Effects of A Neurodevelopmental Treatment Based.3
Effects of A Neurodevelopmental Treatment Based.3
Effects of A Neurodevelopmental Treatment Based.3
net/publication/5551347
Article in Pediatric physical therapy: the official publication of the Section on Pediatrics of the American Physical Therapy Association · February 2008
DOI: 10.1097/PEP.0b013e31815e8595 · Source: PubMed
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Effects of a Neurodevelopmental
Treatment-Based Trunk Protocol
for Infants with Posture and
Movement Dysfunction
Sherry W. Arndt, PT, DSc, PCS, Lynette S. Chandler, PT, PhD, Jane K. Sweeney, PT, PhD, PCS,
Mary Ann Sharkey, PT, MS, PhD, and Jan Johnson McElroy, PT, MS, PCS
Ohana Physical Therapy (S.W.A.), Hilo, Hawaii; School of Physical Therapy (L.S.C.), University of Puget Sound,
Tacoma, Washington; Rocky Mountain University of Health Professions (L.S.C., J.K.S.), Provo, Utah; Therapeutic
Research Services (M.A.S.), Spokane, Washington; Spokane Falls Community College (M.A.S.), Spokane, Washington;
Jan McElroy Physical Therapy, LLC (J.J.M.), Columbia, Missouri; and Department of Physical Therapy Curriculum
(J.J.M.), University of Missouri, Columbia, Missouri
Purpose: This study was used to evaluate the efficacy of a neurodevelopmental treatment (NDT)-based se-
quenced trunk activation protocol for change in gross motor function of infants aged 4 to 12 months with
posture and movement dysfunction. Infants who received a dynamic co-activation trunk protocol were com-
pared with a control group who received a parent-infant interaction and play protocol. Method: A repeated
measures randomized block design was used. A masked reliable examiner assessed infants before, immediately
after, and 3 weeks after intervention using the Gross Motor Function Measure (GMFM). Results: The NDT-
based protocol group made significantly (P ⫽ 0.048) more progress than the control group from pretest to
posttest. Conclusions: Cautious support was found for (1) sequenced, dynamic trunk co-activation intervention
compared to generalized infant play; (2) high-frequency, short-term, task-specific intervention; and (3) direct
service by NDT-trained pediatric therapists specializing in infant intervention. (Pediatr Phys Ther 2008;20:11–
22) Key words: developmental disabilities, human movement system, infant, infant development, motor
skills, physical therapy, postural equilibrium
Pediatric Physical Therapy NDT-Based Protocol for Posture and Movement Dysfunction 11
approach in pediatric therapy, it is important that we study took place within the context of a 3-week NDTA
have more definitive research on the efficacy of the NDT Advanced Baby Course. The course was based on the NDT
treatment approach for infants. problem-solving process for managing sensory-motor im-
Eight randomized controlled trial (RCT) studies6 –13 pairments in infants aged 4 to 12 months. The general
on the efficacy of early therapy for infants were identi- theoretical assumptions and application of the NDT ap-
fied in the literature in the last 20 years. Five of the RCT proach used in the NDT Advanced Baby Course were de-
studies6,7,10 –12 were conducted with infants younger than 1 scribed by Howle in 2002.16 Infants in this study demon-
year as subjects. The participants in these five studies were strated gross motor delays with posture and movement
infants born prematurely and identified by high risk factors dysfunction that were characterized by impairments in ori-
predisposing them to the development of CP. Researchers enting responses of the head and trunk.
in three of the RCT studies6,7,12 reported in subsequent The capacity of a single study to be used to demon-
articles8,9,13 results of extended follow-up (FU) for the same strate the efficacy of an entire approach is generally con-
infant populations. With the exception of one study12 that sidered outside the realm of possibility in today’s research
used a combination of NDT and sensory integration (SI), environment. An approach, such as NDT, that can be indi-
no treatment was investigated in these studies other than vidualized to meet the needs of persons with different di-
the NDT approach. Except for the Girolami and Campbell agnoses across the lifespan is inherently too variable to be
study,10 the NDT therapy was vaguely defined with no studied in its entirety. Instead, specific aspects of such an
identified protocol and therapy providers were not cited as approach can be investigated using well-designed studies
having received specific NDT infant training. All investiga- with operationally defined protocols and homogeneous
tors in the eight RCTs6 –13 examined the following question: participant groups.
