURE

Currently 27 children attend sessions. The

program is held over a day and a half per

week and runs for an eight to nine weeks

block, four terms per year. Children are

chosen for each treatment block according to

certain selection criteria, which includes

parents’ preferred duration of involvement.

In each 11/4 hour session we have the time to:

• Review parents’ comments about progress

• Address parents’ session goal choice (of the

current 2-4 goals each child has)

• Utilize Neuro-Developmental Treatment

(NDT) strategies towards goal achievement

• Address ‘carryover’ ideas as requested by

parents

• Document the outcome of each session and

plan for the next

• Offer support and advice on new issues

which may have arisen

• Review goals and outcomes for the

treatment block at the last session and

begin to plan for future goals with parents

SETTING FUNCTIONAL MEASURABLE GOALS

These may be related to communication;

postural control/mobility; leisure skills; self-

care, including eating/drinking; and hand

skills for play/classroom tasks.

Examples:

• An eight year old boy stepping up one

step to be able to use the toilet himself.

• A baby learning to hold and drink from

a bottle

• A six-year-old girl moving from a seated

position to a standing position to walk 10

steps with a walker as needed in a

classroom setting

• A teenager working on speech clarity

and volume to read out project material

to a class

• A two-year-old learning to move his

hand to activate a toy switch

• A seven-year-old utilizing a communi-

cation device to communicate

Children attending KIDS+ may have appar-

ently “mild” functional limitations, such as

difficulty with manipulation skills; oral motor

control issues, such as saliva control; or higher

level balance skills, such as required in team

ball games. Severity of disability progresses to

children who have no independent mobility,

verbal communication, or grasp.

TREATMENT

The underlying treatment approach used in

the KIDS+ program is Neuro-Developmental

Treatment, which was initially developed by

Dr. and Mrs. Bobath in the U.K. It is an

advanced therapeutic approach practiced by

experienced occupational therapists, physical

therapists, and speech-language patholo-

gists. This “hands-on” approach is used in

working with children who have central

KIDS+A PEDIATRIC NDT PROGRAM IN AUSTRALIA

By Kate Bain, OT

N D T W O R L D W I D E


I

nervous system (CNS) insults which have

resulted in difficulties with posture and

movement (NDTA Web site ’03).

Therapists using NDT treatment have

completed advanced training in Bobath/NDT.

As the PT and OT in the KIDS+ program,

we are also the Australian Bobath/NDT

Instructors qualified respectively in the U.K.

and U.S. We also attended the NDTA

Advanced Baby Course, taught by Suzanne

Davis in Melbourne in 2001.

We work closely with children, helping

them to become as independent as possible;

we also work collaboratively with family,

caregivers, and physicians in the ongoing

development of this comprehensive

treatment program.

Our focus is firstly on the strengths and

abilities of each child related to the specific

goal/skill identified. The impairments that

a child may have in relation to that goal or

skill are then assessed, using task analysis to

identify the system impairments impeding

that child from achieving his or her func-

tional goal. Formal assessment tools, such

as the PEDI (Haley et al 1992), GMFM

(Russell et al 2002), and The Melbourne

Assessment of Unilateral Upper Limb

Function (Randall et al 1999) are also used

to measure changes in function over time.

Examples of systems impairments related

to tasks:

• Insufficient length in muscles, such as hip

adductors/ internal rotators for climbing on

playground equipment

• Reduced range of active reach—for

example, arms above head to comb hair,

or reach forward to a tap

• Low tone/weakness in jaw musculature for

chewing

• Inability to adequately coordinate head and

eye movements to watch a film at the theatre.

• Distal neuromuscular/biomechanical

dysfunction—e.g., pre-shaping of hand for

picking up a spoon, or coordination of a

dynamic tripod grasp for writing

• Inability to vocalise during parallel play

at childcare

• Insufficient strength, for example, to lift

foot to hand to put on shoes for PE

• Inability to weight shift the trunk/pelvis

within the task to free another part of the

body for mobile function, for example, to

wipe bottom

• Insufficient endurance to pedal a bike

around the preschool path

This analysis and treatment approach

follows a “top down” processing model that

always proceeds from the child’s current

performance in the task/goal.

NDT treatment is guided by a number

of theoretical models for motor control,

including:

• Neuronal Group Selection Theory:

addressing the selection and fine tuning

of functional CNS neuronal groups

• Dynamic Systems Theory: addressing

the functional linkages between systems

in task performance, e.g., between the

neuromuscular, biomechanical, and

sensory systems in a given task, such as

visually guided reach and grasp (Bern-

stein 1967 cited in Howle 2002). The

treatment strategies used within a KIDS+

session address impairments through the

relevant systems.

Examples of treatment strategies related

to system impairments:

• Elongation of muscle groups/soft tissue for

joint alignment, such as hamstrings, or

the latissimus musculature, to increase

range of movement for dynamic control of

the pelvis in floor sitting

• Facilitation of weight shifting, which may

combine with these approaches, as required,

for example, in transitional movements

required to get up from the floor

• Treatment strategies to improve lip closure

for saliva control and swallowing, such as

resistive activities utilizing musical

blowing toys

• Systematic desensitization of tactile hyper-

sensitivity in hands; for example, using hand

sized toys which also develop dynamic

palmar control. Both treatment strategies

support manipulation with hands.

• Strengthening of hip and knee extensors

for stepping

• Dynamic weight bearing through upper

extremities in play in prone to increase

coactivation in shoulder girdle muscu-

lature, and in turn, for improved control

in targeting and timing during wide range

reaching

• Traction and vibration through the ribcage

to increase respiratory volume for breath

control and phonation

• Stimulation techniques to improve head

raising and vision for “looking play”; for

example, using linear vestibular movement

and/or light intermittent compression to

the head, aligned in midline.

Playfulness and “child lead” involvement

in an enriched treatment environment is

integral to every NDT session to maximize

motivation, self esteem, and encourage

learning to occur.

Other theoretical underpinnings to NDT

include knowledge from motor development

and motor-learning theories, sensory inte-

gration theory, biomechanics, neurophysi-

ology, and pathophysiology. An example of

applied motor-learning theory is the

necessity of independent practice by children

in order to consolidate and generalize goals

in their natural environments. Contextual

factors related to these environments are

taken into account, and practice opportu-

nities are given within each session to

strengthen the child’s skill within the task.

Fellow team members, such as childcare and

pre/school integration aides, are invited into





sessions. Therapists visit these settings out

of the program, when possible.

Treatments are also planned within a

framework of family-centred practice (King

2002). Parents are always asked in KIDS +

sessions about aspects they wish to learn to

practice or carryover into home settings.

Examples of further practice through

home programs which are considered

compatible with family-centred practice:

• Playful lengthening/“massaging” interactions

at care times, such as nappy change time

• Rough-and-tumble strengthening play

• Books and songs

• Riding a scooter or bike

• Undressing at bath time

• Use of vertical surfaces–blackboard,

fridge–sibling involvement

• Swimming

• Eating – finger foods/using cutlery, drinking

from a cup

EVIDENCE BASED PRACTICE

Research by Knox and Lloyd-Evans in 2002

showed significant improvements occurred

in the self-care domain, as rated on the PEDI,

by a group of children who had undergone

Bobath Therapy. Examples of improvements

among the children were increased inde-

pendence in self dressing and personal

hygiene, such as grooming, and bathing. In

addition there was a significant decrease in

caregiver assistance required for transitional

movements, locomotion indoors and

outdoors, and in managing stairs.

Adjunct therapies such as the use of spe-

cialized equipment,post-botox programming,

orthotics, and constraint induced (CI) thera-

py may also be used in conjunction with KIDS+

sessions to maximize function.

Other treatment frameworks, such as

cognitive behavioral approaches, are often

incorporated with NDT as necessary.

