CRITIOUED 93

7/NDT EVALUATION

Table 7.1.
Neurodevelopmental Clinical Observations
Yes patient is able to perform No patient is not able to perform
PA physical assistance (max/mod/min) I = independent

partial performance NT Not Tested

Sits Symmetrically ACTIVE WEIGHT SHIFT IN SITTING
Head in midline & erect Lean forwards with (circle 1)
Shoulder height is even: R> ?<L (circle 1) anterior/neutrallposterior tilt
with
Neutral pelvic tilt Lean 1/3 way back towards supine
tit
Equal weight on both hips: R>?<L (Circle 1) posterior/neutral/anterior
Symmetrical hip abduction: R> ? <L Higher furnctioning patients:
Both feet lat on floor Sideways to R/runk elong
Sideways to Litrunk elong
SUBLUXATION fingers wide on . side Active trunk rotation to A
Scapula downwardly rotated Active trunk rotation to L
Lateral runk flexion side
Arm internally rotated/pronated

AUTOMATIC REACTIONS WHILE ROLLING: Choose only one!

No log-roll during LE Derotative
procedure (trunk is flaccid)
Log-folls upper body during LE Derotative procedure
Log-rolls using unsate arching and limb retraction (Neck Righting)
Log-rolls safely with neck, shoulder, and hip flexion (Neck Righting)
Segmentall rolls bul can't stop roll, even at edge (Body Righting)
Can stop segmental roll at any point in space (Equilibrium Reactions)

LE EXTENSION SYNERGY DURING ADLS IN SITTING: P Present A = Absent

Hesists external rotation when legs cross or foot rests on opposite knee
Resists knee flexion when crossing hemiplegic lég over sound leg
Knee extends so hemiplegic foot rests in front of sound foot on flo0or
Resists hip flexion when patient tries to touch hemiplegic foot on floor
Resists ankle dorsitlexion when trying to put shoes on

PLACING REACTION of arm. ECCENTRIC CONTROL of - arm

Arm in RIP at side Lower arm at side of body
Arm in RIP diagonally Lower arrm diagonaly
Arm in front of body Lower arm in tront of body

EQUILIBRIUM IN SITTING: tilt to PROTECTIVE EXTENSION IN SITTING

Left Right Left Right
Vertical head righting Vertical head righting
Trunk elongation of Lateral trunk flexion of
weightbearing side weightbearing side
Rotation w/posterior tilt Rotation w/anterior tilt
Abduct uphill arm/leg9 Extend downhill arm/leg

Patients often have some quality movements while weight. For example, if you lean to your right side while
sitting, you put more weight on your right hip and thigh.
lacking others. Each movement component should be
If the trunk on the same side as your right weightbearing
individually scored as present, impaired, or absent
(+,,-). This profile of assets and deficits enables leg becomes longer, you exhibit trunk elongation of the
you to treat each patient's specific need for
automatic weightbearing side. However, if the trunk on the same
reactionsS. side as the right weightbearing leg becomes shorter, you
Trunk elongation is an important characteristic that exhibit lateral trunk flexion. Trunk lateral flexion is a
distinguishes an equilibrium response from protective part of a protective extension response rather than an
(see Table 7.1). Trunk elongation of the equilibrium response, so it is important to know which
extension
weightbearing side is the NDT solution to the confu- of the two axial strategies the patient is using in ordèr
sion about the two sides of the trunk. Right and left
change, depending on whether you are facing or sitting
to score these two automatic reactions correctly.
It is often difficult to see whether the trunk is geting
next to the patient. Auto mechanics solved a similar longer or shorter because adult patients wish to remain
problem by referring to the driver's and passenger's fully dressed. To make it even harder, patients often use
side of a car. rigid fixing when they are tilted off balance. This restricts
The Bobaths identified the weightbearing side of the their automatic reactions to very small movements
trunk by first identifying the limb that bears the most instead of the large movements shown in textb0oks.
94 N/NEURODEVELOPMENTAL FRAME OF REFERENCE