Does early pediatric therapy intervention improve out- An operationally defined protocol was used in this
comes for infants with high risk for CP? study specifically to address the role of trunk activities in
Researchers in four of the five studies6 –9,11–13 reported orienting responses as they relate to functional motor skills
nonsignificant results on the efficacy of pediatric therapy
in infants. By using an operationally defined protocol that
to improve outcomes for infants with high neuromotor risk
was linked to a specific impairment common to a group of
on any of the postintervention outcome measures at 1 year
infants with posture and movement dysfunction, the au-
of age,6,7,11,12 and on extended FU assessments at 18
thors of this study examined the efficacy of a single aspect of
months,12 24 months,8,12 30 months,11 4 years,13 or 6 years
the NDT approach: sequenced dynamic trunk co-activation
of age.9 In all studies, methodological problems were iden-
intervention. Although the trunk activation activities used
tified: (1) absence of identified functional delay in study
in this study are not previously published as a protocol in
participants6 –9,11–13; (2) infrequency of intervention6 –9,11–13;
this form, the concepts and facilitations employed in the
(3) lack of rater reliability and validity in outcome mea-
sures6-9,11-13; and (4) absence of operationally defined NDT protocol have been taught in the NDT approach and are not
intervention protocols.6 –9,11–13 the original work of the authors.
Girolami and Campbell10 conducted the single study
that included an operationally defined NDT-protocol in- Purpose
tervention. The NDT-protocol was delivered 12 to 15 min-
utes twice daily for 7 to 17 days by a Neurodevelopmental This study was designed to evaluate the efficacy of a
Treatment Association (NDTA) instructor with expertise NDT-based sequenced trunk co-activation protocol for
in infant treatment. The researchers studied 19 infants at change in gross motor function in infants with posture and
postconceptual ages of 34 to 35 weeks in a special care movement dysfunction. A group of infants who received a
nursery. To assess postural control, they used the Supple- dynamic trunk protocol during functional activities was
mental Motor Test, a precursor of the Test of Infant Motor compared with a group of infants who received a parent-
Performance (TIMP).14,15 Even with a small sample size infant interaction and play protocol. The parent-infant
and short intervention duration, statistical significance group was used to control for attention, maturation, and
(P ⫽ 0.002) for improved postural control in prematurely environment. Both groups received study intervention in
born infants was reached in the NDT-protocol intervention addition to their routine ongoing early intervention (EI)
for infants with high neuromotor risk compared with a services by therapists and teachers.
matched control group who received identical amounts of It was hypothesized that (1) infants with posture and
attention and positioning. When the eight RCTs were com- movement dysfunction receiving an infant NDT-based se-
pared, Girolami and Campbell’s10 was the only investiga- quenced trunk co-activation (STA) protocol for 10 hours
tion in which a significant change was reported. over 15 days would make greater gains in gross motor
To avoid the methodological problems identified in function compared to infants receiving a parent-infant play
the RCT studies6-9,11-13 discussed above, the study pre- (PIP) protocol for 10 hours over 15 days; and that (2)
sented here used an operationally defined protocol, ther- infants with posture and movement dysfunction receiving
apy providers with specialized infant training, high fre- 10 hours of an infant NDT-based STA protocol would
quency of intervention, and a valid outcome measure for maintain gains in gross motor function at the 3-week FU
infants with posture and movement dysfunction. This evaluation session.
