The Practice of Speech-Language Pathology from a Neuro-Developmental Treatment Perspective

18 The Practice of Speech-Language Pathology from a Neuro-Developmental Treatment Perspective

Rona Alexander

This chapter outlines the history of when and how the profession of speech-language pathology became an integral member of the Neuro-Developmental Treatment (NDT) team. The mutual information and skill exchange between the two entities, specifically in the areas of feeding and swallowing, speech/sound production, and language, cognition, and communication, is presented. Clinical examples of how the practice of speech-language pathology within the NDT Practice Model demonstrate the problem solving and decision making used to address clients’ activity and participation domains of the International Classification of Functioning, Disability and Health (ICF).

Learning Objectives

Upon completing this chapter the reader will be able to do the following:

• Define who a speech-language pathologist (SLP) is in terms of professional responsibilities and functional outcomes addressed in client management.

• List at least three skills NDT education enhances in the professional skills of SLPs.

• Analyze a speech-language pathology outcome with a specific participation or activity of a client in his or her own practice using the NDT Practice Model.

18.1 Historical Perspectives on Speech-Language Pathology within NDT

Speech-language pathologists (SLPs) began exhibiting interest in the work of Dr. and Mrs. Bobath in the mid-1960s. Helen Mueller came from Switzerland where she was working as a speech therapist in a school for children with cerebral palsy to study with the Bobaths in London and was instrumental in defining the focus of practice for speech-language pathology within Neuro-Developmental Treatment (NDT). She developed the basic NDT speech curriculum, which has been included in the NDT/Bobath approach since 1968 (Helen Mueller, NDTA Award of Excellence videotaped acceptance, May 2001). This core curriculum included information in the areas of oral motor development and treatment, feeding and swallowing development and treatment, respiratory-phonatory development and treatment, early sound/speech production development, and prelinguistic and cognitive development and their relationships to children with cerebral palsy.

Suzanne Evans Morris was the first SLP from the United States to successfully complete an NDT basic pediatric course in London in 1964. Since that time, Dr. Morris has had a significant influence on the speech-language pathology curriculum taught in NDT courses and used within NDT in the United States. She has played an important role in advancing knowledge in the principles and practice of NDT and speech-language pathology in the examination of and intervention for children with neuromotor impairments through her extensive writings and workshop presentations (Suzanne Evans Morris, PhD, personal communication, March 2010).

The early and continuing connection that exists between NDT and speech-language pathology has helped to solidify the focus within NDT on the importance of teamwork and on a holistic approach to the examination of and intervention for children and adults with central nervous system (CNS) pathophysiologies. In addition, this relationship between NDT and speech-language pathology has played a role in reinforcing the need for SLPs to be actively engaged in services, especially in the areas of feeding and swallowing function, oral motor and oral sensory function, respiratory-phonatory function, and prelinguistic and early cognitive function as they relate to infants and children with neuromotor problems.

According to the American Speech-Language-Hearing Association’s (ASHA’s) “Scope of Practice in Speech-Language Pathology” policy document from 2007, “Speech-language pathology is a dynamic and continuously developing profession.”1 It has had a strong presence in both educational settings as well as medically based settings. “The overall objective of speech-language pathology services is to optimize individuals’ ability to communicate and swallow, thereby improving quality of life.”¹ Today, “speech-language pathologists address typical and atypical communication and swallowing”¹ in the areas of speech sound production (i.e., articulation, apraxia of speech, dysarthria, ataxia, dyskinesia); resonance (i.e., hypernasality, hyponasality); voice (i.e., phonation quality, pitch, loudness, respiration); fluency; language (i.e., phonology, pragmatics, morphology, syntax, semantics, prelinguistic communication); cognition (i.e., attention, memory, sequencing, problem-solving, executive functioning); and feeding and swallowing (i.e., oral, pharyngeal, laryngeal, esophageal). These represent an expansion from the areas of traditional focus in speech-language pathology that existed in the late 1960s to today, when we include areas such as feeding and swallowing, which NDT has long viewed as essential as a focus for SLPs.

