NEURODEVEPMENTAL

TREATMENT EVALUATION
CRITIQUED
Group 2
Names : Shahin Bateri
Shalini redkar
priyanshu Prabhu
pradnya tulaskar
ritika
INTRODUCTION
• NDT certified therapists look at and what they feel when they assess
movement

• Procedures that assess axial control , automatic reaction , and limb

control come from three different sources
1. Formal evaluation tools
2. Clinical observation
3. Normal development trends
 REFLEX DEVELOPMENT
• Abnormal reflex development is commonly seen in children with brain damage, such
as cerebral palsy.
• It is rarely seen in adult patients. If adult patients have abnormal tonic and phasic
reflexes, they quickly disappear
•
Reflexes have three essential characteristics
(1). First, they can produce realignment of the head and limbs but do not move the
body through space. For example, the ATNR can move the arms and legs into a fencer
position.
(2 )Second, they are triggered by outside stimuli, like a noise making making an infant
turn his/her head to look for the sound.
(3) Third, these reflex movements are stereo- typed but never obligatory in normal
infants.
• Stimulus always produces the same predictable movement or
posture, but with repetition, the reflex loses its ability to provoke a
response.

Tonic reflexes are considered to be normal as long as they disappear at

the appropriate time and are not obligatory.
• Procedures for reflex evaluation have been published in numerous
texts

• However, many of these sources cite Fiorentino’s Reflex Testing

Methods for Evaluating CNS Development
• Remember that reflexes become inhibited gradually.

• If you feel or see an inconsistent or weak response, it probably

means that higher centers are gradually inhibiting the spinal cord and
brainstem reflexes.

• However, just because you observe a weak or inconsistent reflex

doesn’t make it clinically significant.

• Clinical observation of voluntary movements is necessary to assess

the influence of reflexes at this final stage of recovery.
• Decision tree process needs to be applied to defuse your anxiety when you see the long
list of reflexes.

• This list can be broken down into small groups that have varying significance.

• Oral reflexes, such as the rooting, gag, and suck reflexes, are vital only if you are heavily
involved in feeding and speech issues.
• Neonatal reflexes such as Stepping Reactions and the Galant Reflex are fascinating, but
their clinical significance is unknown.
• Phasic reflexes, like the Moro, Flexor Withdrawal, and Crossed Extension, need to be
formally assessed only when they produce strong motor responses that consistently
interfere with evaluation and early treatment.
• Other reflexes such as ATNR ,STNR, tonic labyrinthine, palmar grasp should be evaluated
routinely in children
-

These tonic reflexes can linger for long periods of time in brain-
damaged children and have devastating effects.

They can impede motor development and produce severe deformities

that eventually interfere with autonomic functions like breathing.

In brain-damaged adults, they are rarely seen or are present in a mild

version once the coma lifts.
AUTOMATIC REACTIONS

1. Essential characteristics

2. Test modification
Essential characteristics
• Righting reactions have three essential characteristics
• (1). First, righting reactions are initiated by the person for a purpose
instead of by outside stimuli.
• (2)Second, movement produced by the reaction facilitates movement
through space like rolling.
• (3)Third, the movement is a “chain reaction” that cannot be stopped in
mid- sequence.
• For example, once you start rolling you may roll off the bed because you
can’t stop.
Types of righting reactions
• Vertical righting reactions
. 1 optical righting
2 labyrinthine righting procedures

• Rotatory righting reactions

1 . neck righting
2. Body righting
Vertical righting reactions
1 Optical righting
• Optical righting is tested with the eyes open and it returns the head to
a vertical upright position.
• Optical righting is often called vertical head righting.
2 Labyrinthine righting
• Labyrinthine righting produces the same head adjustment, but is
tested with vision occluded.
• Labyrinthine righting is rarely tested because tilting patients with their
eyes closed is very threatening.
Rotatory righting reactions
• Rotary righting reactions enable us to twist body parts out of
alignment from the longitudinal axis of the body and then return to a
symmetrical alignment.

• The ability to untwist is very helpful when we use rotation to make a

transition from one posture to another, like sitting up on the edge of
the bed.

• Rotary righting includes neck righting which enables us to log-roll, and

body righting, which enables us to roll segmentally.
• Equilibrium reactions and protective extension have three essential
characteristics

• First, these reactions enable a person to quickly prevent or minimize

falls without having to think about it.

• Second, the person can stop the movement anywhere in the sequence.
For example, a person can stop in mid-roll as soon as the hand touches
the alarm clock.

• Third, the movement can be modified for each new situation.