TABLE 1
Preestablished Therapeutic Intervention Received over Study Duration of 8 Weeks in Addition to Research Intervention
Total Minutes
Preestablished EI
Occupational Early Childhood Therapeutic
Groups Therapy Physical Therapy Speech Therapy Interventionist Intervention
STA group (n ⫽ 5) 1740 min/8 wk or 43 360 min/8 wk or 45 960 min/8 wk or 120 480 min/8 wk or 60 3540 min/8wk or 111
min/wk (n ⫽ 4) min/wk (n ⫽ 1) min/wk (n ⫽ 1) min/wk (n ⫽ 1) min/ wk (n ⫽ 4)
PIP group (n ⫽ 5) 2340 min/8 wk or 59 1440 min/8 wk or 90 0 min 180 min/8 wk or 23 3960 min/8 wk or 99
min/wk (n ⫽ 5) min/wk (n ⫽ 2) min/wk (n ⫽ 1) min/wk (n ⫽ 5)
Pediatric Physical Therapy NDT-Based Protocol for Posture and Movement Dysfunction 13
(3) examination of posture and movement components, bics instructor (specialist in postpartum exercises) provided
eg, alignment, weight shift, base of support, movement experiential exercise opportunities for parent and infant while
strategies, postural control, as they relate to functional ac- doing activities of daily living, eg, pushing a stroller, playing
tivity skills and limitations (Appendix A, Fig. 3, Fig. 4); with their infants, picking up and putting down their infants.
and (4) systems review to determine the impact of sys- Led by a psychology graduate student (mother of a child with
tem and subsystems as they relate to functional activities CP), the parents also had an opportunity for parent-to-parent
and limitations, eg, respiratory, visual, cardiovascular, sharing and problem solving.
neuromuscular, musculoskeletal systems.16(p.181–253) Each Data Analysis. The data were analyzed using repeated-
individualized intervention plan was developed to meet the measures, nonparametric statistics. Nonparametric statis-
functional goals collaboratively established by the parents, tics were used because the sample was small and did not
therapists, and course faculty based on infant and parent meet the assumptions of normality and homogeneity of
needs and concerns. The intervention sessions emphasized variance required for parametric statistics. A one-tailed test
transitional activities (eg, rolling, prone to sitting, sitting to of significance was congruent with the alternative hypoth-
quadruped to sitting, quadruped to standing) and followed eses. The level of significance (alpha) was held at 0.05 to
a fluid sequence of engage, prepare, align, activate repeti- protect against a Type I error. The within-group analyses
tion, and home repetition. The STA protocol intervention examined mean GMFM group scores over time, ie, pretest,
was applied specifically to the “activate” portion of each posttest, 3-week FU, using the Friedman two-way analysis
activity sequence (Appendix A). Execution of the STA pro- of variance by ranks statistic, 2 r, for each group. When 2
tocol involved (1) facilitation of a dynamic co-activation of r was significant, post hoc, pairwise differences were tested
trunk flexors and extensors in the sagittal plane that is with Wilcoxon signed-ranks statistic. The Mann-Whitney
adequate to the demands of a specific functional activity, U test was used to detect between-group differences on the
(2) facilitation of active weight shifting in the frontal plane change of mean GMFM group scores, ie, pretest to posttest,
to produce “elongation on the weight-bearing side,” while posttest to 3-week FU, and pretest to 3-week FU.
maintaining the appropriate dynamic co-activation of
trunk flexors and extensors,16 and (3) facilitation of active RESULTS
functional trunk rotation in the transverse plane, while Of the 19 infants randomized into two groups, only 10
maintaining dynamic co-activation of trunk flexors and infants (STA: n ⫽ 5, PIP: n ⫽ 5) completed at least 80% of
extensors and active trunk elongation of the weight-bear- the intervention sessions, attended both posttest sessions,
ing side. Functional trunk rotation is considered to be in- and were included in the statistical analysis. Despite par-
tegral to the development of equilibrium behaviors for ticipant attrition, there was no significant difference be-
variability in motor responses20 and higher level tween groups on variables that might have affected their
balance.16(p.41) The facilitation of functional trunk rotation response to intervention (Table 2).
