Hospital incorporates NDT approach to therapy, and will study the results
Focus is on long-term success, not costs
Neurodevelopmental treatment (NDT) as a philosophy for rehabilitation of neurologically injured patients was introduced more than four decades ago, but in recent years it is becoming a popular way for therapists and rehab facilities to improve patient outcomes and long-term efficiency.
NDT training gives therapists a model for treating the whole patient through work with the patient, the family, and interdisciplinary teamwork. While it incorporates traditional therapy techniques, NDT involves additional training in how to treat and manage the patient’s ability to function through the principles of movement science. Training is offered through the Neuro-Developmental Treatment Association (NDTA) of Laguna Beach, CA.
A philosophy, not a program
"You are always looking at the whole person, and that’s the first and foremost thing, to understand the person you’re working with," says Tod Cain, OTR/L, an active NDT approach occupational therapy instructor and the supervisor of occupational therapy at Siskin Hospital for Physical Rehabilitation in Chattanooga, TN.
"The NDT approach is not a program. It’s a way of treating patients," Cain says. "It’s more of a philosophy of how you approach patients."
While therapists can receive NDT training and then incorporate what they learn into their practice, it is far more effective for an entire rehab organization to endorse the concept and use the model in its treatment of neurologically injured patients, Cain says.
"Many variables can influence a person’s recovery," Cain explains. "There’s the actual damage to the brain, of course, and then there are things such as the environment in which the person is functioning, and how the person used to move, the family support, and how the family approaches the patient."
It takes a commitment from managers for the approach to work, and this includes a short-term financial commitment in training staff, Cain says.
"In the age of stricter reimbursement, it is extremely important that therapists are skilled at what they’re doing," Cain says. "The more skilled therapists are, the better patients are going to recover."
Cain says he believes the NDT approach is helping Siskin Hospital improve its positive outcomes, so he is working with a neuropsychologist to study patient outcomes under the process of grading patients’ activities, which incorporates the NDT approach.
The hospital also assesses outcomes through a competency exam given to each therapist annually.
"Each year, we complete a competency on all diagnoses and types of patients that our therapists treat," Cain says. "We go through an entire checklist of chart reviews and code treatments, and we make sure therapists are competent in treating their patients."
While the competency program does not specifically address the therapists’ use of NDT, it does include an assessment of whether the patient is receiving the right treatment, whether or not it includes NDT, Cain says.
"If the person needs this approach, you give them this approach, and if they don’t, then you give them something else," Cain adds. "So that’s why we call it more the principles and philosophy of NDT vs. technique."
Here is how the rehab facility incorporates the NDT approach in treatment of stroke and brain-injured patients:
• Addressing the patient’s specific limitations: Grading a patient’s activities is a way to positively reinforce the patient for progress while taking into consideration that each individual patient has limitations and attributes.
"If we have someone who has specific range-of-motion deficits, then we may have to address that, and then we need to get the individual who is working on activities that are meaningful to them," Cain says.
Therapists trained in NDT are encouraged to grade the patient’s activities so that a particular task is made easier, giving a patient an opportunity to complete it successfully.
"If they’re given a task that they can’t realistically accomplish, then they may work toward it, but in a way that’s not therapeutic, and it may defeat them," Cain says. "If we grade activities to make people successful, then they’ll be active and successful in the activity, and they’ll be doing it more and more."
As the patient’s skill improves, the activity can be graded at a more challenging level.
• Looking at the patient’s environment: Once a patient is taught to do particular activities, the next step under NDT is to look at all of the methods that are working for the therapist and the patient and put them together in the patient’s typical environment.
"In the clinic we have tools, but at home they may not have them, so we may have a patient who can do certain motor acts in the therapy clinic, but at home the patient is unable to do them because the two environments do not match," Cain says.
Setting up stations at home
Siskin Hospital therapists will address this issue by visiting the patient’s home and observing how the patient and the family interact and carry out daily exercises.
"We will go in and restructure certain things in the environment," Cain says. "We’ll set up stations at the patient’s house."
For example, if a patient has limited movement on the right side but needs to brush teeth each morning, the therapist might provide a sliding board for the sink. This will enable the patient to brush her teeth with her left hand while placing her right arm on the sliding board and pushing into that, both for support and to improve that arm’s strength, Cain says.
Therapists also might spot environmental obstacles, such as countertops that are too high or too low, and these can be modified to suit the patient’s abilities.
Since the hospital bills these visits as therapy sessions and not as home evaluations, they typically are fully reimbursed by third-party payers, Cain says.
"You sit down with the case managers and tell them how you’re going to help the patient function in the house," Cain says. "We get it paid as a regular therapy visit for outpatient treatment."
The hospital may incur a little more cost because therapists making home visits are not able to have the same level of daily productivity, but to reject such a program because of this expense would be short-sighted, Cain says.
"If you look at the patient satisfaction that comes from going out to the house and showing them how to function there, then that justifies any extra costs," Cain adds. "But there does need to be an acceptance of this from the administration level on down."
This is another reason the NDT approach requires administrative buy-in, because it is not a strict, number-crunching approach to therapy. "If they’re not willing to look at the big picture, it won’t work," Cain says.
Hands-on approach advocated
• Physically handling patients: Sometimes therapists incorporate all of the above practices into treatment and their patients still do not improve. So there’s a third aspect to NDT that involves learning how to use body, mind, expressions, and one’s entire self in a way that will help the patient accomplish tasks and activities, Cain says.
"We need to handle patients and help them learn how to interact with the environment appropriately," he says. "And we help them be successful, and we can do that through physical handling."
Therapists must be hands-on, guiding a patient’s arm into a position that is active. Even if patients cannot complete a range of motion and may not be able to move a tool by themselves, they can at least get a feel for the movement, Cain says.
"We can get them in a position where their muscles can fire most accurately," he explains. "As we work with them, our hands are on patients when they need to be helped."
Also, therapists can provide challenges to the patient’s injured side of the body through physical handling, Cain says.
Therapists often will teach a patient to get by as best they can, using only their uninjured side of the body to walk and dress. The NDT approach says therapists need to teach them to use the injured side and develop its potential, as well, Cain says.
"Through handling techniques, we can help a patient find movement that they may not have had for years," Cain notes. "We take patients who’ve had their stroke literally 10 to 15 years ago and they had no movement in those arms for that long, and within one session they are able to move their arms."
With traumatic brain injury patients, there may be multiple factors to consider, including cognitive deficits and behavioral issues, so therapists will need to handle not only the patient’s body, but also the patient’s cognitive and emotional being.
"We focus on what’s keeping this individual from resuming meaningful life roles," Cain says.
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