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PT 154 PT 154 Therapeutic Exercise 3 Theoretical underpinnings of therapeutic exercises and activities for neurological and developmental conditions. Edward.

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Presentation on theme: "PT 154 PT 154 Therapeutic Exercise 3 Theoretical underpinnings of therapeutic exercises and activities for neurological and developmental conditions. Edward."— Presentation transcript:

1 PT 154 PT 154 Therapeutic Exercise 3 Theoretical underpinnings of therapeutic exercises and activities for neurological and developmental conditions. Edward James R Gorgon MPhysio PTRP Chair and Assistant Professor Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

2 What impairs movement?

3 Path to abnormal movement Attempt to move  Obstacles to efficient movement  Compensatory movement strategy  Repeated practice of compensatory strategy  Learned use of compensatory strategy Carr J & Shepherd R (Eds) (1987). A motor relearning programme for stroke (2 nd ed), Rockville, Aspen.

4 Motor control theories Motor control theories A review of key concepts and applications

5 Reflex theory ■ Motor behaviors as a function of the presence or absence of controlling reflexes ■ Enhancing or reducing the effect of various reflexes during motor tasks Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2 nd ed). Baltimore, Lippincott Williams & Wilkins.

6 Hierarchical theories ■ Motor behaviors as a result of loss of higher-level CNS control and subsequent exaggeration of normal reflexes and / or appearance of pathological reflexes ■ Inhibiting (or facilitating) reflex activity and regaining control by higher CNS centers over lower centers during motor tasks Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2 nd ed). Baltimore, Lippincott Williams & Wilkins.

7 Motor programming theories ■ Motor behaviors as determined by abnormalities in central pattern generators and higher-level motor programs ■ Learning the correct rules for action and applying motor programs through available effectors Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2 nd ed). Baltimore, Lippincott Williams & Wilkins.

8 Systems theory ■ Motor behaviors as a result of mechanical constraints in the body that shape the expression of NS control ■ Addressing musculoskeletal system impairments that impact upon overall motor control ■ Addressing interacting impairments among multiple body systems Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2 nd ed). Baltimore, Lippincott Williams & Wilkins.

9 Ecological theory ■ Motor behaviors as a function of the ability to satisfy or adapt movement to task and environmental requirements ■ Developing the ability to achieve functional tasks in multiple ways ■ Develop the ability to come up with best solutions for movement problems given existing limitations Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2 nd ed). Baltimore, Lippincott Williams & Wilkins.

10 Motor control theories – in contrast HIERARCHICAL theorySYSTEMS theory  Sensory stimuli determine posture  Separation of voluntary and reflex  Top-down control  Behaviors organized around task goals  Anticipatory, predictive control  Normal movement strategies Horak F& Shumway-Cook A (1989).

11 Motor control theories – in contrast ■ In terms of theory on motor skill acquisition ■ In terms of theory on dyscontrol ■ In terms of theory on function recovery following brain injury and issue of functional carryover

12 Motor control theories – in contrast HIERARCHICAL theorySYSTEMS theory  Inhibit abnormal tone  Integrate primitive reflexes  Fractionalize movement by breaking up muscle synergies  Effectively achieve task goals  Improve use of prior experience and anticipatory postural adjustments  Access appropriate and efficient movement patterns  Improve adaptability to context Horak F& Shumway-Cook A (1989).

13 Skill learning principles and critical variables Skill learning Key principles and critical variables

14 Skill defined ■ Consistently attaining an action-goal with some ECONOMY OF EFFORT ■ Involves an INDIVIDUAL SOLUTION to the problem of how to efficiently organize movement to produce an action-outcome consistently ■ Is TASK-SPECIFIC Gentile (2000)

15 Skill learning processes ■ Explicit learning processes ■ Implicit learning processes Regulation of intersegmental force dynamics Blending of successive movement components Coupling of simultaneous components

16 Practice Practice is critical in motor learning ■ …practice, when properly undertaken, does NOT consist in repeating the means of solution of a motor problem time and again, but in the process of solving the problem time after time by techniques which we have changed and perfected from repetition to repetition… practice is a particular type of repetition without repetition Bernstein (1967) ■ Considered the most important determinant of learning

17 Practice Practice is critical in motor learning ■ Preparation of the patient for practice ■ Distribution of practice ■ Variability of practice ■ Order of practice ■ Whole practice and part practice ■ Structure of the environment during practice ■ Mental practice

18 Patient preparation for practice ■ Verbal instruction ■ Visual demonstration / illustration; patient’s observation of motion patterns ■ Manual guidance ■ Mental organization of movement timing ■ External focus vs internal focus ■ Visual scanning of “far” environment

19 Distribution of practice ■ Massed practice ■ Distributed practice

20 Variability of practice ■ Blocked practice – early stage, complex, whole-body tasks? ■ Random practice – early stage, seated manipulative tasks?