A few further comments about KIDS +:

• With parents’ permission regarding confi-

dentiality, we are happy to work closely

together with other agencies and thera-

pists. This includes sharing goals and

outcome reports and including other

therapists in our sessions.

• Case management can be arranged with

families.

• Parent evaluations guide us in program

development.

KIDS+ also incorporates a separate resi-

dential Farm Treatment Program. This is an

intensive therapy program which we have

held on a number of occasions, for 2 – 3

days with families who live in the country

and are unable to attend weekly therapy. It

is based on a program I attended which was

run by Regi Boehme for families at “The

Center” in Montana. In place of the beautiful

deer which ran through the mountains on

the Boehme’s ranch, the children here in

Australia see kangaroos in the bushland and

help to feed farm animals as their families

combine a holiday with therapy. This

program currently awaits funding, as below,

and will then continue.

This year, another long-held wish came

to fruition: funding of families for the weekly

KIDS+ program. This was driven by parents

and resulted in the formation of the KIDS

Plus Foundation, which has deductible gift

recipient and income tax exempt charitable

status (www.kidsplus.org.au). It is run by

an energetic and enterprising co-ordinator

and Board of Directors, who continue to

oversee the smooth running of the program.

It fully funds 27 families, both current and

future, to receive the therapy they are seeking

for their children. ■

Kate Bain OT, is an OT NDT Instructor

(U.S.A) and partner in Children’s Therapy

Services in Geelong, Australia. She can be

reached at [email protected].

REFERENCES:

Erhardt, Rhoda P. (ed.). (1999) Parent Articles

about NDT. Therapy Skill Builders: Tucson,

Arizona.

Haley S M, Coster W J, Ludlow L H, Halti-

wanger J T, and Andrellos P J. (1992). Pedi-

atric Evaluation of Disability Inventory:

Development, Standardization, and Admin-

istration Manual, Version 1.0. Boston, MA:

Trustees of Boston University, Center for

Rehabilitation Effectiveness.

Howle J. in collaboration with the NDTA

Theory Committee. (2002) Neuro-Develop-

mental Treatment Approach Theoretical Foun-

dations and Principles of Clinical Practice NDTA.

ICF (2001) Disability–International

Classification of Functioning,Disability and Health

www.aihw.gov.au/disability/icf/index.html. World

Health Organization.

King G. (2002) Family-Centred Service:

Concepts, Measurement, and Implications

AusACPDM Sydney, Sept.

Knox V and Lloyd–Evans A. (2002) Evalu-

ation of the Functional Effects of a Course

of Bobath Therapy in Children with Cerebral

Palsy: A Preliminary Study. Dev. Med. &

Child Neurology, 44: 447-460.

NDTA Web site Neuro-Developmental

Treatment Association (NDTA–USA).

www.ndta.org

Randall MJ, Carlin J, Reddihough DS,

Chondros P, Randall MJ, Johnson LM,

Reddihough DS. (1999) The Melbourne

Assessment of Unilateral Upper Limb Function

Test Administration Manual. RCH

(Melbourne).

Russell D, Rosenbaum P, Avery L, and Lane

M. (2002). The Gross Motor Function

Measure (GMFM-66 & GMFM-88) User’s

Manual Clinics. Developmental Medicine No.

159. Published through Mac Keith Press in

the U.K. and distributed through Cambridge

University Press.

the internal rotation and pronation attitude, with the thumb fol-

lowing along in the pattern by flexing, adducting and pronating

in towards the palm. The adducted thumb position consequently

leads to tightness in the soft tissue connecting the thenar at the

palm at the carpal transverse arch, and narrowing of the palm.

There is an impact on the web space where the lack of soft tissue

flexibility limits active expansion and results in a loss of range of

motion in the thumb. In addition, the tightly adducted thenar

eminence precipitates hyper-extension at the CMC joint during

attempted use, and the thumb is unable to move towards antepo-

sition, which is the movement that makes it functional in opposi-

tion of the fingers. The neurological impact may also lead to dif-

ficulty with accessing selective motor control and differentiation

of movement of the thumb away from the hand and in function-

al ranges opposing the fingers.

Clinically, treatment and orthotic management of thumb is

critical to the ability to functionally use the hand and is key to the

reduction of the impact of tone throughout the upper extremity.

Thumb alignment and function is an ongoing challenge and con-

cern for all therapy disciplines. The thumb position effects the

overall efficiency of hand use in activities of weight bearing, gross

grasps (as needed for transitions on the floor and use of mobility

devices), selective use of other fingers of the hand (such as point-

ing the index finger for augmentative communication), and

development or use of a variety of refined grasps and complex

manipulation strategies (as are needed for all activities of daily

living and writing skills). To best understand treatment strategies

and the types of splints that are effective, it is first important to

understand the structural design, muscular components, and

active movements of the thumb.

THE THUMB AND WEB SPACE

Skeletal/Structural Considerations

The thumb emerges from the palm wedge as a narrow triangular

block supported from underneath by the fleshy curved thenar

eminence. The first web space is created by a triangular connec-

tion of soft tissue on the ulnar aspect of the thumb and the radi-

al aspect of the index finger. The web space between the thumb

and the index finger is designed by the long bone of the thumb

between the carpalmetacarpal joint (CMC) and the metacarpal-

phalangeal joints.

Thumb movement is much greater than that of the fingers

because of the attachment of the first metacarpal to the trapezi-

um bone by a capsular ligament only, which allows much wider

excursions in movement than the other four. The saddle-shaped

trapezium bone of the carpal (wrist) bones articulates with the

first metacarpal of the thumb. The saddle-shaped joint is signifi-

cant in that it allows good range of motion in many directions

and movement in two planes, sagittal and frontal. The

metacarpalphalangeal I (the thumb) also differs from II through

V in these other ways: more massive, capsule not as taut laterally,

and there is available axial rotation. Two small bones known as

the sesmoid bones are imbedded into the palmar fascia of the

thumb and serve for tendon attachment—again allowing for

much more range of motion.

Muscle Attachments/ Kinesiological Components

The muscles that move the various articulations of the thumb ray

increase in number in proportion to the planes of movement of the

joints they mobilize (Tubiana 1984).

The muscles responsible for movement of the thumb include:

Extrinsic: The long muscles of the thumb. Anterior: tendon of

long flexor. Posterior: tendons of the long abductor, the short

extensor, and the long extensor

Intrinsic: The thenar muscles: the adductor and the first dorsal

interosseous muscle. The thenar muscles also act together with

the flexor pollicis longus to flex the proximal phalanx.

The muscles responsible for the opening up of the first web

space are:

• Extrinsic: long abductor and short extensor

• Intrinsic: short abductor and opponens

The thenar muscles form a cone whose summit is the base of

W E B T A P I N G

1 0 • N D T A N E T W O R K • M A Y / J U N E 2 0 0 5 • C L I N I C A L T O O L S

(Management of Web Space continued from page 1)

Above: External Thenar Muscles: (1) Abductor pollicis brevis (2) opponenspollicis (3) flexor pollicis brevis. Internal thenar muscles: (4) oblique head ofadductor (5) transverse head of adductor. (Adapted from Tubiana, Raoul.)

INTRINSIC MUSCULATURE OF THE THUMB

W E B T A P I N G

N D T A N E T W O R K • M A Y / J U N E 2 0 0 5 • C L I N I C A L T O O L S • 1 1

the proximal phalanx (Tubiana 1984). These muscles can be

divided into two groups to differentiate their contributions to

functional components of grasp.