within each session is dependent upon the age of the infant The STA within-group mean GMFM scores (Fig. 1)
and the specific functional skill within the chosen activity. were significantly different over time (P ⫽ 0.01). Post hoc
Each step in the STA protocol creates the base needed comparisons for pretest to posttest STA intervention were
for the next step in the sequence. Intervention that incor- significant (P ⫽ 0.02), and pretest to 3-week FU were also
porates the STA protocol produces dynamic trunk co-activation significant (P ⫽ 0.02). Although the PIP group experi-
in sequenced trunk movements adequate for the demands enced a positive trend in their GMFM scores pretest to
of transitional activities. In an infant-led session, the indi- postintervention, the within-group difference in the PIP
vidualized application of the protocol may seem different mean GMFM group scores were not significantly different
for each infant and vary within a session depending on the (P ⫽ 0.08) over time. The between-group difference on the
functional activity of interest to the infant.* change of mean GMFM group scores was significant (P ⫽
Parent-Infant Play Group. Infants in the PIP group 0.048) from pretest to posttest in favor of the STA protocol
received enriched PIP activities delivered by their parents group (Fig. 2). The first hypothesis that infants with pos-
who were guided by a licensed Child Life Specialist (Ap- ture and movement dysfunction receiving 10 hours of an
pendix B). The primary aim of the PIP was parent-infant infant NDT-based STA protocol would make greater gains
interaction and enriched directed play for visual, tactile, in gross motor function compared with infants attending
auditory, social, cognitive, emotional, and communication 10 hours of a PIP protocol group was supported.
developmental skills.21 Although not individualized or spe- For the STA protocol group, there was no significant
cifically selected for trunk activation, all activities chosen by difference (P ⫽ 0.25) between posttest and 3-week FU
the Child Life Specialist were appropriate for the age group of mean GMFM group scores. For the PIP group no signifi-
infants and inherently encouraged motor skills, eg, head con- cant difference was found between posttest and 3-week FU.
trol, weight shifts in prone, reaching, and sitting, for the infant The second hypothesis that the NDT-based STA protocol
to participate in the interaction and play activities. An aero- group would maintain motor gains at the 3-week FU ses-
sion was supported.
The between-group difference of the mean GMFM
*NDT-based STA protocol with clinical example is available by request to change group scores, pretest to 3-week FU, was not signif-
the first author. icant (P ⫽ 0.11). The GMFM mean group scores in both
Parent-Infant Play
Variables NDT-Based STA (n ⫽ 5) (PIP) (n ⫽ 5) Test Statistic
AIMS score
5% rank 1 2 Fisher’s Exact Test:
⬍5% rank 5 4 P ⫽ 1.0
MAI
Head orienting 2 Fisher’s Exact Test:
Sagittal 3 yes, 2 no 2 yes, 3 no P ⫽ 1.0
Frontal 3 yes, 2 no 0 yes, 5 no P ⫽ 0.167
Trunk orienting 0 yes, 5 no 1 yes, 4 no P ⫽ 1.0
GMFM pretest Mean 22.16, SD 13.91, Mean 16.86, SD 17.64, Mann-Whitney U
Range 5.31–39.68 Range 0.67–44.85 test ⫽ 9, P ⫽ 0.55
Gender
Males n⫽4 n⫽4 2 Fisher’s Exact Test:
Females n⫽1 n⫽1 P ⫽ 1.0
Corrected Age at Pretest Mean 8.95 mo, SD 2.93, Mean 8.9 mo, SD 3.59, Mann-Whitney U
Range 5.25–12.0 Range 4.0–11.75 test ⫽ 12, P ⫽ 0. 01
Gestational Age Mean 34, SD 5.68, Mean 35.4, SD 6.77, Mann-Whitney U
Range 27–40 Range 25–40 test ⫽ 11.5, P ⫽ 0.84
35–40 wk 3 3
32–35 wk 1
28–32 wk 1
⬍28 wk 1 1
Degree of Severity Pearson 2: 2.2,
Mild* 1 df ⫽ 2, P ⫽ 0.333
Moderate† 3 1
Severe‡ 2 3
Attendance Mean 9.4, SD 0.89, Mean 8.8, SD 0.84, Mann-Whitney
Range 8–10 Range 8–10 U test ⫽ 7.5, P ⫽ 0.31
10 sessions 3 1
9 1 2
8 1 2
*Mild: Normal muscle tone or generalized hypotonia; scores at the 5th percentile rank on AIMS.