I recommend watching the shoulder on the weight down on the pelvis (see Fig. 7.2). Posterior pelvic tilt
bearing side. lf the SHOULDER on the weightbearing is defined backwards movement of the ASIS, The
as a

sicde goes UP, the trunk is elongating. If the SHOULDER force for posterior tilt involves the
couple hamstrings
on the weightbearing side goes DOWN, the trunk is pulling down and the abdominals pulling up on the
shortening (see Fig. 7.1). Sometimes you can see fat rolls pelvis
form on the side that is shortening if the patient has Pelvic tilt is even harder to see than trunk elongation
his/her shirt off. because patients who fix exhibit only a small range of
Pelvic tilt is another characteristic that distinguishes motion unless tilted far enough to actually fall. Again.
equilibrium reactions from protective extension (see I recommend watching the shoulders. When the pelvis
Table 7.1). Posterior tilt is associated with an equilibrium tilts, the center of gravity is disturbed, so the patient
reaction, while anterior tilt is associated with protective pulls his/her SHOULDER(s) in the OPPOSITE direction
extension (4). Anterior pelvic tilt is defined as aforward from the PELVIS to use his/her trunk as a counterweight
movement of the anterior superior iliac spine (ASIS). It to keep from falling.
is produced by a force couple, which is two muscles The patient's trunk must be tilted behind vertical to
pulling in opposite directions to create a rotary move observe the following shoulder movements. When you
ment (5). The force couple for anterior tilt involves the tilt the patient straight backwards until the trunk is
low back extensors pulling up and the hip flexors pulling behind vertical, you know the patient is using posterior

Trunk Elongation Lateral Trunk Flexion

1. The shoulders don't catch your eye because they remainn 1. Now the shoulder on the weightbearing side catches your
level-BUT attention. The left shoulder has moved down towards the
2. The left shoulder has moved up relative to the left hip to left hip to produce trunk shortening of the weightbearing
produce trunk elongation of the weightbearing side and side.
3. The right shoulder has moved down toward the
right hip
to produce trunk shortening of the non-weightbearing side.
2. The right shoulder has moved up relative to the right hip,
BUT the trunk elongation is not as pronounced as the elon
4. Note the full hip hiking on the
This response is not always this
non-weightbearing side. gation shown in the left hand picture because the right hip
pronounced. You may has also hiked upwards.
have to slide one hand under this hip to feel if
is present.
hip-hiking

Figure 7.1. Trunk elongation (left) and lateral trunk flexion (right).
 7/NDT EVALUATION CRITIQUED 95

ANTERIOR TILT FORWARD.

POSTERIOA TILT BOTH SHOULDERS
pelvic tilt if
move

backwards, the shoul-

Back However, when tilted diagonaly
Extemal When you tilt the patient
extensorsS obllque ders respond asymmetrically.
abdominals the trunk is belind vertically,
diagonally backwards until tilt if the
is using posterior
you know the patient side m o v e s
WEIGHTBEARING
SHOULDER on the
SHOULDER on the
FORWARD. Conversely, when the
BACKWARDS, the
WEIGHTBEARING side m o v e s
use pro-
Rectus tilt and is prepared to
abdominis patient is using anterior thrown backwards
tective extension in the arm that
is
what the patient is doing,
(see Fig. 7.3). If you're not sure
motions and weight-shift
imitate the patient's shoulder
Hip to feel what your pelvis is doing.
flexors Hamstrings
Anterior Superior lliac Spine (ASIS) Decision Tree Process
to
The decision tree process also
needs to be applied
test every
the longlist of automatic reactions. If you
Figure 7.2 Force couples for pelvic tilt. too
automatic reaction, you may spend
patient for every if prioritize
much time evaluating this skill. It helps you

Anterior Pelvic Tilt

Posterior Pelvic Tilt
has 1. Because the shoulder on the weightbearing side (left) has
1. Because the shoulder on the weightbearing (left)
side
moved backward relative to the right shoulder, we know
we know
moved forward relative to the right shoulder, that the pelvis has tilted in the opposite direction (i.e., for-
direction (i.e., back-
that the pelvis has tilted in the opposite
ward)
ward). 2. Note the trunk rotation.
2. Note the trunk rotation. 3. Imagine the left arm reaching for the floor to break his fall
3. Imagine both arms coming forward to help pull the body
i.e., protective extension).
back up to midline.

and anterior (right) pelvic tilt.

Figure 7.3. Posterior (left)