1. External thenar muscles: abductor pollicis brevis, opponens,

and flexor pollicis brevis

• Innervated by median nerve, and attach to sesamoid

bones

• Functional contribution is circumduction

• They are pronators

2. Internal thenar muscles: oblique and transverse heads of the

adductor, first palmar interosseous muscle

• Innervated by ulnar nerve

• Functional contribution is to bring thumb metacarpal toward

index metacarpal at end of opposition, and to reinforce

• They are supinators

Movements of the Thumb

Terminology used to describe the movements of the thumb is

complex and may vary between authors, researchers, and clini-

cians. In the thumb, the multifaceted nature of the angles of

alignment afforded by the saddle joint and loosely strung tendon

structure provide the basis for movement into more than one

plane of movement at a time. In describing movements, we need

to designate a point of reference. There are actions associated

with the accepted physical planes of movement, namely: flexion

and extension in the sagittal plane, abduction and adduction in

the frontal plane, and rotation in the coronal plane.

Describing movements becomes tricky because the point of

reference, or starting point for opposition of the thumb to the

palm and to each finger involves an angle of circumduction (or

the angle of spatial rotation) formed by the intersection of two

planes (Tubiana 1984).

In clinical practice, it is not often important for us to measure

precise angles of separation, but it is important to have terminol-

ogy to describe consistently the movements that we observe and

effect through our intervention. The terminology which best pro-

vides the clinician with descriptions of movement of the thumb

metacarpal as it applies to function includes in the frontal plane

adduction (or flexion-adduction), and abduction (or extension-

abduction). Positions of the thumb in the sagittal plan are best

described as anteposition and retroposition. The movement car-

rying the thumb ray into anteposition is accompanied by internal

rotation (pronation) of the thumb. The movement of the thumb

ray into retroposition is accompanied by external rotation

(supination). This has been described as automatic longitudinal

rotation (Kapanji 1972).

Opposition is a combined movement which involves all three

segments of the thumb. The metacarpal segment moves into

anteposition, and then in adduction, a movement that is accom-

panied by automatic longitudinal rotation into pronation. The

proximal phalanx flexes, pronates, and radially deviates. The dis-

tal phalanx flexes to variable degree and this is accompanied by

some degree of pronation relative to the demands of the grip.

There is not one opposition, but a whole range of oppositions

which allows for a wide variety in grips (Tubiana 1984).

Treatment of the Thumb/ Web Space

Treatment of the thumb and web-space begins with recognizing

the relationship of the hand to wrist position and ranges of move-

ment, forearm position and its available mobility into ranges of

pronation and supination, elbow range and graded control into

ranges of flexion and extension, and shoulder girdle stability. The

range and control of reach is related to the integrity and selective

movement control of proximal joints. The orientation of the

hand in space is most naturally and smoothly led by the move-

ment of the thumb, which facilitates the rotation through the

forearm into ranges of pronation and supination. In the follow-

ing focus on treatment and orthotic management of the web

space and thumb, the influence of the upper extremity is also

assumed and acknowledged.

Treatment of the hand for improved web space mobility and

soft tissue extensibility begins with addressing the palmar intrin-

sics with strategies to get width across the palm and into the lon-

gitudinal arches. The carpal transverse arch at the base of the

palm creates the connection horizontally between the thenar and

hypo-thenar. The characteristic flexion-adduction position of

the thumb assumed in tight and fisted hands limits expansion

and width within the palm across this arch. The oblique arches

are important to address as well: they often lack any presence in

Above: (1) Oblique adductor pollicis (2) Transverse adductor pollicis (3)First dorsal interroseous. (Adapted from Tubiana, Raoul.)

LATERAL VIEW OF THE THUMB WITH THE THUMB

IN ANTEPOSITION

a tight hand, especially in situations where the neurological dam-

age is from birth as opposed to being acquired. The oblique arch-

es are used in opposition of the thumb to each finger. Clinically

we know that slow, deep input can be inhibitory and relaxing. In

approaching the arches of the hand in treatment, it is beneficial-

ly to use a constant, deep input and move into an expanded arch

formation during lengthening strategies (Boehme 1988).

One suggested strategy specific to the web space, following gen-

eralized opening of the hand through expansion across the trans-

verse arches, is for the clinician to

encircle the long bone of the thumb

with her hand and to move it into

abduction and extension while using

the thumb and index finger of her

other hand to sink deep into the apex

of the triangle of the web space. Deep

input and gentle oscillations help to

relax the tension and to effect actual

change in the length of the tissue.

Following this strategy up with

widening of the hand through the

oblique arches, and gradually moving

the thumb into ante-position pre-

pares the alignment and extensibility

of the web space and affords the pos-

sibility of moving the thumb into

positions of opposition in relation-

ship to palm and fingers.

In addition to addressing align-

ment and elongation of tissue, treat-

ment strategies should include weight

bearing over a contoured surface (or

different sized contours) and presen-

tation of functional activities to facil-

itate active use of thumb to palm and

fingers. It is at this point the clinician

is wise to begin thinking about use of

a splint or taping techniques to main-

tain the benefits achieved by the active

hands on strategies.

THUMB/WEB SPACE MANAGEMENT THROUGHSPLINTING AND TAPING

Static Splints

In some instances in the progression of treatment, choosing to

immobilize the thumb by using a static orthosis or splint is an

appropriate choice. The immobilization of joints in positions of

newly achieved range of motion is important if the individual is not

able to immediately call into functional all use of the available range.

In this instance, the static splint may be put on with a variable wear

schedule and removed for practice and exercise. Another reason to

choose immobilization is to assure maintenance of full available

range for an individual whose limitations in accessing muscle con-

trol—secondary to severity of neurological damage—are so great

that there is little or no potential for them to do so.

Static splinting does not always

mean full immobilization, however.

The use of static splinting to immo-

bilize one or more joints encourages

more efficient practice of distal joint

function upon a base of good align-

ment and can facilitate the emer-

gence of grasp patterns. Some exam-

ples of customized static splints that

immobilize the CMC joint of the

thumb and support width in the web

space are: 1) Thumb MP

Immobilization Splint, 2) CMC

Immobilization Splint, 3) Thumb

CMC Immobilization Splint, and 4)

Thumb Abduction Immobilization

Splint (Jacobs & Austin 2003). These

splints are named for the joints that

are incorporated into the splint and

will take on a slightly unique form

each time they are customized to an

individual, depending on the choic-

es of splinting materials and strap-

ping methods.

Pictured here are customized splints

designed by this author, each for a

unique purpose. The Palmar Web

Splint, Figure 1, is helpful in maintain-

ing the web space as well as encourag-

ing the support of the width of the

palm in wide transverse arches.

The CMC/MP Web Splint in Figure

2 & 3 immobilizes the CMC and MP of the thumb while maintain-

ing a wide web space. The special functional feature of this particu-

lar splint is that it is designed to position the pad of the thumb in

opposition of the pads of the index and third finger. The CMC/MP

Web Splint is great for providing stability to the base of the thumb

W E B T A P I N G


F I G U R E 1

F I G U R E 2

F I G U R E 3

Palmar Web Splint

CMC/MP Web Splint

CMC/MP Web Splint

W E B T A P I N G


and web space, and encouraging prac-

tice of functional digital grasps.

A variety of commercially available

splints provide wrist and thumb sup-

port. Some of the name brands

include Comfort Cool, Liberty,

Thermo-Form, and Otto-Bock, and

Benik. These options are available in

catalogs such as North Coast Medical

and Sammons Preston Rolyan, or

directly from the company named.

Semidynamic Splints

Semidynamic splints position and

support the hand and/or wrist for

optimal function, but do not neces-

sarily immobilize any particular joint.