†Moderate: Abnormal muscle tone (high, fluctuating, low) distributed in the lower extremities or on one side of the body; scores ⬍5th percentile rank on AIMS.
‡Severe: Increased tone, fluctuating tone, or severely low tone distributed in bilateral upper and lower extremities; scores ⬍5th percentile rank on AIMS.
groups demonstrated high within-group variance during estimate. The nonparametric Mann-Whitney U statistic did
this 3-week postintervention period. This high variance reflect a significant group difference, P ⫽ 0.048, given the
was likely responsible for the nonsignificant differences observed 8.2 mean group change difference (GMFM points),
between groups, pretest to 3-week FU. with an observed effect size index of 1.12. Post hoc power was
Power Analysis. The study sample size estimate (n ⫽ 49% when computed using the observed values and actual
20 per group) was calculated a priori to provide 80% power sample sizes in the study groups. We recognize that the small
at the 0.05 alpha level based on an unpaired two-group sample size in this study is necessarily linked to imprecision
comparison of pre-to-postintervention change scores with in the point estimate of the treatment effect. Therefore, the
a one-tailed hypothesis. The power calculations were based results of this study will need replication in a future trial with
on the minimally important effect size index being “large” a larger sample size.
by Cohen’s conventions for unpaired comparisons. 22(Table C.2, p.720) Clinically Important Change. Infants in the NDT-
This means that the study would have had an 80% chance based STA protocol group made a mean change on the
of obtaining P ⱕ 0.05 on the comparison of score changes GMFM of 13.3 and the PIP group made a mean change on
if the true difference of the mean changes had been 0.8 the GMFM of 5.1 at the end of intervention. These numer-
times as large as the within-group variability of the changes ical scores used for the statistical analyses of the study do
(ie, the pooled within-group standard deviation). not describe the clinically important change in function
Because of attrition and local policies, the analyzed sam- that is often more relevant to parents and therapists.
ple size was 5 per group. Statistical power for this study based Russell et al19 calculated the relationship of the actual
on the actual sample sizes of n ⫽ 5 per group, and using the a change in GMFM scores to parental and therapist judg-
priori estimations (ie, effect size index 0.8, P ⬍ 0.05, one- ment of the magnitude and importance of change in gross
tailed hypothesis) would have been approximately 31% if the motor function. Russell et al19 determined a “large positive
estimations had been accurate. Although the sample size was change” in gross motor function as judged by parents and
smaller than originally planned, it turned out that the ob- therapists was reflected by an actual GMFM change of 11.4
served effect size was considerably larger than the original and 24.6, respectively; a “medium positive change” was
Pediatric Physical Therapy NDT-Based Protocol for Posture and Movement Dysfunction 15
Fig. 2. Between group difference: mean change after interven-
tion. Mann-Whitney U test (Pretest to Posttest: P ⫽ 0.048, signif-
icant; error bars ⫽ ⫾5% error). STA group: mean 13.3; median 8.1;
Fig. 1. Within group differences over time. Friedman 2-way
range 22.8; SD 9.74; SEM 4.36. PIP group: mean 5.1; median 6.5;
ANOVA by ranks (STA: P ⫽ 0.01, PIP: P ⫽ 0.08, significant, error
range 11.6; SD 4.88; SEM 2.18.
bars: ⫾5% error). STA Group: Pretest—mean 22.16; median 27.4;
range 34.37; SD 13.9. Posttest—mean 35.46; median 40.42; range
44.74; SD 18.9. 3-week FU—mean 34.21; median 34.83; range GMFM at the end of intervention of 5.1. This score would
52.45; SD 20.3. PIP Group: Pretest—mean 16.86; median 12.35; be described as a “medium positive” change by the parents
range 44.18; SD 17.6. Posttest—mean 21.94; median 12.14; range
and a “small” to “medium” positive change by therapists.
