Defining Moment The Power of Practical Advice Employing contemporary theories of neurorehabilitation and neuroplasticity to enhance children's lives. By Sara Kerrick, PT | March 2020 I am a pediatric physical therapist. I embrace and integrate the contemporary neurodevelopmental treatment (NDT) practice model, as defined in the textbook "Neuro-Developmental Treatment: A Guide to NDT Clinical Practice," into my treatment planning. I do so based on a defining moment I experienced when I was a PT student at Northern Arizona University. One of my professors was Carl DeRosa, PT, DPT, PhD, FAPTA. His directive "Do what works" made an indelible impression on me. I use an NDT treatment model because of my clients' favorable outcomes. I have worked with many children who have made functional gains in their skills and have improved their participation at home, in school, and in their community as a result of my using the NDT framework for critical thinking. More recently, some less than favorable journal articles have addressed the use of NDT with children with cerebral palsy. These pieces do not represent the NDT treatment model that I and many other therapists — pediatric and adult — use. While early NDT theory was grounded in a hierarchical/neuromaturation model, the practice model has evolved along with our understanding of neuroscience. My NDT knowledge base is rooted in current theories of neurorehabilitation and neuroplasticity. I have deepened my understanding of motor control, motor learning, motor development, neuroplasticity, and how the brain adapts and changes to produce functional movement based on a goal that the person values. I appreciate how well my NDT mentors have integrated the most current theories for the "why" in neurorehabilitation into their teaching, education, and practice. My foundational skills for all my clients are built on the concept of alignment relative to the individual's base of support and center of mass. The goal is more efficient posture and movement centered on a functional task or goal. I am very aware of posture and how my clients are organizing themselves for function from their base of support. This focus on alignment facilitates ease and efficiency of movement for enhanced function. Insufficient attention to this concept promotes an atypical posture. This eventually results in less efficient and less functional movement patterns. With NDT, I use my knowledge of typical movement, postural control, and motor development to guide my treatment progression. I am aware of how each client's center of mass is aligned over the base of support. I ask, "What is the potential for movement? Is it efficient and effective for function now and in the future?" I recognize the need for a lifespan perspective. I use manual handling as both an assessment tool and an intervention that facilitates active assistive movement, enhances sensory reception, and guides movement. My goal is to decrease my tactile, verbal, and visual cues so that my clients' movement increasingly is internally driven. I encourage active problem-solving to promote increased variety of movement. I empower my clients to challenge themselves. I address body structures and functions in my treatment plan — in context, per NDT — for more efficient and effective movement and posture to enhance function and participation. NDT originally was developed as a treatment approach for children with cerebral palsy and for adults who had experienced a stroke or head injury. As a pediatric PT, my application of NDT has expanded beyond children with cerebral palsy to those with a wide variety of neuromuscular diagnoses. It's a framework for how I approach assessment, evaluation, and treatment. My clients have a variety of needs based on their unique body structure and function, where they live and play, and their specific functional goals. I have experienced many "aha" moments while working with them. M.K., for example, wanted to be able to pass a ball on a rope to a peer during a game. With NDT guiding my analysis of her movement and posture, I determined that she needed to use her core strength to stabilize her trunk and use her arms more freely. She then could move the ball along the rope without pulling her friend over. She was now using her arms while stabilizing with her trunk to control her postural control—creating a "V" (shoulder horizontal abduction and flexion with elbow extension), versus a "U" (shoulder abduction and extension with elbows flexed) with her arms to move the ball along the rope to her friend. M.P.'s goal, meanwhile, was to shoot hoops with her peers and participate fully in recess activities. My history with her started when she was a toddler. We worked together on addressing her posture and movement in learning to walk — first with a walker, then gradually decreasing the required level of assistance. I have focused on enhancing her active problem-solving to increase her speed, efficiency, and, most important, her confidence on the playground. Together, we have integrated bimanual control of her arms and legs, which enables her to make the most of her attempts to shoot the basketball for height and accuracy. I've worked on improving the overall balance and postural control of another client, S.S., by analyzing her alignment relative to her center of mass and base of support. The initial goal was for her to be able to walk into the clinic while holding her mother's hand instead of being pushed in her wheelchair. She is now working toward holding her younger sister's hand, which allows their mom to walk into appointments with her daughters without use of a S.S's walker, stroller, or wheelchair. S.S. once needed a walker to navigate the beach. She now runs on the beach, chasing waves. Working collaboratively with my clients and their families, I'm constantly evaluating and reevaluating outcomes. While my theoretical understanding of why neurorehabilitation science has changed, I continue to integrate a contemporary NDT practice model into my sessions. The reason? Because it works. Sara Kerrick, PT, is a physical therapist at Mary Bridge Good Samaritan Children’s Therapy in Puyallup, Washington. She is a board-certified clinical specialist in pediatric physical therapy and is certified in neurodevelopmental treatment of pediatric patients.