Motor Control Approaches Neurodevelopmental Theorists/Theories: Catherine Trombly, Task-Focused, Motor Learning, Margaret Rood, The Bobaths (NDT), Signe Brunnstrom, PNF, Carr & Sheppard Reference: Cole & Tufano, Chapter 19

FOCUS Neuroanatomy & Neurophysiology Principles of Neuroscience Treatment of paralysis, flaccidity & spasticity of muscles resulting from damage or disease to the central nervous system Treatment of Movement disorders Framework focus: body structures, body functions, process skills, contexts, and activity demands.

Basic Assumptions Each 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.

Assumptions: Traditional Theories The remainder of the theories are currently known as “hierarchical” or “traditional” theories of motor control, including Rood The Bobaths – NDT Brunnstrom Proprioceptive Neuromuscular Facilitation (PNF) Carr & Shepherd

Basic 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.

Rood, 4 Basic Principles Sensory 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.

Rood, 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).

Rood identified 8 ontogenetic motor patterns in the following sequence Supine withdrawal Segmental rolling Pivot prone (prone extension) Neck co-contraction Supporting self on elbows All fours movement patterns Standing Walking

Rood, 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.

The Bobaths, Drs. K. (physiologist) & B The Bobaths, Drs. K. (physiologist) & B. (physiotherapist), British - 1948 AKA Neurodevelopment Treatment (NDT) Originally designed their therapy techniques for persons with hemiplegia (caused by CVA, or stroke) Also worked with children with cerebral palsy NDT focuses on the sensation of movement; it is not movement itself, but the sensation of movement, that is learned and remembered

Bobaths, 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.

Brunnstrom, Signe - physical therapist, 1950-1970s Focuses on reflexes which provide the components of normal movement Proprioceptive (resistive) & exteroceptive (tactile) stimulation are used to elicit reflexes in the recovering adult hemiplegic Patients are encouraged to think about the movement and to gain control Brunnstrom also uses associated reactions and synergies A synergy is a total flexion or extension movement of a joint or limb

Brunnstrom’s 6 Stages of Recovery Flaccidity, no voluntary movement Synergies or minimal voluntary movement Synergies performed voluntarily Some deviation from synergy Independent or isolated movement Individual joint movement nearly normal with minimal spasticity

Proprioceptive Neuromuscular Facilitation (PNF) Developed by Herman Kabat, PhD, MD and modified by many contributors since the ’40s Uses diagonal & spiraling patterns of movement Guides thinking about the sequence of normal development Eleven basic principles (see Cole, p. 242) Uses two diagonal patterns crossing the mid-line for each major body part, often incorporating verbal commands.

Carr & Shepherd’s Motor Relearning Programme (for persons with stroke) Contemporary approach (1990s) Uses dynamical systems model of motor control Emphasize interaction between performer and environment Does not accept the hierarchical sequence of motor relearning proposed by other theorists Like other theorists, Carr & Shepherd discourage the early use of compensatory strategies

Carr & Shepherd, cont. Clients taught to avoid abnormal compensation for weak muscles Treatment techniques based on extensive study of how normal movement occurs during functional tasks Acknowledge critical role of cognition in motor learning Movement patterns practiced in context of tasks, rather than exercises

Carr & Shepherd, 7 Categories of Functional Daily Activities Upper limb function Orofacial function Sitting up over the side of the bed Balanced sitting Standing up & sitting down Balanced standing Walking

Function and Dysfunction Function assumes the ability to plan and execute normal voluntary movement Dysfunction is viewed as neurophysiologically based; CNS deficits result in abnormal muscle tone and lack of voluntary purposeful movement Each theorist has a separate way to measure the extent of dysfunction

Change Changes in motor control are physiologically induced. Engagement in activity can produce physiological change leading to motor control Individuals relearn movement patterns in a predictable developmental sequence Theorists differ in the use of early reflexes to produce movement Handling, sensory stimulation, and manipulation of affected muscles can facilitate motor relearning

Assessment and Treatment Specific to each theorist These “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.

Transition 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.

Task Focused Approach: Trombly Occupational Functioning Model – introduced in 1995 Descending hierarchy of tasks & roles Goal is to develop competency & self-esteem Context & environment surround and -permeate all levels of the hierarchy When clients have mastered the foundation capacities, they move on to task-focused interventions (individual or group) Trombly calls this “occupation as end”

Task Focused Approach, cont. Five general principles: 1. Client centered focus 2. Occupation based focus 3. Person & Environment – enablers/barriers 4. Practice & Feedback - encoding 5. General treatment goals – role fulfillment, problem-solving skills re: best way to accomplish valued tasks

Dynamical Systems Theory & Trombly Applied to physical disabilities, this theory combines reflexive and voluntary motor control CNS 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.

Assumptions: 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

The End Next time: Motor Learning Frame of Reference in OT