54.5; SD 21.3. 3-week FU—mean 19.79; median 10.33; range
55.85; SD 22.0. STA within group multiple comparisons: Wilcoxon
DISCUSSION
signed-ranks test (Pretest/Posttest: P ⫽ 0.02*, Posttest/3-wk FU:
P ⫽ 0.25, Pretest/3-wk FU: P ⫽ 0.02, significant). Improvement in gross motor skills may be achieved
with therapeutic intervention of high frequency and short
reflected by an actual change of 5.2 and 7.0, respectively; and duration for a defined population of infants using an oper-
a “small positive change” was reflected by an actual change of ationally defined intervention protocol and delivered by
2.7 and 3.8, respectively. For example, the mother of an infant therapists with advanced, specialized training. The inves-
in this study with a 13 GMFM change score reported, “he is tigators in this study provide evidence for infants with pos-
able to sit up now longer and not fall over. He has even been ture and movement dysfunction when interventions are
able to sit up by himself a few times. He can use his left hand focused on facilitation of dynamic co-activation of trunk
now to pick up toys and it is staying open more of the time. flexors and extensors that supports the demands of a spe-
And he is starting to try to stand up in his crib.” The mother of an cific functional activity. The results have policy implica-
infant with a 7.7 GMFM change score, pretest to posttest, re- tions with regard to (1) generalized play approach deliv-
ported, “he can now hold his head up when I hold him and look ered by early interventionists or direct intervention from
around. He is now rolling over from his back to stomach and licensed professionals, (2) specific protocols of interven-
trying to sit up. He is much more alert.” An infant whose GMFM tion, and (3) quantity of therapeutic intervention.
change score was 0.72 after the intervention was reported by his
mother to “look attentively around and laugh and smile.” Improvement in Motor Function
According to the findings of Russell et al,19 the STA The NDT approach when applied according the pub-
group mean change on the GMFM of 13.3 would be de- lished principles and assessment guidelines with interven-
scribed by the parents as a “large positive” change. Thera- tion structured according to the sequenced trunk activa-
pists would describe the same change as a “medium” to tion protocol seems to produce improved motor
“large” change. The PIP group made a mean change on the performance when provided to infants with posture and
Pediatric Physical Therapy NDT-Based Protocol for Posture and Movement Dysfunction 17
Retention of Gains The balance between using generalized intervention-
The within-group mean GMFM scores from posttest ists and licensed professionals with subspecialty training in
to 3-week FU provide evidence that gains made from a infant development and movement science within the EI
short, intensive NDT-based STA protocol can be main- service delivery model is in need of further evaluation.
tained for the short term. Although skills are maintained, Continued research is essential to define the quantity of
continued specific sequential trunk activation intervention intervention, the specific intervention protocol, and the
is likely needed to promote further progress. skills of the provider for optimal and cost-effective out-
The wide variance in both groups of GMFM change comes for infants with posture and movement dysfunction.
scores posttest to 3-week FU generates questions regarding Limitations
the infants’ underlying body system impairments and sub-
sequent functional gross motor limitations. Participants Four primary features of the study limiting the gener-
whose scores declined in the postintervention to 3-week alizability of results are (1) small sample size, low power,
FU period seemed to have motor limitations strongly influ- and purposive convenience sampling, (2) rater masked to
enced by sensory processing dysfunction. Although sensory group assignment but not to study intent, (3) outside rou-
testing was not conducted, numerous sensory defensive be- tine EI therapeutic services tracked but not controlled, and
haviors were observed during intervention. Future research (4) infant cognition not tested. The small sample size in
should include discriminatory measures to differentiate in- this study was a result of the referral policies of the specific
fants with and without sensory processing dysfunction. Such locale (eg, economics; Health Insurance Portability and
identification of infants with sensory processing dysfunction Accountability Act) and the 44% to 50% attrition rate. The
may help clarify which infants will better retain gains made primary reason for attrition in the PIP group was that par-
with the NDT-based STA protocol intervention. ents were interested in participating in the study only if
In future research, the retention of gains should be as- their infants were in the STA treatment group. No measure
sessed over a longer FU period than in the current study. directly assessed the infants’ cognitive level, although it is
Varying periods of intervention or no intervention is recom- clinically assumed to influence the infants’ motivation and
mended to discover which schedule(s) yield maximal gains ability to learn. Future development of a motor-free cogni-
and retention effects for specific disabilities and impairments. tive tool for infants’ ages 4 to 12 months is needed. Infant
cognitive abilities may then be used to more equitably
Instrument and Rater Reliability stratify groups before randomization.