For example, coaches teach football players to suppress protective
extension so they can concentrate on catching the ball instead of
putting out their hand to break their fall.
Test modification
• The Fiorentino book is the best resource for learning the administrative and
scoring protocols for automatic reactions

• However, procedures for testing equilibrium reactions may have to be modified.

• It is especially difficult to keep brain-damaged children from falling off the tilt
board.

• To prevent accidents, therapists have modified tilt-board procedures.

• One modification involves getting on the tilt board to hold the child and
determining if his/her response matches your normal response.
• It is dangerous to evaluate rotary righting in adults by twisting their heads to make them
roll.

• the Derotative Procedure is a better alternative

• This procedure involves turning the patient from supine to prone by holding onto the legs.

• If the patient does not log-roll (i.e., he/she leaves the shoulder girdle behind on the mat),
axial tone is usually very low.

• This is an early warning sign that neck and body righting will be delayed.

• Rolling onto the sound side is the most important way to evaluate rolling in a stroke
patient.
• This elicits retraction of the hemiplegic arm and leg while the sound
side is pinned underneath the body

• Evaluation of equilibrium reactions in adult patients is especially

difficult.

• Adult-size balls and bolsters are available, but they are even more
unstable and difficult to control than tilt boards if you have a severely
impaired adult patient.

• Adult patients are usually tested sitting on a matt table or standing.

Initially, the patient Sitting on a matt table or standing.
• Initially, the patient is gently moved away from vertical while the
therapist holds the shoulders.

• the patient can tolerate this, distal segments, like the lower leg, can be
used.

• Using the distal body parts produces a more valid response because
they stress the patient more and therefore have the most potential for
eliciting a visible automatic reaction.

• While the use of distal body parts blocks abduction of the uphill uphill
leg, leg, it also gives the therapist something to hang onto if the patient
starts to fall.
EVALUATION OF SYNERGY
Brunstorm described how to evaluate synergies in movement therapy
in hemiplegics.

They are the pathological synergies in which several muscle groups

contract together to produce stereotyped primitive mass movements.

There is no isolated movements of one body part like the wrist moving
alone. (if one muscle group gets activated all muscle groups around all
get activated).

Brunstorm called this lack of separate movement between two parts

as dissociation.
The brunstorm procedure evaluates proximal dissociation of shoulder,
scapula, elbow and distal dissociation of fingers, forearms, wrist.

There are two types of synergies: Flexor synergy that dominates the UE
And extensor synergy dominates the LE.

The flexor dominance in UE is because of the repeated

contraction(eccentric) in order to raise or lower the arm against gravity.
NOTE the patient cannot perform isolated movements when bound by
synergy patterns).

The extensor dominance in the LE is because of concentric and eccentric

contraction of the LE while walking etc.
Patients rarely exhibit full rom for the movement.

EXAMPLE: For may have full flexion ROM in the elbow but may not be
able to supinate, on the other hand some pts may have an elbow
flexion of 45 degrees with supination present.

The brunstrom protocol helps differentiate these kinds of situation’s

In stage 3 estimates can be recorded as ½ rom or 90 degrees of rom.
This is important because it helps the therapist identify the overactive
muscle and inhibit them and further facilitate the weaker muscles.
,
• Please note follow stage 4 and 5 given in the page as it gradually
introduces the component of flexion and extension synergy(example
raising arm above 90 degrees needs abduction and elbow extension)

As Ots We need to asses effect of LE synergy in daily ADL AND IADLS.

Particularly hip External rotation
• INSTRUCTIONS FOR ADMINISTRATING BRUNSTROMS SYNERGY
EVALUATION:STAGE (NO MOVEMENT INITIATED)

• : Passively move the extremities through the actual synergy

pattern, no resistance should be felt.

• Then patients is asked to assist the motion, no active motion

should be felt.
• STAGE (SYNERGIES FIRST APPEAR): Repeat the same as above only this
time during passive motion resistance is felt and during assisted
motion some active motion is felt

• STAGE (SYNERGIES INITATED VOLUNTARILY):Demonstrate full synergy

patterns.
• Ask the patient to imitate you. Estimate how much range is exhibited
for each ROM.
• If any motion is missing demonstrate the specific movement and ask
the parient to imitate you
• STAGE (MOVEMENTS DEIVAITING FROM SYNERGY):
• Ask patient to imitate each motion. Raise the arm forward horizontal with elbow
extended. Perform Pronation and Supination bilaterally.