Clinicians generally use material such

as Neoprene or “Fabri-foam” to

design these splints. Many of the soft

splints that are commercially avail-

able can be classified under this cate-

gory. Examples of such splints include

a variety of splints from a number of

different companies, most of which

are available through professional

rehabilitation catalogs or from the

companies that created them. The

Benik Company makes splints out of

neoprene material, some of which are

designed to support the thumb web space, and there are modifi-

cations that take the support across the wrist as well. Benik offers

a pediatric sizing kit for purchase to help with ordering the cor-

rect size to fit. Neoprene, on its own, at times is not enough to

hold the web space of a tight hand; therefore, using a low-temp

plastic to customize reinforcement is usually a good idea.

The Joe Cool Splint is another web space/thumb support

option, also made out of neoprene. This company sells a splint

that is called a thumb splint, and one that is called a glove which

supports the long bone of the thumb, as well as providing some

input to the webspace. A variety of other splints in this category

are commercially available through the catalogs noted above, or

directly from the company that holds the trademark for the

design, such as the McKie Splint.

The splint in Figure 4, designed by this author, is named The

Peanut. This splint is very versatile

and can be secured with strapping or

used in combination with a neoprene-

type splint. The benefit of The Peanut

is that it supports the width of the web

space while not interfering with opti-

mal mobility of the thumb joints. The

strapping options are numerous, and

depending upon the direction of pull,

can include support for the carpal

transverse arch or oblique arches.

Taping for support and to prevent

collapse of the web space is another

option that offers lots of possibilities

for dynamic support and does not

interfere with functional use of the

hand. Taping can facilitate function, as

well. Tape can be applied directly at

the webspace on the hand to encour-

age maintained width and efficient

thumb alignment, and also can be

used to facilitate the use of thumb

and/or wrist extensors by following

the muscle groups into the forearm.

Figures 5 and 6 show one way tape can

be applied to support web space width

and carpal arch formation.

The different types of tape available

each offer different properties. The

choice of which tape to use and when

is generally left up to clinical judgement. Courses are available for

continuing education credits that provide clinicians with guide-

lines for use of tape, contraindications, and precautions. Some of

the brand names of tape typically used therapeutically are:

Coban, Kinesiotape, and Leukotape.

Understanding the unique structural aspects of the thumb joint

and all the movement that it affords is essential in treating the

thumb and the web space through splinting. Inhibition of tight-

ness includes addressing soft tissue extensibility, joint range of

motion, and achieving maximal alignment through use of

orthotics or taping. Improved hand skill can be achieved by focus-

ing on the alignment of the thumb towards abduction-extension,

with maximum function obtained through approximating func-

tional ranges in anteposition, which is necessary for the use of

thumb opposition. ■

F I G U R E 4

F I G U R E 5

F I G U R E 6

The Peanut

Tape

Tape

W E B T A P I N G


Bonnie Boenig, M.Ed, OTR/L, is an NDTA occupational therapy

instructor. She is in private practice and also a clinical specialist for

Lifeworks of Southwest General Health Center in Middleburg Heights,

Ohio. Easy-to-use kits of the customized splints featured above are

available for on-line purchase through boenigwork@ aol.com.

REFERENCES:

Alexander, R, Boehme, R, Cupps, B. (1993). Normal Development of

Functional Motor Skills. San Antonio, TX.: Therapy Skill Builders.

Boehme, R. (1988). Improving Upper Body Control. Tuscon, AZ:

Therapy Skill Builders.

Calis-Germain, B. (1993). Anatomy Of Movement. Seattle, WA :

Eastland Press.

Case-Smith, J. and Pehoski, C. (1992). Development of Hand Skills

in the Child. Rockville MD.:AOTA, Inc.

Cech, D. and Martin, S. (1995). Functional Movement Development

across the Life Span. Philadelphia, PA., W.B. Saunders Company.

Erhardt, R. (1982). Developmental Hand Dysfunction. Laurel, MD:

RAMSCO Publishing.

Gowitzke, B, and Milner, M. (1980). Understanding the Scientific

Bases of Human Movement, 2nd Edition. Baltimore, MD: Williams

and Wilkins.

Henderson/Pehoski. (1995). Hand Function in the Child. St. Louis,

MO: Mosby Publishers

Hogan, Laura and Uditsky, Tracey (1998). Pediatric Splinting

Selection, Fabrication, and Clinical Application of Upper Extremity

Splints. San Antonio, Texas. Therapy Skill Builders.

Hogarth, B. (1988). Drawing Dynamic Hands. New York, NY.

Watson-Guptill Publications.

Howle, J. (2002). Neurodevelopmental Treatment Approach

Theoretical Foundations and Principles of Clinical Practice.

California: NDTA Association.

Jacobs, MaryLynn and Austin, Noelle (2003). Splinting the Hand

and Upper Extremity. Baltimore, MD: Lippincott Williams and

Wilkins.

Jenkins, D. (1998). Hollinshead’s Functional Anatomy of the Limbs and

Back, Seventh Edition. Philadelphia, PA: W.B. Saunders Company.

Kapanji, I. (1982). Upper Limb. In The Physiology of the Joints, Vol

1. New York: Churchill Livingstone.

Kase, K, Hashimoto T, and Okane T. (1998). Kinesio Taping Perfect

Manual. Kinesio Taping Association: Universal Printing and

Publishing, Inc.

Kendall, F, McCreary, E, and Provance, P. (1993). Muscles Testing

and Function, 4th Edition. Baltimore, MD: Williams & Wilkins.

Netter, F. (1995). Interactive Atlas of Human Anatomy. Summit, NJ:

Ciba-Geigy Corporation.

Ryerson, S. and Levit, K. (1997). Functional Movement Reeducation.

Philadelphia, PA: Churchill Livingstone.

Tubiana, R.(1984). Examination of the Hand & Upper Limb.

Philadelphia, PA:W.B. Saunders Co.

1. Benik Corporation 11871 Silverdale Way NW, #107 Silverdale,WA

800/442-8910 • www.benik.com

2. Boenig Workshops and Consultants, Inc.P.O. Box 87, Berea, Ohio [email protected]

3. Joe Cool Company9448 Dove Lane South Jordan, Utah

Phone: 800/233-3556 • www.joecool.com

4. McKie SplintsP.O. Box 16046, Deluth, MN 55816Phone: 888/4SPLINT (477-5468)

www.mckiesplints.com

5. North Coast Medical Hand Therapy Catalog

Phone: 877/213-9300 • www.ncmedical.com

6. Sammons Preston RolyanPO Box 5071

Bolingbrook, IL 60440Phone: 800/323-5547

www.sammonsprestonrolyan.com

SPLINTING MATERIALS RESOURCES:


y name is Terri Lynn Hinson and I am 22 years old. I am

a senior at McGavock High School in Nashville, Tennessee.

I was born with cerebral palsy on November 13, 1982 and was

on life support for three months. They didn’t think that I would

live (I weighed just 2 lbs., 9 oz.). I was adopted by my grand-

parents, Ellen and Billy Hinson. I am so thankful that they took

me in as their own child.

I started school when I was 13 months old. When I was three

years old I started using a communication device with a head stick

called a Light Talker [manufactured by Prentke Romich]. I was

very excited about using a communication

device because I like to carry on conversa-

tions with people.

When I was five I was the Clinic Bowl

Child to raise money for Vanderbilt

University. They had a dinner for the Junior

Chamber of Commerce to introduce me to

them. I said the Pledge of Allegiance on my

Light Talker. When I was six, I was on

Channel 4. They had a story about children

using speaking devices.

I used a head stick for a long time. My speech pathologists,

Cathy Lackey and Colleen Hatcher at Vanderbilt University,

worked with me weekly for many years. When I was in the second

grade I had hip surgery. I was in a body cast and couldn’t use my

head pointer. Mom and I worked for six weeks to learn to use

my hands on the Light Talker.