The evaluative tool used in this study was validated CONCLUSION
for infants with posture and movement dysfunction (ie, A short-duration, high-frequency NDT-based infant
CP) to measure change over time as a result of interven- protocol focused on dynamic co-activation of trunk flexors
tion. Studies reported earlier, ie, Goodman et al,6,9 Piper et and extensors and specifically sequenced trunk move-
al,7,8 Weindling et al,11 and Salokorpi et al12,13 used out- ments significantly improved gross motor function in in-
come measures that were standardized on typically devel- fants with posture and movement dysfunction compared to
oping populations. The use of appropriate outcome instru- a nonindividualized Parent-Infant-Play protocol that only
ments with reported reliability and validity for specific indirectly addressed the trunk. These motor gains were
populations and interrater reliability of examiners masked maintained for 3 weeks. Providing attention through
to group assignment and study intent are critical for ad- guided, enriched play activities and interaction with social
dressing the question of intervention efficacy in specialized support did not significantly improve infant motor perfor-
populations with posture and movement dysfunction. mance during the same time period. The infants with pos-
ture and movement dysfunction made gains that seemed
Policy Implications to be the result of the short-duration, high-frequency,
Possible challenges to EI policy related to service de- sequential trunk activation interventions provided by
livery models and frequency of intervention are generated pediatric therapists specializing in the NDT approach
by this study. Scrutiny must be given to the national trend for infants.
of using a generalized play approach delivered by early
interventionists with therapist consultation for motor in- ACKNOWLEDGMENTS
tervention services to infants with posture and movement The authors are grateful to Barry Chapman, MS, PT,
dysfunction. The researchers of this study suggest that fo- for his role in testing infants, and to Mitzi Wiggin, MS, PT,
cused intervention specifically matched to identified im- for specific support recruiting families, providing the re-
pairments and delivered by a NDT-infant-trained therapist search site, and testing the infants. Special acknowledg-
can produce a significantly higher level of motor skill im- ment is given to Kristy Loper, BA, Child Life Specialist, for
provement compared with nonfocused intervention deliv- her coordination of the parent-infant play group. Dr. Ed
ered by a more generally trained interventionist when pro- Gracely, Dr. John Pezzullo, and Dr. Steve Allison gener-
vided at the same increased frequency. A generalized play ously assisted in the sample size write-up. The authors also
approach may have benefits in other areas, ie, cognition, wish to thank the infants and parents who participated in
social; however, this may not be true for motor skills. this study.
Pediatric Physical Therapy NDT-Based Protocol for Posture and Movement Dysfunction 19
• Appropriate orienting of head and body parts to the
support surface for maximal contact and proprio-
ceptive sensory input.