• (FULL ROM is emphasized in this alternating motion STAGE (RELATIVE INDEPENDCE):

• When patient raises arm over the head, arm is in full shoulder flexion with elbow
extension is seen.
• During pronation/supination the arm can be held forwardsin horizontal or sice
norizontal bosicon

• STAGE 6(MOVEMENT COORD NEAR NORMAL):

• Some spasticity may be present in quickmovements, no synergy patterns are
available, some awkwardness is noted
SPEED TEST: The fist must touch both chin and knee. One stroke equals
one round trip.
Forearm is Neutral.

WRIST STABLIZATION: Watch for wrist flexion, when the elbow flexes
which would interfere with retrieval of objects.

WRIST FLEXION AND EXTENSION: Performed with fist closed around the
object. Watch for
finger extension when the wrist flexes.
• WRIST CIRCUMDUCTION: Elbow stabilized against the trunk with
forearm in pronation to prevent elbow and forearm stabilization.
•
GRASP: Release is not required to pass the hook grasp, but it is required
to pass for lateral prehension up to spherical grasp.

INDIVIDUAL THUMB MOVEMENTS: Hand is in patients lap with forearm

resting in neutral position. Wiggle extended the thumb up and down
for vertical motions and side to side horizontal motions.

OTHER SKILLED MOVEMENTS:writing.etc

EVALUATION OF MUSCLE TONE:

Muscle tone is defined as the continuous and passive-partial contraction of the muscle or the
muscle’s resistance to passive stretch during the resting state.

THERE ARE 4 METHODS TO EVALUATE TONE:

Manual assessment of resistance in passive motion
Mechanical devices such as strain gauges to measure “resistance to passive motion.
Visual Observation for restriction in movements
EMG to asses the electrical activity of the muscles in movements
Mechanical device and MG are reliable but requires a lot of time to be admin, hence its not
logical in a clinical use.
The tone evaluation procedure assesses spasticity by evaluating the resistance to motion. This
procedure requires two steps:
1 .Measure the amount of tone
2. Where in the range the resistance is felt.
Each movements that elicits resistance is circled.

Unlike the passive ROM goniometery, the examiner estimates where

the in the range the resistance is first felt, not whether the patients has
full ROM.

Only the estimates of where the resistance is felt are recorded such as
mid range or about
Recording the exact degree of variability is not required because of
subject variability.
Muscle tone can vary with room temp,pain, fear and fatigue.
• Even though slow passive elongation is generally safe, there are three
instances when passive elongation may not provide reliable indication of
muscle tone

• Adult patients often resist to passive elongation of the trunk, neck and
pelvis. (invasion of these private zone and fear of falling will result in
patients fixating their body)
•
• NECK: Ask the patients to look up, down and left and right. If neck rom is
incomplete assist the patient and try to note resistance.
• TRUNK: may have to use active weight shifts. (Note resistance felt and range
you felt it)
• PELVIC TILT: via active assistive techniques if you coordinate manipulation of
pelvis with look, leaning and breathing.
Steps:
Stand in front of the patient who is sitting with their hand resting on
your shoulder.
Have the patient look up at the ceiling and take a deep breath and lean
forward while you step back. Use your flattened hands on the back of
the patient to pull the pelvis forward.
• Then have the patient look down and blow out, lean back behind the
vertical as you step forward and gently push the ASIS posteriorly for
posterior tilt
• Important points to note:
If block the patients movement by you standing still yourself or pump
the patients pelvis out of synchrony with breathing, leaning and
looking, its much more difficult to get the patient to follow your lead.
Scapula movement cannot be assessed in degrees. Its assessed in cms.
Using few muscle groups to estimate tone in the patient as flaccid or
rigid is false.
Thorough evaluation of all muscle groups should be done. (Note that in
brain damaged patients mixed tone is present.)
A complete cephalocaudal evaluation of tone is required for further
intervention planning.
DEFICITS IGNORED BY FORMAL
ASSESEMENT:
:
The clinical observations generated by the NDT Approach are: symmetrical sitting, axial shifts, shoulder
subluxation are ignored by the formal assessment.

Assessment of symmetrical sitting can be done visually, except for equal weight on both hips. This
characteristic is difficult to analyse via visual inspection. It helps to physically lift each buttock to examine
if one hip can be lifted easier than the other.

Be prepared for assistance during weight shifts. The patient may have passive elongation of trunk muscles
and yet not have independent axial shifts. Note that axial weight shifts forwards and backwards require
observation of pelvic tilt.

Shoulder Subluxation is the visible separation of the GH joint.

.

Shoulder subluxation can also be done by downward rotation of scapula, which is ignored by formal
assessments. It is reported using the amount of fingers fit into the gap between the scapula and
head of humerus

You can easily detect downward rotation in scapula by examining the superior and inferior margin
of the scapula.(if the distance b/w the SA is lesser than the distance between the IA)

Downward rotation maybe caused by the muscle paralysis in that make up the force couple for
upward rotation.

