November 4, 2010
The Why In Assessment
It can sometimes be a challenge during assessment to decide what the primary movement issue is that is causing the child is to have difficulty with motor skills. We may have access to a diagnosis and assessments that help us to pinpoint what skills the child is having difficulty with and even how much difficulty they are having. But determining why the child is having difficulty is key; if we understand what systems are primarily involved and how, we will better know where and how to intervene. This is where our theoretical knowledge base and clinical problem solving skills come in to play.
Neuro-Developmental Treatment (NDT) theory accepts that in order to reduce the complexity of movement, systems are interconnected1. NDT teaches us that the trunk
is a key player in all motor tasks, and when it is not stable, both proximal and distal skills are impacted1,2. An important contribution to our assessment is examining how the child is organizing their postural control with the components at their disposal – in other words, the postural compensations they are using to complete the function. This in turn gives us clues about which muscles are not activating and why.
Sensory Integration (SI) theory teaches us to look at every functional task as a sensory event, with the possibility of contribution from any or all of the 7 senses: vision, hearing, taste, smell, touch, proprioception and vestibular2. In my experience, when we assess how a child is using these senses, we may not adequately understand how they are using visual and vestibular input for balance and functional mobility skills. SI also teaches us about sensory modulation and the need to have a CNS arousal level that matches each task – the “just right state”.
Thirdly, Dynamic Core for Kids teaches us to consider the neurological strategy involved in postural control. The inner core unit (respiratory diaphragm, transversus abdominis, pelvic floor and multifidus) is neurologically wired to be a key player in anticipatory postural control3,4,5. This in turn gives us that stable trunk for all distal functions: gross motor, fine motor, oral motor and phonation. We can now assess and intervene effectively with specific strategies aimed at connecting these four specific muscles into postural control and function.
Of course, nothing occurs in isolation, such is the nature of dynamic systems. The art of assessment lies in peeling back the layers to determine what system is impacting when and how much. As we learn more about postural control and develop our clinical problem solving skills, the why in assessment becomes clear.
1. Howle JM (ed): Neuro-Developmental Treatment Approach. Theoretical Foundations and Principles of Clinical Practice. California, NDTA, 2003
2. Barthel Kim: Evidence and Art. Merging Forces in Pediatric Therapy. Victoria, 2004
3. McCook DT, Vicenzino B, Hodges PW: Activity of deep abdominal muscles increased during submaximal flexion and extension efforts but antagonist contraction remains unchanged. J Electromyogr Kinesiol 2009 Oct: 19(5): 754-62.
4.Tsao H, Galea MP, Hodges PW: How fast are feedforward postural adjustments of the abdominal muscles. Behav NeuroSci 2009 123(3): 687-693.
5. Hodges PW, Gandevia SC: Activation of the human diaphragm during a repetitive postural task. J Physiol 2000 522(1): 165 – 175.