Day 2
Eye-hand coordination Eye-hand coordination Sitting, head and trunk control and UE reaching
“What’s Squeaking” p. 95 Listening
“Get that Bubble” p. 115 Cause and Effect Sitting on adult’s knee with feet weight-bearing
“Bubbles for Baby” p. 96 Visual Development
Day 3
Tactile Stimulation Social development Sitting, head and trunk control
“Footsie Prints” p. 100 Tactile Stimulation Supine, UE reaching
“Tickle me textures” p. 45 Trust
Body awareness
Day 4
Language Development Emotional and Language Development Sitting, head and trunk control and reaching
“Baby’s First Books” p. 93 Visual Supine and UE reaching
“Eyes, Nose, Mouth, Toes” p. 94 Body Awareness Sitting: adult’s knee with feet support
Suggested home activities Tactile Stimulation
“Babbling with your baby” p. 68 Listening
Social Development
Day 5
Tactile Stimulation Body Awareness Supine, prone small weight shifts
“Infant Massage” p. 28 Emotional Development Rolling over
Social Development
Tactile Stimulation
Day 6
Social Development Balance Inclined supine weight shifts to sides and head to feet
“Blanket Swing” p. 48 Social Development Rolling toward side
“Friendly Faces” p. 72 Trust Sitting on adult’s lap
Upper-body strength Sitting with back support, head and trunk control
Suggested home activities Social Development
“Peek-a-boo” p. 67 Visual Discrimination
Object Permanence
Day 7
Tactile Stimulation Fine Motor Ring Sitting
“Surprises Inside” p. 105 Problem-solving
Finger Play (pudding, play dough, balls) Tactile Stimulation
Social Development
Day 8
Listening Skills Listening Reclined sitting supported in car seat
“Sound Spots” p. 52 Social Development Supine weight shifts
“Cradle Songs” p. 46 Visual Development Prone head lifting, (trunk extension) over adult’s shoulder
Day 9
Communication Communication Supine
Baby swapping Social Development Sitting in lap
Listening Prone head lifting over adult’s shoulder
Visual Development
Day 10
Tactile Stimulation Social Development Prone, arms reaching, weight shift laterally
Pudding play Tactile Stimulation Sitting, hand weight-bearing
Plasticene goo hand prints Trust
Hand Prints (variation of “Footsie Prints”
p. 100)
*Page numbers refer to reference 21.
Pediatric Physical Therapy NDT-Based Protocol for Posture and Movement Dysfunction 21
and extensors,16 and (3) facilitation of active functional trunk in postpartum exercises, assisted the Child Life Specialist
rotation, while maintaining dynamic co-activation of trunk in the intervention activities for the parents and infants.
flexors and extensors and active trunk elongation of the The parents delivered the enriched play activities,
weight-bearing side, ie, transverse plane. Functional trunk with guidance from the Child Life Specialist for 30 min-
rotation is integral to the development of equilibrium behav- utes at each of the 10 intervention sessions (Table 3).
iors for variability in motor responses20 and higher level The play activities, selected from Gymboree, A Parent’s
balance.16(p.41) Functional trunk rotation is facilitated as ap- Guide to Baby Play,21 targeted various areas of develop-
propriate for the age of the infant and the specific functional ment, such as: visual, tactile, auditory, social, cognitive,
skill within the chosen activity. emotional, and communication.
Each step in the STA protocol creates the base needed The psychology graduate student planned and led the
for the next step in the sequence. Intervention that incor- discussion sessions. The topics she included during the six
porates the STA protocol produces dynamic trunk co-activation 30-minute blocks were (1) importance of self care; (2)
in sequenced trunk movements adequate for the demands ways to feel empowered; (3) Elizabeth Kubeler-Ross’s
of transitional activities. In an infant-led session, the indi- stages of grieving, particularly in relation to their infant’s
vidualized application of the protocol may seem different disability; (4) coping skills for managing an infant with a
for each infant and within a session depending on the func- disability; and (5) sharing their “stories.”
tional activity of interest to the infant.‡ The postpartum aerobic instructor led the parents in a
comfortably paced, general body fitness routine that in-
APPENDIX B cluded their infants. Each session involved continuous ac-
tivity for 30 minutes, during four of the 10 group sessions.
Parent-Infant Playgroup Protocol
The instructor demonstrated ways to pick-up and put
A licensed Child Life Specialists coordinated the PIP down the infants with appropriate body mechanics to re-
group that met for 10 one-hour sessions over a period of 15 duce the risk of back injury and to tone the abdominal
days. A graduate psychology student, who was a mother of muscles of the adult. She demonstrated ways to push the
a child with CP, and an aerobics instructor who specialized infant in the stroller to perform gentle body muscle
stretching and strengthening activities. The instructor
incorporated holding, lifting, and moving the infant for
‡NDT-based STA protocol with clinical example is available by request to adult upper and lower body strengthening activities dur-
the first author. ing play times.