Lateral trunk flexion also downwardly rotates the scapula Now the rotator cuff muscles no longer
hold the head of the humerus on an included ramp.

RESULT=SUBLUXATION.
NORMAL GROSS MOTOR TRENDS
• Normal gross motor development has been divided into four
trends.
• Each trend shows how normal children mature from primitive to
transitional to mature behavior.
• The essential characteristics of normal motor trends are important
because they identify the movement strategies that your patient is
using
• These movement stratergies are not made clear on even well-
accepted developemental assessments.
• The essential characteristics of normal motor trends pinpoint the
active movement stratergies you want your patient to relearn.
•
Developmental ages for motor milestones have been included simply to
validate the sequence of maturation, these developmental ages should
also remind therapist who are working with adult patients that many of
the motor skills that require retraining normally develop in first three
years of life.
Gross motor Trend 1

->Hypotonic To Strong Axial Flexion.

1)Physiological Flexion
2)Emerging Axial Flexion
3)Mature Axial Flexion
This trend is called “Flexor to Extensor Tone.” The primitive stage of this trend and
trend 1 are the same

From the common beginning of “physiological flexion” the normal infant develops
mature flexion and extension in equal amounts

However,brain damaged patients often lack this normal balance,so flexors and
extensors have to be evaluated with two separate trends

During the primitive stage extensor tone is present in the neck and low back but
absent in the thoracic region

Extension develops later in the thoracic region of the trunk. This is an exception to
the cephalocaudal development of the extensor tone in the limbs.
The transition phase of this trend is called “extension with retraction”
because of the retraction of the head,scapula and pelvis.

Neck hypertension and scapular elevation combine to give a characteristic

look of “no neck Hands loosely fisted means the MP joints are in neutral
position while the PIP and DIP joints are still flexed

This produces weight bearing on the heel of the hand ,the thenar
eminence, the knuckles, but not on the center of the palm
GROSS MOTOR TREND 2
• Extension with retraction is a safe transitional stage for normal
infants, but it quickly disappears as flexion emerges to balance
extensor activity.
• It is very dangerous for brain- damaged patients because they get
stuck in this stage
• . They refuse to give up this transitional strategy because it gives them
the ability to hold a posture stiffly.
• Extension with retraction quickly leads to the neck, shoulder and
pelvic blocks.
• Neck elongation is a classic NDT term that means the back of the
neck becomes long
•.
• It is different from the full neck flexion,where the chin rests on the
sternum so the patient looks down at his/her stomach.

Neck elongation is important because it produces just enough chin

tucking to permit the eyes to give down at the hands.

• It is different from jaw-jutting, where the neck hyperextends but the

chin juts forward so the head is in the front of the body. .
• Jaw-jutting often goes undetected because it allows the patient’s
eyes to look straight ahead at the therapist rather than at the ceiling,
as in classic neck hyperextension

• Most adults have to be evaluated for mature extension of the arms

while weight bearing on one elbow or on one extended arm in side-
sitting on a mat table.
Gross Motor Trend 3

Hand Foot Preparation

1)No palm/heel contact

2)Emerging contact
3)Prolonged contact
This trend is called “Hand/Foot Preparation. "Lack of hand and foot preparation is
primarily a pediatric concern.

Normal infants progress to full palmar and plantar contact because they actively
seek out stimuli.

They spend hours chewing on their feet and mouthing their fists to desensitize
hands,feet and mouth

This sensory input inhibits tactile defensiveness in primitive palmar and planter
reflexes

Brain- damaged children usually avoid this sensory input and often lack the motor
skills needed to produce it.
• Full weight-bearing and hand function cannot develop normally if
palmar/plantar contact is not present.

• Normal infants bear weight on the thenar eminence in prone for three
months before thumb use is seen in grasp.

• Weight-bearing stretches out physiological flexion of the hand and inhibits

the grasp reflex.

• This sequence shows how gross motor experiences pave the way for fine
motor skills.

• Surely brain-damaged patients can benefit from this weight-bearing

experience.
GROSS MOTOR TREND 4

This trend is called “Mobility Superimposed On Stability.”The primitive stage of

holding a posture is NOT recommended for treatment.

While normal infants work briefly on maintaining static postures, brain-damaged

patients use this opportunity to rigidly fix.Static postures produce only a
momentary increase in muscle excitation followed by hanging on elongated
muscles in poor postural alignment.