The Light Talker didn’t have as many sentences on it as I wanted,

and I couldn’t store sentences in it. I was 11 years old when I got

my Liberator communication device [made by the Prentke Romich

Company], which has a large vocabulary. It was easier for me to

communicate because I could make up my own sentences. My

Liberator also has a printer on it.

When I was 11 years old I was a cheerleader for the Donelson

Warriors. We went to a compe-

tition at DuPont High School.

Leslie Gregg was our cheerleading

coach, and we worked out a

routine around me using my

Liberator. The dance was called

“Rock Around the Clock”. I was in the middle and they cheered

around me. We came in second place. Cheerleading was a wonderful

experience because I felt like I had really achieved something in

my life and I made friends.

Also when I was younger, our class at

school was asked to be special guides at the

Hermitage (Andrew Jackson’s home). We

had to dress in old dresses. We programmed

a greeting to the visitors and I sat beside a

portrait and had to say something about

the picture

When Al Gore was running for Pres-

ident I got to go to the Opryland Hotel to

meet him.

In my Life Skills class at school, and at nursery schools and nursing

homes when we go to work, I have used my Liberator and Pathfinder,

which has picture words in it for things like,“It’s nice to meet you,”

and “What’s up?” The children would go home and tell their parents

that they met a girl who talks with a box! They said that she sings

Christmas carols and nursery rhymes with it.

I started making greeting cards this year with my Pathfinder and the

computer. I have a special mouse. The Pathfinder is my keyboard.

I have lots of friends and I go to church. One friend is Whitney.

She uses a Delta Talker and a power chair like I do. I have another

friend who has cerebral palsy. He is 17 years old. ■

Terri Hinson is a senior at McGavock High School in Nashville, TN.

She can be reached at 615-889-9182.

Finding My VoiceADVENTURES WITH MY COMMUNICATION DEVICES

By Terri Lynn Hinson

PAT I E N T A N D FA M I LY P E R S P E C T I V E

M

I was very excitedabout using a

communication devicebecause I like to

carry on conversationswith people.

N D T N E W S


2005

This exceptional two-and-a half-day conference has been

designed especially for you, the NDT practicing clinician. Mary

Ann Sharkey, PhD., PT will set the conference theme in the opening

general session as she addresses the question: “How Can We

Measure the Effectiveness of NDT in the Clinic?” Fifteen hands-on

facilitation labs based on case-presentations will be presented

by an eminent faculty of NDT Instructors. Other conference

highlights include an Exhibitor Showcase, Panel Presentation,

Roundtable Discussion Session, Networking Reception, Luncheon,

and more…

For more detailed information and to register for the NDTA ANNUAL CONFERENCE,

please visit the Conference Page at www.ndta.org

Lezlie Adler, OTSteve Anderson, PT

Kim Barthel, OTLauren Beeler, PT-CI

Judith Bierman, PT-CILois Bly, PT-CI

Kristine Brandel, PTSuzanne Davis, PT-CI

Monica Diamond, PT-CIKay Folmar, PT-CI

Cathy Hazzard, PT-CIAnn Heavey, SLPKacy Hertz, PT-CI

Therese McDermott, SLPMadonna Nash, OT

Teddy Parkinson, PT-CIMechthild Rast, PhD, OT

Mary Ann Sharkey, PhD, PTBeth Tarduno, OTR

NDTA™ is pleased to announcethe 2005 Conference Faculty:


FRIDAY, SEPTEMBER 30, 20057:30am – 8:30am . . . . . Continental Breakfast

8:30am – 10:00am . . . . Opening General Session:» Being a Clinical Detective: Clues for Success • Mary Ann Sharkey, PT, PhD

10:00am – 10:30am . . . Break

10:30am – 11:30am . . . Concurrent Sessions:» It’s About Being A Kid • Lauren Beeler, PT, PCS, CI, Kim Barthel, OTR

and Therese McDermott, MHS, CCC-SLP» Adult Case Video Presentations • Monica Diamond, PT, CI and Cathy Hazzard, PT, CI

11:30am – 12:30pm . . . Lunch On Own

12:30pm – 2:30pm . . . . CONCURRENT LABS (PEDIATRIC):» What Goes Up Must Come Down • Lauren Beeler, PT, PCS, CI» Reach For The Stars • Kim Barthel, OTR» That’s What I Was Talking About • Therese McDermott, MHS, CCC-SLP

CONCURRENT LABS (ADULT)» Straighten Up and Fly Right • Cathy Hazzard, PT, CI, MBA and Teddy Parkinson, PT, CI» Alignment & Activation • Monica Diamond, PT, CI and Beth Tarduno, OTR

2:30pm – 3:30pm . . . . . Exhibitor Showcase & Afternoon Break3:30pm – 5:30pm . . . . . Concurrent Labs Repeat6:00pm – 8:00pm . . . . . Exhibitor Showcase & Reception • Staffed Poster Session • Silent Auction

SATURDAY, OCTOBER 1, 20057:30am – 8:30am . . . . . Exhibitor Showcase & Continental Breakfast

8:30am – 10:15am . . . . CONCURRENT LABS (PEDIATRIC)» In Sync: Baby Lab • Lois Bly, MA, PT,CI & Madonna Nash, OTR/L» More To Talk About • Therese McDermott, MHS, CCC-SLP and Kacy Hertz, PT, CI» So Close…Yet So Far Away: The Mildly Involved Child • Lezlie Adler, MA, OTR, FMOT

and Suzanne Davis, PT-CI

CONCURRENT LABS (ADULT)» Problem Solving for Functional Gains with Low Level Adult Hemiplegia •

Steve Anderson, PT and Beth Tarduno, OTR» He’s Walking…Now What? • Kay Folmar, PT, CI and Kristine Brandel, PT

10:15am – 11:15am . . . Exhibitor Showcase & Morning Break11:15am – 1:00pm . . . . Concurrent Labs Repeat1:00pm – 2:30pm . . . . . Networking Luncheon – ‘Meet Your NDTA’

2:30pm – 4:30pm . . . . . CONCURRENT GENERAL LABS» Extreme Make-Over: Clinic Edition • Kay Folmar, PT, CI» Play In The Context Of NDT • Mechthild Rast, PhD, OTR/L» Getting In Touch With Technology • Ann Heavey, MS, CCC-SLP (Moderator)» A Leg To Stand On: Better Stance Makes Things Swing • Teddy Parkinson, PT, CI

and Lauren Beeler, PT, PCS, CI» Let’s Get On The Ball With NDT • Judith Bierman, PT-CI

5:00pm – 10:00pm . . . . Optional Off-Site Event: Carl’s Back Porch

SUNDAY, OCTOBER 2, 2005

8:00am – 9:45am . . . . . Breakfast Roundtable Discussion Session • Mary Ann Sharkey, PT, PhD (Moderator)9:45am – 10:15am . . . . Break10:15am – 12:00pm . . . Panel Discussion • Lezlie Adler, MA, OTR, FMOT (Moderator)

SCHEDULE AT A GLANCESCHEDULE AT A GLANCE

G A I T A N A L Y S I S

tilt, hip, knee, and ankle flexion and extension. Axial or rotational

abnormalities are difficult to quantify by simply watching the patient

walk.Videos taken from the front and the side will aid in this process,

as the video can be slowed or stopped to help with the analysis.

MOTION ANALYSIS LABORATORY

Observational gait analysis is limited in its ability to determine the

biomechanical causes of a patient’s gait abnormality. Although one

can infer causation, without measurements of muscular activity

(dynamic EMG) or kinetics, one can rarely be sure of the etiology

of a problem. For example, a child might have an equinovarus foot.