21 Order of practice ■ Blocked order practice ■ Serial order practice ■ Random order

22 Whole practice or part practice ? ■ Whole practice ■ Part –whole practice; progressive part practice

23 Classification of tasks ■ Discrete tasks ■ Serial tasks ■ Continuous tasks Schmidt (1988)

24 Structuring the environment during practice ■ Regulatory conditions normally operative in the task Accentuating regulatory conditions Eliminating non-regulatory conditions ■ Level of biomechanical complexity ■ Level of information processing complexity

25 Classification of tasks Classification of tasks Gentile (2000)

26

27 Mental practice ■ Theoretical underpinnings ■ Always combined with physical practice (!) ■ When appropriate to use ■ When inappropriate to use

28 Speed and accuracy in practice ■ As near-normal performance as possible

29 Transfer of learning with practice ■ Bilateral transfer ■ Use of lead-up activities

30 Feedback Feedback facilitates motor learning ■ Mode of feedback ■ Augmented feedback ■ Precision of feedback ■ Intensity of feedback ■ Schedule of feedback

31 Mode of feedback ■ Internal feedback ■ External (augmented) feedback

32 Augmented feedback ■ Knowledge of results (KR) ■ Knowledge of performance (KP)

33 Precision of feedback ■ General focus feedback ■ Specific focus feedback

34 Intensity of feedback ■ Constant (frequent) feedback ■ Intermittent (varied) feedback

35 Schedule of feedback ■ Immediate feedback vs delayed feedback ■ Concurrent feedback vs terminal feedback Summary feedback Faded feedback Bandwidth feedback

36 Phases of skill learning Recall PT 152 unit Physiology of motor learning and memory ■ Fitts and Posner’s stages of motor learning* Cognitive stage; Associative stage; Autonomous stage ■ Neo-Bernsteinian stages of motor learning Novice stage; Advanced stage; Expert stage ■ Gentile’s stages of motor learning Getting the idea of movement Fixation / diversification Getting the idea of movement stage; Fixation / diversification stage

37 Phases of skill learning ■ Early phase of skill learning “Getting the idea of movement” stage ■ Later phases of skill learning Fixation / diversification stage

38 Initial phase of skill learning ■ Setting the task goal Selecting the functional task Promoting self-efficacy and avoiding “goal confusion” ■ Structuring the environment Using normal regulatory conditions ■ Promoting selective attention Using an external focus and accentuating regulatory conditions Observing, mentally organizing, visually scanning

39 Initial phase of skill learning ■ Planning the movement General advice on movement organization Whole practice, unless task is naturally “breakable” Typical-performance speed and accuracy Mental practice ■ Performing the movement Avoiding interferences: cues, feedback, manual guidance

40 Initial phase of skill learning ■ Augmented feedback Unambiguous Intermittent Knowledge of results Knowledge of performance ■ Decision making Modify task? Modify environment?

41 Later phases of skill learning ■ Organizing practice by structuring the environment Use of different types of tasks Use of random practice Increased practice time to increase movement efficiency ■ Organizing practice using an effective practice schedule Use of distributed practice, unless fatigue is of little significance Mental practice ■ “Fading” augmented feedback Terminal feedback using KP or KR

42 The patient as an active learner The patient as an active learner Some basic concepts and guidelines

43 The patient as an active learner ■ Involves ACTIVE PRACTICE of everyday tasks instead of passive receiving of therapeutic intervention ■ Involves being given the opportunity to practice tasks as much as possible (e.g., practice outside the clinical setting)

44 The patient as an active learner ■ Configuring the organizational structure for active learning Function of staff, role of patients, and interaction of these Clarifying policies and procedures (e.g., via drawing up contracts) Promoting autonomy and responsibility in patients consistently Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.

45 The patient as an active learner ■ Configuring the physical structure for active learning Architecture / design of therapy workspaces Providing suitable materials to enable “intra-clinical” practice Providing suitable materials to enable “extra-clinical” practice Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.

46 The patient as an active learner ■ Active learning through independent practice Explicit (written / illustrated / diagrammed / recorded) instructions Feedback from the environment – correct performance – errors to avoid Organized and self-monitored (or semi-supervised) practice Recording and illustration of progress in therapy Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.

47 Intervention models to improve motor function

48 Intervention models Intervention models – an overview ■ FUNCTIONAL / TASK-ORIENTED training model

49 Intervention models Intervention models – an overview ■ NEUROMOTOR DEVELOPMENTAL training model Neurodevelopmental Treatment (NDT) Proprioceptive Neuromuscular Facilitation (PNF) Neuromuscular / Sensory stimulation techniques

50 Intervention models Intervention models – an overview ■ COMPENSATORY training model

51 Intervention models Intervention models – an overview ■ ECLECTIC training model

52 Required reading ■ O’Sullivan SB. Strategies to improve motor function. In: O’Sullivan SB & Schmitz TJ (2007). Physical rehabilitation (5 th ed). Philadelphia, FA Davis Company.


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