When SLPs begin their NDT education, they start with a general base of knowledge in areas that compose the practice of speech-language pathology. This, however, does not mean that they may practice in all areas of speech-language pathology with children and adults with neuromuscular impairments. They “may practice only in areas in which they are competent (i.e., an individual’s scope of competency), based on their education, training, and experience.”1

With NDT education, SLPs learn to analyze and understand the influences of postural alignment, postural control, body mechanics, kinesiological characteristics, typical movement development, atypical and compensatory patterns of movement, and body system interactions on all functional activities related to communication and feeding and swallowing. They gain new insights into the relationships among the feeding and swallowing problems, oral sensory and oral motor issues, respiratory coordination problems, voice and resonance issues, language and cognition issues, and the posture and movement problems that individuals with neurological pathophysiology may experience.^2,3 Therapeutic handling (i.e., graded movement facilitation provided by the therapist and one core element of intervention in the NDT Practice Model) provides the SLP with knowledge of a more extensive foundation of strategies to incorporate into intervention directed toward the learning of new movement experiences that influence the individual’s communication and feeding and swallowing function.^3,4,5 In the simplest terms, NDT helps SLPs become more competent in providing services for individuals with neuromotor problems. They see the individual as a whole, connecting his or her communication and feeding and swallowing function with all other aspects of that individual’s posture and movement during the variety of functional activities he or she participates in each day.

From an NDT perspective, the examination process requires extensive observation and analysis of the performance of functional tasks and the posture and movement behaviors used by the individual during these tasks. In accordance with the International Classification of Functioning, Disability, and Health (ICF), NDT-educated SLPs describe the abilities and limitations of an individual to participate in specific life situations (social functions domain) and to actively perform a task (individual function domain) as part of their examination process. Further evaluation will result in the delineation of specific body structure and function integrities and impairments in individual body systems, including the musculoskeletal, neuromuscular, sensory, gastrointestinal, cardiovascular, respiratory, and perception/cognitive systems. It is also necessary to identify environmental factors and personal factors that may be influencing an individual’s activities, body structure and functions, and participation. In addition, the NDT-educated SLP will collect information on effective and ineffective posture and movement behaviors (e.g., head control, trunk control, symmetry, balance, alignment) that are influencing the child or adult’s communication and feeding and swallowing function. This information can then be used to create an intervention plan of care that reflects the needs of the individual and his or her family.

The NDT-educated SLP brings to examination and intervention a strong foundation in typical developmental characteristics as well as in changes in body biomechanics and kinesiology over time. Understanding the typical development of oral, pharyngeal, and respiratory function as they relate to feeding and swallowing, speech/sound production, language and cognition, and communication development is not sufficient for the SLP working with individuals with CNS impairments. To fully understand how these areas progress and change over time, SLPs must relate their development to the changes that occur in general body movement activities, shoulder girdle and upper extremity function, and pelvic/hip and lower extremity function as well as the development and integration of all areas within sensory processing.^2,6 Through this more comprehensive knowledge of typical development, normal biomechanics, and kinesiology, the NDT-educated SLP recognizes the significant influences that changes in posture and movement behaviors can have on feeding and swallowing function and communication.

Through an NDT framework, the SLP gains greater knowledge about atypical development, the effects of aging, and the occurrence of compensatory patterns of movement as a consequence of body system impairments. Whether providing intervention services for children or adults with CNS pathophysiology, SLPs must understand the process by which atypical/compensatory movement patterns develop and the variety of factors (e.g., biomechanical, environmental, personal, alignment, sensory awareness) that may influence the atypical/compensatory patterns of movement used by an individual.^4,7

For example, a child or adult with neuromuscular system impairments and retraction of the cheeks and lips may use head and neck hyperextension with shoulder girdle elevation when drinking liquids from a cup. An NDT-educated SLP will use his or her knowledge of typical and atypical movement when devising an intervention plan for the implementation of appropriate intervention strategies working toward changes in this individual’s cup-drinking activity. Initially, the SLP will observe the individual during activities other than cup drinking to determine if cheek/lip retraction and head/neck hyperextension with shoulder girdle elevation are evident during other functional activities. Selected handling strategies will be used to optimize the alignment of the body over the base of support in sitting, encouraging neutral head flexion, neck elongation, and shoulder girdle depression.⁸ Strategies to elongate the cheek/lip musculature paired with sensory input to ready the cheeks/lips for activation will be provided.⁹ The individual will be guided through oral activities that encourage active lip closure, lip protrusion, and lip opening that do not involve drinking before presenting cup-drinking activities. The SLP will assist in facilitating appropriate head, neck, and shoulder girdle alignment during the oral activities and cup drinking. As the individual begins to take over internal control of the head, neck, and shoulder girdle with increased cheek/lip activity, the SLP will reduce the use of handling strategies during the task.

Because SLPs have the potential to address so many areas, the areas that have had a long-term connection with NDT will be used more specifically to discuss what NDT brings to speech-language pathology intervention for children and adults with neuromotor challenges. Areas of speech-language pathology that will be discussed include feeding and swallowing, speech/sound production, and language, cognition, and communication.

