2FOCUS Neuroanatomy & Neurophysiology Principles of Neuroscience Treatment of paralysis, flaccidity & spasticity of muscles resulting from damage or disease to the central nervous systemTreatment of Movement disordersFramework focus: body structures, body functions, process skills, contexts, and activity demands.
3Basic AssumptionsEach theorist has a somewhat different approach, assessment technique, and intervention strategies.Most neurodevelopmental approaches require specialized training.These theorists use a behavioral learning approach to motor control based on the sequence normal developmental.
4Assumptions: Traditional Theories The remainder of the theories are currently known as “hierarchical” or “traditional” theories of motor control, includingRoodThe Bobaths – NDTBrunnstromProprioceptive Neuromuscular Facilitation (PNF)Carr & Shepherd
5Basic Assumptions, cont. Margaret Rood, the earliest theorist, is both an occupational and physical therapist. She stresses the importance of early reflexes in the relearning of motor control.Rood first used her techniques effectively with children with cerebral palsy.She believed that a baby uses reflexes to move initially but modifies them and eventually replaces the reflexes with voluntary movement.
6Rood, 4 Basic PrinciplesSensory input is required for normalization of tone and evocation of desired muscular responses.Sensory motor control is developmentally based.Movement is purposeful, engagement in activities is required to produce a normal response.Repetition of movement is necessary for learning.
7Rood, cont.Facilitation techniques: light stroking, brushing, icing, and joint compression are used to facilitate movement.Inhibition techniques: joint approximation (light compression), neutral warmth, pressure on tendon insertion, and slow rhythmical movement are used to inhibit unwanted movement (i.e., spasticity).
8Rood identified 8 ontogenetic motor patterns in the following sequence Supine withdrawalSegmental rollingPivot prone (prone extension)Neck co-contractionSupporting self on elbowsAll fours movement patternsStandingWalking
9Rood, cont.Positioning is a primary concern, especially when little voluntary control exists.Extensive use of mats, bolsters, balls, and other specialized equipment is common in the Rood approach.Movement patterns can be incorporated into games, such as tug of war, to provide an occupational focus to regaining motor control.
10The Bobaths, Drs. K. (physiologist) & B The Bobaths, Drs. K. (physiologist) & B. (physiotherapist), BritishAKA Neurodevelopment Treatment (NDT)Originally designed their therapy techniques for persons with hemiplegia (caused by CVA, or stroke)Also worked with children with cerebral palsyNDT focuses on the sensation of movement; it is not movement itself, but the sensation of movement, that is learned and remembered
11Bobaths, cont.Reflex inhibiting postures are used to inhibit primitive reflexes (RIPs).Sensory stimulation is regulated with great care.Weight bearing, placing and holding, tapping and joint compression are used to activate normal movement and posture.Compensation (such as one-handed feeding and dressing) using the noninvolved side is discouraged during recovery from stroke because it results in inactivity and poor recovery on the involved (paralyzed) side.
12Brunnstrom, Signe - physical therapist, 1950-1970s Focuses on reflexes which provide the components of normal movementProprioceptive (resistive) & exteroceptive (tactile) stimulation are used to elicit reflexes in the recovering adult hemiplegicPatients are encouraged to think about the movement and to gain controlBrunnstrom also uses associated reactions and synergiesA synergy is a total flexion or extension movement of a joint or limb
13Brunnstrom’s 6 Stages of Recovery Flaccidity, no voluntary movementSynergies or minimal voluntary movementSynergies performed voluntarilySome deviation from synergyIndependent or isolated movementIndividual joint movement nearly normal with minimal spasticity
14Proprioceptive Neuromuscular Facilitation (PNF) Developed by Herman Kabat, PhD, MD and modified by many contributors since the ’40sUses diagonal & spiraling patterns of movementGuides thinking about the sequence of normal developmentEleven basic principles (see Cole, p. 242)Uses two diagonal patterns crossing the mid-line for each major body part, often incorporating verbal commands.
15Carr & Shepherd’s Motor Relearning Programme (for persons with stroke) Contemporary approach (1990s)Uses dynamical systems model of motor controlEmphasize interaction between performer and environmentDoes not accept the hierarchical sequence of motor relearning proposed by other theoristsLike other theorists, Carr & Shepherd discourage the early use of compensatory strategies
16Carr & Shepherd, cont.Clients taught to avoid abnormal compensation for weak musclesTreatment techniques based on extensive study of how normal movement occurs during functional tasksAcknowledge critical role of cognition in motor learningMovement patterns practiced in context of tasks, rather than exercises
17Carr & Shepherd, 7 Categories of Functional Daily Activities Upper limb functionOrofacial functionSitting up over the side of the bedBalanced sittingStanding up & sitting downBalanced standingWalking
18Function and Dysfunction Function assumes the ability to plan and execute normal voluntary movementDysfunction is viewed as neurophysiologically based; CNS deficits result in abnormal muscle tone and lack of voluntary purposeful movementEach theorist has a separate way to measure the extent of dysfunction
19Change Changes in motor control are physiologically induced. Engagement in activity can produce physiological change leading to motor controlIndividuals relearn movement patterns in a predictable developmental sequenceTheorists differ in the use of early reflexes to produce movementHandling, sensory stimulation, and manipulation of affected muscles can facilitate motor relearning
20Assessment and Treatment Specific to each theoristThese “traditional” models have also been called “reflex-hierarchical” or “neuromaturational” because they are based on “relearning” movement in a normal developmental sequence.New evidence tends to disprove the effectiveness of these approaches.
21Transition from Motor Control to Motor Learning Began in 1990s with classic article by Mathiowetz & Bass Haugen, and Trombly’s Slagle Lecture.The following introduces Trombly’s model as changing OT’s thinking about establishing or restoring voluntary movement.
22Task Focused Approach: Trombly Occupational Functioning Model – introduced in 1995Descending hierarchy of tasks & rolesGoal is to develop competency & self-esteemContext & environment surround and -permeate all levels of the hierarchyWhen clients have mastered the foundation capacities, they move on to task-focused interventions (individual or group)Trombly calls this “occupation as end”
23Task Focused Approach, cont. Five general principles:1. Client centered focus2. Occupation based focus3. Person & Environment – enablers/barriers4. Practice & Feedback - encoding5. General treatment goals – role fulfillment, problem-solving skills re: best way to accomplish valued tasks
24Dynamical Systems Theory & Trombly Applied to physical disabilities, this theory combines reflexive and voluntary motor controlCNS receives/interprets multiple cues from the environment and involves multiple subsystems when planning to reach desired goals (preferred tasks & roles)Occupational performance is a product of the interaction between the person, the task, and multiple environmental factors.
25Assumptions: Task Focused Approach Trombly’s task focused approach is based on theories of motor learning and dynamical systems theory.Meaningful tasks are graded and sequenced according to each client’s needs & abilities.Each task requires experimentation using different strategies & contexts in order for motor skills to be learned.Currently the preferred approach in OT for intervention after stroke/CNS damage
26The EndNext time: Motor Learning Frame of Reference in OT