With observational gait analysis and a good physical examination,

one might determine that there is swing phase varus and

recommend a certain procedure such as a split posterior tendon

transfer. However, the same pattern can be present from other

etiologies, such as tibialis anterior spasticity with a normal tibialis

posterior pattern. The gait lab can provide much more information

(electromyography, force plate, foot pressure, and kinetic data)

which may clarify the picture. It is often difficult in a short clinical

examination to determine the amount of extrapyramidal activity

a patient has (for example athetosis or ataxia). The variability

present in the gait of patients with athetosis, ataxia or dystonia is

much easier to determine with the motion analysis laboratory than

with simple observation.

Kinematics: Kinematics is the portion of the gait study in which

the dynamic range of motion of a joint (or segment) is measured.

When one observes a person walking, rotational abnormalities in

the transverse plane may be confused with sagittal or coronal prob-

lems. For example, a child with severe femoral anteversion may ap-

pear to have increased adduction or knee valgus when viewed from

the front. Three-dimensional motion analysis helps eliminate some

of the ambiguity of visual analysis.

Standardized reflecting skin markers or markers mounted on

wands are captured by CCD (charge-coupled device) cameras while

the patient walks down a walkway in the Gait Lab. [Figure 1] These

cameras are positioned so that three-dimensional analysis of the

data can be performed. The images are processed by a computer to

derive the graphs of the kinematic plots. The same joint range of

motion which one observes on visual inspection is now displayed

with actual numbers and a plotted curve. These can be compared

to age specific norms and different conditions of walking (barefoot,

brace, shoes, etc.) and they can easily be compared to previous gait

studies such as the pre-operative condition. The three-dimension-

ality permits the assessment of dynamic rotational problems which

cannot be observed in a routine manner. Stride-to-stride differ-

ences can be assessed and plotted to determine the variability of

the gait. A patient with an athetoid or ataxic problem will have

marked variability which may be missed in the clinical setting.

Kinetics: Kinetics describe the forces acting upon a moving body.

The resultant joint moments and forces are derived from force plate

measurements and the kinematic data. Also required is anthropo-

metric data (e.g. leg length, foot length, etc.). As the patient walks

through the Gait Lab, her foot strikes one or more force plates. The

transducers are set up such that vertical force, fore-aft shear, medi-

al-lateral shear, and torque can be measured and compared with

norms. When these data are combined with the kinematic and an-

thropometric data, a representation of the force at each joint (joint

moment) can be determined.

Kinetics can be reported as internal moments in which the force

at a joint is assumed to be secondary to muscle activity. Ligament

stretch, joint morphology, contractures, etc. may also contribute to

the moment. Kinetics can also be described as external moments in

which the force acting upon a joint is thought to be a response to

the ground reaction force. Besides the conceptual underpinnings,

the only difference between the two is a positive or negative sign.


(Walking Through the Gait Lab continued from page 1)

F I G U R E 1 Child with markers in motion analysis lab.


MUSCLE ACTIVITY IN GAIT

Although the action of the muscles can be inferred from watching

a patient walk, it is often difficult to determine which muscle is

active or inactive during a particular motion. This knowledge may

or may not be very important in determining which therapeutic

intervention will correct the problem. It is critical in helping to

determine which muscles should be used as a “motor” in a muscle

transfer. For example, one may feel that if a patient has an equino-

varus foot deformity, then a split posterior tibial tendon transfer

should be performed to correct it. However, there are many instances

in which there is little or no activity of the posterior tibialis muscle

during the gait cycle in a patient with equinovarus. Other causes

of equinovarus could include an overactive anterior tibialis muscle

or a combination of anterior tibialis and posterior tibialis muscle

overactivity. Fixed hindfoot varus could also be present. In these

patients who have not had dynamic electromyography, the wrong

procedure would have been performed.

Surface or fine-wire electromyograph (EMG) measures the muscle

impulses. When one is interested in group muscle activity, such as

the gastrocsoleus or adductors, then surface electrodes suffice. There

is a problem with “cross-talk” from adjacent muscles, but these

usually do not alter clinical decisions. In deep,

buried muscles (for example, tibialis posterior

or flexor digitorum profundus) fine-wire elec-

trodes must be placed to get any meaningful

information. One must weigh the information

gained from fine-wire EMG data with the

minimal discomfort the patient experiences in

its placement. Young children often are not

able to cooperate with this somewhat techni-

cally demanding procedure.

FOOT PRESSURE

The measurement of pressures of the foot is

helpful in patients who have subtle varus or

valgus foot deformities or in those with

increased pressure at certain points such as a

diabetic or Charcot foot. Not only can this be

utilized to define the problem, this can also

determine if the proposed solution (e.g.

orthotic, shoe modification, or surgery) has

improved the pressure concentration.

Case Example: A four year and five month

old boy with spastic diplegic cerebral palsy

presents with bilateral toewalking and internal rotation of the

limbs. He wears bilateral ankle-foot orthoses but falls up to twen-

ty times per day. He is able to ride a tricycle, can climb stairs and

has an endurance of about one half mile. The experienced referring

orthopedic surgeon thought that he should have bilateral heel cord

lengthenings.

The physical examination demonstrates mild hip flexion con-

tractures and an increase in femoral internal rotation of 70

degrees bilaterally. He has a popliteal angle of 150 degrees (30

degrees) and plantar flexion contractures at the ankle of 15

degrees. He has hyperreflexia and has a positive Ely-Duncan test

suggestive of rectus femoris spasticity.

The kinematic data demonstrated, in the sagittal plane:

increased anterior pelvic tilt, minimal increased flexion of the hip,

diminished and delayed peak knee flexion in swing and a marked

increase in ankle plantar flexion throughout the gait cycle.

Frontal or coronal plane abnormalities included: increase pelvic

obliquity in stance phase and increased adduction throughout the

cycle. Transverse plane abnormalities included: increased femoral

rotation, tibial rotation which followed the femoral rotation and

an internal foot progression angle.


F I G U R E 2 Preoperative Kinematics.


The electromyography data showed full cycle activity of the rectus

femoris but most importantly, increased activity in swing phase;

full cycle activity of the vastus lateralis; minimal but out of phase

activity of the adductors; mostly stance phase activity of the gastroc-

soleus; and full cycle activity of the tibialis anterior.

Based on his physical examination, review of the videotape and

integration of the gait data, the following procedures were recom-

mended: bilateral varus derotational osteotomies of the femurs,

psoas lengthening at the pelvic brim, adductor longus recession,

distal medial hamstring lengthening, rectus to semitendinosus

transfer and Strayer gastrocnemius recession. Although some of

these procedures could have been predicted by a meticulous exam-

ination of the child, not all of them would necessarily be suggested,

such as the rectus transfer based on the kinematic and elec-

tromyographic data.

One year after the surgery, the child was no longer falling, was

playing soccer and learning to roller blade. The kinematic plots

show that the parameters have all returned to near normal.

Practical Uses of the Gait Lab: The most common use for

clinical gait laboratories in the United States is for the evaluation

of children with developmental disabilities, particularly cerebral

palsy and myelomeningocele. These children have very complex

gait problems combined with the underlying neurological insult.

It is often very difficult to completely evaluate these patients in a clin-

ical setting and gait analysis has been very helpful in formulating

treatment plans. DeLuca et al reviewed 91 patients who had rec-

ommendations for surgery from experienced physicians and then

compared the recommendations based on gait analysis. They found

that the addition of gait analysis data resulted in changes in surgi-

cal recommendations in 52% of the patients with an associated re-

duction in cost of surgery, not to mention the impact on the patient

for performing the inappropriate procedure. Kay et al performed

a similar study in 97 patients with an even higher number (89%)

of treatment plan alterations.

The development of new surgical techniques and orthotics have

benefited from research performed in motion analysis laboratories.

There is often a clinical question as to the need for an orthotic and then

to determine the appropriate orthotic. Several studies have evaluated

the efficacy of various orthotics in the management of children with

developmental disabilities. These all have practical applications for

patient management.