18.1.1 Feeding and Swallowing

Today’s SLPs receive basic knowledge in the area of swallowing and swallowing disorders (i.e., dysphagia) as a requirement in their college/university programs. The focus of the majority of these university courses is on adult swallowing and swallowing disorders, with limited information provided in the area of pediatrics. To competently work in the area of feeding and swallowing with adults or children, SLPs should obtain extensive supervised practical experiences in this area with the specific age groups they intend to serve. In addition, they should attend a variety of advanced-level continuing education seminars/courses to more fully understand all of the influences that affect an individual’s feeding and swallowing function (i.e., gastrointestinal, respiratory/airway, oral sensory and oral motor, pharyngeal sensory and pharyngeal motility, neuromotor, musculoskeletal, behavioral) and how to incorporate this knowledge into the examination and intervention services they provide. These services generally focus on the oral, pharyngeal, and respiratory coordination issues that influence feeding and swallowing.

SLPs, with knowledge of NDT for adults or pediatrics, expand their knowledge and experience to better understand the activity limitations, the body structure and function integrities and impairments, and the influence of posture and movement that an individual with CNS pathophysiology and feeding and swallowing issues may experience. Ineffective posture and movement behaviors impact on all areas of feeding and swallowing and must be addressed by the SLP if progress is to be made.

SLPs have a special knowledge of the structures and functions of the oral and pharyngeal mechanisms. The NDT-educated SLP also understands oral and pharyngeal functions as they relate to typical movement development, postural alignment, postural control, biomechanics, and body system interactions and impairments. This NDT perspective provides a foundation from which a more comprehensive evaluation of an individual’s functional abilities and limitations can be conducted in the areas of feeding and swallowing. In addition, it provides a foundation of understanding in posture and movement that expands the areas in which intervention strategies must be directed as part of the individual’s intervention plan of care to improve oral, pharyngeal, and respiratory function during eating, drinking, and saliva management activities.

For example, a 2-year-old boy has a primary diagnosis of cerebral palsy, athetoid quadriplegia. He is held at a 60° angle on his mother’s lap for bottle drinking and spoon feeding during mealtimes because she does not believe that he eats as well when he is put in his high chair. Cheek/lip retraction, forward/backward suckling movements of the tongue with a thick tongue contour, and unstable, poorly graded jaw movements are evident throughout bottle-drinking and spoon-feeding tasks. It is difficult for the boy to keep his head in midline generally, and he often turns his head to the right when he is working with food or the bottle’s nipple in his mouth. He prefers to hold his body in a more extended posture with significant shoulder girdle and rib cage elevation during feeding and other functional activities (e.g., dressing and undressing, diapering, biting on a biter). Deep bouncing on his mother’s lap helps him to calm and organize periodically during mealtime as well as during other activities when he becomes disorganized.

The SLP with a foundation in NDT will further analyze the relationship between this boy’s oral, pharyngeal, and respiratory activity during general movement activities as well as upper extremity activities and compare these activities to what is seen during feeding and swallowing tasks. In intervention, therapeutic handling will be used, working toward changes in the child’s postural alignment and body movements that will provide a better foundation for changes in oral, pharyngeal, and respiratory coordination function. Handling strategies directed toward increasing rib cage mobility, activating the abdominal musculature, activating the hip musculature against the base of support in sitting, stabilizing the shoulder girdle complex on the rib cage, and increasing elongation of the neck with shoulder girdle depression as part of an active base of postural control and movement on the part of the child, will provide the foundation on which changes in oral and pharyngeal function can be stimulated.10

As the child exhibits more active symmetrical postural control and movement, these more effective postures and movements can then be integrated into establishing a more supportive, stable postural foundation for eating and drinking tasks at mealtime. Equipment can be adapted to assist in maintaining a more appropriate postural alignment with the least amount of effort on the part of the child so that the focus can be on modifying oral and pharyngeal activity to improve nutritional intake.¹¹ Intervention continues to be used as a time to integrate advances in postural control and movement with advances in oral and pharyngeal function during a variety of activities, including feeding and swallowing tasks. Mealtime continues to be a time to incorporate and practice oral and pharyngeal skills that have been gained in intervention that now result in improved nutritional intake and hydration. With a foundation of more active postural control and movement, as well as more active oral and pharyngeal control and movement, the child will progress in the use of his lips, cheeks, jaw, anterior tongue, and posterior tongue, resulting in advances in eating and drinking.¹²

When an adult has feeding and swallowing issues as a result of a stroke, immediate attention is classically drawn to the implementation of compensatory strategies to assist the individual in coping with oral and pharyngeal dysfunctions. However, the NDT-educated SLP will direct the interventions toward the underlying body system impairments and system interactions (i.e., neuromuscular, musculoskeletal, sensory, perceptual/cognitive, gastrointestinal) and posture and movement behaviors that are resulting in the individual’s activity limitations.

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