Think of how hard it is for you to sit up straight with no back support for extended
periods of time.
GROSS MOTOR TREND 4

This trend is called “Mobility Superimposed On Stability. The primitive

stage of holding a posture is NOT recommended for treatment.

While normal infants work briefly on maintaining static postures, brain-

damaged patients use this opportunity to rigidly fix. Static postures
produce only a momentary increase in muscle excitation followed by
hanging on elongated muscles in poor postural alignment.

Think of how hard it is for you to sit up straight with no back support for
extended periods of time.
Normal Fine Motor Trends
The test items for the fine motor (FM) trends were pulled from developmental
assessments.
• They are helpful for patients who are not able to perform adult level fine motor
tasks like writing and buttoning.
• In FM Trends Il and III, the cube tasks require standard 1-inch cubes.
• The pellet task can be done with any small object such as a bent paper clip.
The spoon task can be done without food.
• The pencil task is restricted to drawing straight lines or a circle.
• The 9-Hole Peg Test can be used instead of difficult pegs like the thin brads used
in Purdue Peg Test.
Fine Motor Trend I
•This trend is called “Mass to Dissociation Movement.”
• It assesses independence from synergy and proximal
dissociation.
• This trend documents only upper extremity dissociation.
Synergy Bound not used in treatment.
Emerging independence from synergy.
Independence from synergy.
The few developmental milestones that focus on lower extremity
dissociation include:
> Kicks reciprocally in supine (2 months)
• Runs one foot up and down opposite leg(4 months)
• Kicks with hip extension and knee flexion in prone (4 months)
• Reciprocal movement represents dissociation of one leg from the other.
• The ability to simultaneously use hip extension and knee flexion
indicates freedom from pathological limb synergy.
Fine Motor Trend II
• This trend is called ‘Static Ulnar to Radial Grasp.”
• This trend represents distal dissociation.
• "• This trend represents distal dissociation.3.No thumb involvement
• Thumb flexion.Thumb opposition.
• Initially, the hand works like mitt, which the ulnar side of the hand
being the primary contact point with objects.•With maturation the
thumb , index ,and middle fingers become dissociated from the hand
and are able to contact objects
.• Grasp is initially achieved with the palm and all the fingers and later
with just the tips of the radial fingers
.• This trend only assesses static grasp.Release of objects and reaching
are ignored by this trend.
Fine Motor Trend III
1.
2.
3.
• This trend is called “Distal Fixing to Distal Dissociation.”
Distal fixing with proximal mobility.
Distal mobility with external support.
Distal mobility with internal proximal stability.
• It shows even more clearly that the forearm, wrist, and fingers develop isolated distal
movements.
• However distal dissociation is preceded by rigid fixing of distal body segments.
•During the transitional phase ,the patient must use a source of external support to make
emerging forearm and wrist movements possible.
•In the mature stage distal mobility is made possible by internal stability or proximal stability
like the scapula.
Decision Tree Revisited
• When time constraints are present, use decision tree process to
decide what to test first.
• A good place to start is the Brunnstrom synergy evaluation.
• This procedure quickly enables you to grade down for the patient
who is flaccid or synergy-bound and grade up for the patient who is in
relative recovery.
Fine motor trend I is the pediatric version of UE synergy evaluation.
 The following clinical observation should also be done very early: sit symmetrically,
active weight-shifts in sitting, shoulder subluxation, automatic reactions while
rolling and LE extension synergy during ADLs

If the patient is in Brunnstrom 1, 2 or 3 must grade down by selecting tests that

evaluate for level skills

• Evaluate muscle tone. If the patient has spasticity the muscle tone results will tell
you which specific motions are likely to be painful as you handle the patient during
ADLs.
• If the patient is flaccid, the muscle evaluation will tell you where spasticity and
contractures are emerging.
Also evaluate Gross Trends Il and III since they measure the need for
physical assistance in static postures

• If a patient is in Brunnstrom stages 4 or 5 you grade up

• Clinical observation of the following procedures is now possible:
placing reactions, eccentric control and equilibrium in sitting and
standing.
• Administer gross Motor Trends I and IV, Which challenge the patient
with weight shifts
• To test for Distal dislocation , administer Fine motor trends 2 and 3
If a patient is in Brunnstrom stage 6 , coordination near normal, which
makes a manual muscle test(MMT) possible.

• However irradiation makes a MMT inappropriate for lower-

functioning brain-damaged patients.
• The test results simply prove that maximal resistance can facilitate
many inappropriate muscles through irradiation.
•MMT is also inappropriate for brain-injury adults who have
pathological limb synergies.
• Until a brain-injury patient has minimal spasticity and relative
independence from synergy, a MMT is difficult to administer and the
results are not a valid test strength.