SUMMARY

Motion analysis is a diagnostic and outcome research tool which

should be viewed as similar to modern radio-

logic imaging techniques of the musculoskeletal

system. While many and possibly most gait

problems can be evaluated with a systematic

visual inspection and complete clinical evalu-

ation, some problems require some or all of the

components of the modern motion analysis

laboratory. Human gait, with its neurological

control, muscular response, and bone and joint

motion is far too complex for any clinician to

appreciate all of the intricacies with simple

observation. Although an overall idea about the

gait can be obtained in this manner, subtleties

and fine nuances of gait cannot. Gait analysis

provides an objective record of a patient’s gait

before and after therapeutic intervention and

should be considered a vital part of the clin-

ician’s decision making. ■

Hank Chambers, MD, is chief of staff at San Diego

Children’s Hospital and Health Center, University

of California at San Diego. He can be reached at

[email protected].


F I G U R E 3 Postoperative Data.


CITY KIDS COURSES 20055669 N. Northwest Hwy Chicago, IL 60646 • (773) 467-5669 • www.Citykidsinc.com • E-mail: [email protected]

May 23-27, 2005 • Five Days $700

NDT for SLPs–An Intro Pediatric Course For Non-NDT-Trained Therapists

June 17-18, 2005 • Two Days $300

Two Days in the Mouth-Building Blocks for Oral TreatmentInstructor: Therese McDermott, MA-CCC-SLP

July 17-18, 2005 • Two Days $300

Into The Mouth of Babes-Feeding for BabiesInstructor: Therese McDermott, MA-CCC-SLP

July 22-24, 2005 • Two and a half days $375

Taping For Improved Alignment and Neuromuscular Re-Education–Kinesiotaping Certification CounselInstructor: Trish Martin, PT, Audrey Yasukawa, MOT,OTR/L, CKTI

August 6-7, 2005 • Two Days For $400

Serial Casting and Splinting Techniques: Part II (Practicum)Instructor: Beverly Cusick, MS, PT

August 12-13, 2005 • Two Days For $350

Neuromuscular Electrical Stimulation For ChildrenInstructor: Gad Alon, Ph.D., PT

September 16-17. 2005 • Two Days $300

SI for STInstructors: Madonna Nash OTR/L & Lisa Mesecar MA, OTR/L

September 18-19, 2005 • Two Days For $300

Why Kids Won’t EatInstructors: Therese McDermott, MA-CCC-SLP, and

Madonna Nash OTR/L

October 24-Nov. 11, 2005

$2500/NDT members • $2700/non-members

NDT Approved Three Week Baby CourseInstructors: Lois Bly, PT, Madonna Nash, OTR/L, Kacy Hertz, PT and

Therese McDermott, MA-CCC-SLP

For further information please call Sheila de Armas at 773/467-5669 x150 or fax 773/314-0079.

All 3 courses for

$1200

Bothcourses for

$550

E D U C A T I O N A L O P P O R T U N I T I E S


Upcoming NDTA Inc. Approved Courses

NDT/BOBATH CERTIFICATECOURSE IN THE TREATMENT AND MANAGEMENT OF ADULTS WITH HEMIPLEGIA

Course #: 05A101Dates: 7/21/2005–7/24/2005

8/18/2005–8/21/20059/15/2005–9/18/200510/13/2005–10/16/2005

Location: Asheville, NCInstructors: Kay Folmar, PT, CICathy Hazzard, PT, CIContact: Ron HoechstetterCarePartners: Staff Development Dept.68 Sweeten Creek Rd.,Asheville, NC 28803828-274-9567 [email protected]_______________________________________

Course #: 05A105Dates: 9/21/2005–9/24/2005

9/27/2005–10/1/200511/09/2005–11/12/200511/14/2005–11/16/2005

Location: Columbus, OHInstructors: Marie Simeo, CI, PTPatricia Bonner, OTContact: David Rupp, Ohio Health6200 Cleveland Ave., Columbus, OH 43231614-566-0562 • Fax [email protected]_______________________________________

Course #: 05A108Dates: 8/3/2005–8/14/2005

11/30/2005–12/5/2005Location: San Jose, CAInstructors: Cathy Runyan CI, OTPeggy Miller, PTContact: Recovering Function408-268-3691 • [email protected]_______________________________________

Course #: 05A109Dates: 10/31/2005–11/18/2005Location: Sunrise (Fort Lauderdale), FLContact: Monica Diamond5403 Middleton Dr., Greendale,WI 53129414-421-8427 • Fax 414-421-8429 [email protected]

Course #: 05A110Dates: 10/17/2005–10/28/2005

11/28/2005–12/3/2005Location: Little Rock,ArkansasInstructors: Nicky Schmidt, PT, CI,Pat Bonner, OTContact: Jeana KelleyBaptist Health Rehab. Institute9601 Interstate 630, Little Rock, AR 72205501-202-7598 • Fax 501-202-7141

NDT/BOBATH CERTIFICATECOURSE IN THE TREATMENT ANDMANAGEMENT OF INDIVIDUALSWITH CEREBRAL PALSY

Course #: 05B102Dates: 6/13/2005–6/17/2005

6/20/2005–6/24/20057/8/2005–7/10/20057/22/2005–7/24/20058/5/2005–8/7/20058/26/2005–8/28/20059/9/2005–9/11/20059/23/2005–9/25/200510/17/2005–10/21/2005

Location: Orlando, FLInstructors: Suzanne Davis, RPT ,Lezlie Adler, OTRMonica Wojcik, SLP, Nancy Marin, OTContact: Kris Fought or Irma Rosa–NDT Course CoordinatorsUCP Child Development Centers3305 S. Orange Ave, Orlando, FL 32806321-281-7129 or [email protected] [email protected]_______________________________________

Course #: 05B103Dates: 4/29/2005–5/2/2005

6/3/2005–6/6/20056/20/2005–6/24/20056/27/2005–7/1/20058/5/2005–8/8/20059/16/2005–9/19/200510/21/2005–10/24/2005

Location: Monticello, NYInstructors: Margo Prim Haynes, PT, CI,

Jane Styer-Acevedo, PT, CI,Loren Arnaboldi, SLP, Kate Bain, OTR/LContact: Denita Newsome JohnsP.O. Box 5316, Philadelphia, PA 19142215-815-4880 • [email protected]_______________________________________

Course #: 05B105Dates: 9/15/2005–9/18/2005

10/6/2005–10/9/200512/1/2005–12/9/20051/26/2006–1/29/20062/22/2006–2/26/20063/15/2006–3/19/2006

Location: Cleveland, OHInstructors: Susan Breznak-Honeychurch,PT, CI, Bonnie Boenig, M Ed, OTR,Rona Alexander, PhD, CCC-SLPContact: New Directions @ 710 Associates710 Central Avenue, Dunkirk, NY 14048716-366-2944 • Fax [email protected]_______________________________________

Course #: 05B107Dates: 7/25/2005 - 8/19/2005

10/17/2005 - 11/11/2005Location: New Castle, Galway, IrelandInstructors: Susan Breznak Honeychurch,CI, PT, Christine Cayo, OT, Rona Alexander, SPContact: Clare Lenehah, Director of ServicesEnable Ireland Children’s Centre GalwaySeamus Quirke Road, New Castle, Galway+353.91.526321 • Fax [email protected]_______________________________________

Course #: 05B108Dates: 7/8/2005–7/13/2005

8/5/2005–8/7/20059/16/2005–9/18/200510/14/2005–10/16/200511/4/2005–11/6/20051/13/2006–1/15/20062/10/2006–2/12/20063/10/20006–/12/20064/21/2006–4/23/2006

Location: Austin (Cedar Park),TXInstructors: Judith Bierman, CI, PT,Gail Ritchie, OTR, Ann Heavey, SLPContact: Susan Alabaugh


Welcome to the 21st century! And what a

century it is destined to be. Globalization.

Consolidation. Instant access. These are all

terms for the new millennium. It is hard to

imagine what the future holds. However one

thing is certain. The more advances we make,

the greater our need for quality leaders.

Leadership must come from the heart.

Leaders must be driven by a passion to facil-

itate and manage change. When I think of

leadership, these are the characteristics that

come to mind.

Throughout my journey with the Neuro-

Developmental Treatment Association

(NDTA), the spirit of volunteerism has been

a prevailing force. Recently, I read an article

by William C. Richardson, President and

Chief Executive Officer of the W.K. Kellogg

Foundation, titled “Leadership Reconsidered:

Engaging Higher Education in Social

Change.” This article made some strong

points, which I would like to share with you.

Richardson wrote, “The capacity to lead is

rooted in virtually any individual and in every

community.” Further, he said a leader can be

anyone, regardless of formal position, who

serves as an effective agent of change.

The point is simple. The potential to be a

leader and a “change agent” is in all of us.

There are many people in this organization

with a passion and drive for change. These

individuals take it upon themselves to get

involved and help motivate others in the

right direction. Leadership is responsible for

communicating (through words and action)

the mission, vision and priorities of an organ-

ization. In October, a number of individuals

made a commitment to embark on a lead-

ership journey. The NDTA Board of

Directors welcomed incoming Secretary

Barry Chapman, Director of Regions Pamela

Moore and Instructor Group (IG) Executive

Committee Chair Kay Folmar. Director of

Public Relations Carol Nunez-Parker and

Director of Research Clare Giuffrida have

returned to their respective positions. Brenda

Pratt, our outgoing President, will lend her

leadership, kanowledge and expertise as Vice

President/President Elect. Our outgoing

Secretary Carrie Mori, Director of Regions

Debbie Evans-Rogers and IG Executive

Committee Chair Nicky Schmidt have been

deeply involved and committed in helping

move our association forward. On behalf of

NDTA, I would like to thank all of these indi-

viduals for their dedication, enthusiasm and

leadership.

In this and upcoming issues of the NDTA

N e t w o r k ,

members will see

the collaborative

work of the

E d i t o r i a l

A d v i s o r y

C o m m i t t e e .

Better than ever,

the publication

continues to

communicate

the direction of

our professions

and NDTA. Its

articles may help

you reshape your

current prac-

tices. They may

cause you to

reflect on the

direction our

association and,

most impor-

tantly, what it all

means to you as

a member. This

issue of the

Network is dedi-

cated to

exploring forced

use/constraint-induced intervention. Make

sure to read Susan Woll’s and Jan Utley’s

article on the close relationship between the

theme and NDT.

Our association is not successful without

the contributions, input and hard work from

our members. I would encourage you to

actively participate in the leadership of NDTA

through committee involvement at a regional

or board level, research development or

educational events. The opportunities to lead

are endless.

Never hesitate to step forward and take on

a leadership role.Your involvement can help

All Members Are LeadersNDTA IS STRONGER WHEN EACH OF US CONTRIBUTES.

BY DEBRA J . PAUL. OTR

Upcoming NDTA Inc. Approved Courses

Administrative Assistant/Continuing Education,Neuro-Developmental Treatment Programs, Inc.817 Crawford,Augusta, GA 30904706-736-1255 • Fax 706-736-1258 • [email protected]_________________________________________________________

Course #: 05B109Dates: 11/7/2005–11/12/2005

12/9/2005–12/11/20051/20/2006–1/22/20062/17/2006–2/20/20063/31/2006–4/2/20064/28/2006–4/30/20066/23/2006–6/25/20067/21/2006–7/23/20068/18/2006–8/20/2006

Location: Salem, NHInstructors: Linda Kleibhan, PT, CI, Barbara Hodge, PT, CI,Rona Alexander, CCC, SLP, PhD, Gail Ritchie, OTR

Contact: Kristen Tortora, Jon Greenwood, PT

Northeast Rehabilitation Hospital

70 Butler St., Salem, NH 03079

603-893-2900 Ext. 766 • [email protected]

NDT/BOBATH APPROVED ADVANCED COURSES REQUIRING THE SUCCESSFUL COMPLETION

OF AN NDT BASIC COURSE

Course #: 05U101Course Title: NDTA Approved Advanced Course in theTreatment of Adults: Upper Extremity CourseDates: 1/18/2006–1/22/2006Location: Sunrise (Fort Lauderdale), FLInstructor: Monica Diamond, CI, MS, PTContact: Monica Diamond, CI, MS, PT414-421-8427 • Fax [email protected]________________________________________________________

Course #: 06Y101Course Title: Advanced Baby CourseLocation: Allentown, PADates: 3/27/2006–4/7/2006Instructor: Lois Bly, CI, MA, PT, Mechthild Rast, PhD, OTR/L,Lisa Glasner, SLPContact: Cindy Miles, PT, MeD, PCS, Cindy Miles and Assoc.3721 Crescent Ct. W,Whitehall, PA 18052610-820-7667 • Fax 610-820-7671 • E-mail: [email protected]

E D U C A T I O N A L O P P O R T U N I T I E S

PEDIATRIC SPEECH THERAPIST:Innovative Outpatient, Private Practice in Whitehall,

Pennsylvania (Near Allentown)

Center & Home Based Services Early Intervention, Preschool & School age

Full Time/Part Time/Per DiemFlexible Hours

Experience a MustLicensed & CCC’s

Contact: Cindy MilesPhone: 610-820-7667

Fax: 610-820-7671www.cindymiles.com

E M P L O Y M E N TO P P O R T U N I T Y

Neuro-Developmental Treatment Association1540 S. Coast Hwy, Suite 203Laguna Beach, CA 92651

Prsrt StdU.S. Postage

PAIDDocumation

T H E N E U R O - D E V E L O P M E N T A L T R E A T M E N T A S S O C I A T I O N • M A Y / J U N E 2 0 0 5 • V O L U M E 1 2 , I S S U E 3

Confused about the Initials NDT?The letters “NDT” are used by many entities (Non-Destructive Testing comes to mind). But in the therapy world since atleast 1983, NDT has stood for Neuro-Developmental Treatment and is associated with the treatment approach originally developed by Karel and Berta Bobath in 1943.

Neuro-Developmental Treatment is:

• An evolving, holistic approach, developed by the Bobaths, in which “everything done in treatment should serve as adirect preparation for specific functional use.” (B. Bobath, 1977, p. 312).

• The most widely used treatment in North America for children and adults with cerebral palsy and for adults withhemiplegia following stroke in North America (as discussed by Cherry & Knutson, 1993; Hayes, McEwen, Lovett, Sheldon &Smith, 1999; Sweeny, Heriza & Markowitz, 1994.

• The therapy approach sanctioned by the Neuro-Developmental Treatment Association (NDTA), whichhas been in existence since the mid-1970s and was registered in 1977 as an association of physical, occupational, andspeech-language therapists who practice Neuro-Developmental Treatment.

• Definitively explained in the 2002 theory book, Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice by Janet Howle in collaboration with the NDTA Theory Committee (published by NDTA, Inc.) The book has been reviewed by a number of national journalists and has been recommended as“the best resource on the current status of the NDT approach....”

If you are planning to take an NDT course or study NDT theory, don’t be confused by initials. Make sure it is a Neuro-DevelopmentalTreatment course, sanctioned or sponsored by NDTA, Inc., with Instructors and Coordinator Instructors that are trained and active with NDTA, Inc.

C O N S U M E R A L E R Ty

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