PTP 512 Neuroscience in Physical Therapy Motor Control: Issues and Theories Min H. Huang, PT, PhD, NCS

Objectives Identify individual, task, and environmental movement constraints Compare and contrast contemporary motor control theories Compare and contrast neurologic rehabilitation approaches with respect to assumptions underlying normal and abnormal movement control, recovery of function, and clinical practices.

Reflection…… What is a theory? What is the value of theory to clinical practice? Reflection. Therapists in neurology base their assumptions about intervention on different philosophical perspectives, which determine how patients are assessed and treated.

How does movement emerge? Discussion. How does movement emerge?

Movement Emerges from the Interaction between Task, Individual, Environment Individual: e.g. 3 year old vs college student vs 80 year old frail individual; motivation, emotion, cognition….etc. Task: e.g. climbing stairs not carrying something vs carrying a box Environment: e.g. icy vs. dry; light vs. dark; shape of the object Give one example.

Environmental Constraints on Movement Regulatory Essential elements that determine the movement, e.g. chair height Non-regulatory Feature that are not essential but may affect the performance, e.g. background noise Give one example.

Individual Constraints on Movement Action “goal-directed” movements Perception Sensory integration Cognition Mental functions underlying the establishment of a goal Action: “degree of freedom problem” - unlimited ways to achieve a goal Perception: ice vs. dry Cognition: judgement, intention. Climb the stairs vs. grass

Task Constraints on Movement The nature of tasks determine the movement required. Classify tasks by Functional category, e.g. gait, bed-mobility, transfer Discrete (definite ending) vs. continuous (no end point), e.g. grasping vs. walking Stable vs. mobility, e.g. sitting vs. walking

Gentile’s Taxonomy for Task Classification Give examples. M: manipulation, Variability: inter-trial variability + present, – absent

Gentile’s Taxonomy for Task Classification   c Body Stability Body Transport – M + M Closed predictable environment – Variability + Variability Open unpredictable environment Give examples. M: manipulation, Variability: inter-trial variability + present, – absent

Motor control theories – a tour through history

Discuss at your table group What did the therapist do? What did the patient do? How did the patient perform the tasks? http://www.youtube.com/watch?v=mCiBehv_FOw&feature=related http://www.youtube.com/watch?v=r5o5S-9zGpE Discussion.

Reflex Theory Reflexes are the building blocks of complex motor behaviors or movements Reflex is the fundamental building block of movements. Sensory stimulus is essential to produce a movement.

Reflex Theory Sir Charles Sherrington, the integrative action of the nervous system (1906) Reflex chaining: complex movements are a sequence of reflexes elicited together This is based on the observation that monkeys were unable to their arm after resection of one side of dorsal root ganglia.  Therefore, sensory inputs must be essential in initiating movements. Note that only one side of the sensory input was removed. Sherrington’s 1906 monograph, published simultaneously in London, New Haven and New York, was based on a series of 10 endowed lectures delivered in 1904 at Yale College in New Haven, Connecticut, under the auspices of the Silliman Foundation.

Limitations of Reflex Theory Unable to explain Spontaneous and voluntary movements Movement can occur without a sensory stimulus Fast sequential movements, e.g. typing A single stimulus can trigger various responses (reflexes can be modulated) Novel movements can be carried out. Voluntary spontaneous movement does not require an outside stimulus to be initiated, unlike reflexes Movement can occur without a sensory stimulus Reflex theory was not supported by Dr. Edward Taub’s studies: deafferented monkeys were able to move the affected arm when the good arm was “constrained” in a sling  “constraint induced movement therapy” Sequences of movements occur too fast to allow for sensory stimuli from the preceding movement to trigger the next movement (e.g. typing) A single stimulus can result in a variety of movements Reflexes can be modulated according to the context Novel movements can be carried out by combing stimuli and response previously learned (e.g. playing piano)

Limitations of Reflex Theory Taub demonstrated that monkeys with bilateral deafferentation were able to move the arms. If with unilateral deafferentation, the monkey relearned moving the affected arm when the good arm was “constrained” in a sling. His findings lead to the constraint-induced movement therapy. Discussion. Stroke Rehabilitation: Constrained-Induced Movement Therapy http://www.youtube.com/watch?v=MMTh2hWvB2g Taub Therapy Clinic: Constrained-Induced Movement Therapy

Hierarchical Theory

Hierarchical Theory Higher centers are always in control of lower centers Higher centers inhibit the reflexes controlled by lower centers Reflexes controlled by lower centers are present only when higher centers are damaged Neuromaturational theory of development The brain determines infant behavior! Higher level controls over the level below it. Cortical association areas -> Primary motor cortex -> Spinal cord Assumption is that higher centers inhibit the reflexes controlled by the lower centers. Neuromaturational theory of development (Gesell, 1950’s) Normal motor development results from ↑ in corticalization of CNS Motor control emerges from reflexes that are organized at higher levels The brain determine infant behavior! Higher level controls over the level below it. For example, brain stem reflexes (which are related to head control, e.g. baby keeping the head up) emerge before midbrain reflexes (which are related to control of body segments, e.g. baby rolling over). This theory ignores other factors, such as musculoskeletal changes during development

Hierarchical Theory

Hierarchical Theory Based on the observation of motor development in children and adults A child’s capacity to sit, stand, and walk is related to the progressive emergence and disappearance of reflexes Brain stem reflexes (associated with head control) emerge before midbrain reflexes (associated with trunk control) For example, brain stem reflexes (which are related to head control, e.g. baby keeping the head up) emerge before midbrain reflexes (which are related to control of body segments, e.g. baby rolling over).

Current Concepts Related to Hierarchical Theory Each level of the motor system can act on other levels Reflexes are one of many processes of motor control Brunnstrom, 1970: “When the influence of higher centers if temporarily or permanently interfered with normal reflexes become exaggerated and so called pathological reflexes appear” -pedal: of or relating to the foot Apedal: without Quadrupedal: on all 4 limbs Bipedal: on 2 limbs The walking or stepping reflex is present at birth; though infants this young can not support their own weight, when the soles of their feet touch a flat surface they will attempt to 'walk' by placing one foot in front of the other. This reflex disappears at 6 weeks as an automatic response and reappears as a voluntary behavior at around eight months to a year old. Thelen’s well-known fish tank experiment demonstrates her assertion that behavior emerges in movement. Newborn infants exhibit an early stepping reflex. When supported under the armpits with feet lowered to a table, a baby will take “steps.” This only lasts for a month or two. After that, it was thought that the reflex becomes inhibited by other parts of the brain as the baby matures. But was it really inhibited? Anyone who’s ever been around babies knows they kick—a lot. They kick when they’re happy, when they’re hungry, when they’re excited, when they’re mad. Lay a young baby down on a blanket or put her in an infant seat, and that baby will soon be flailing her little legs.Thelen noticed that all that kicking looked like stepping in a lying-down position. She wondered, How could the maturing brain exert an inhibitory influence in one posture but not in another? Thelen considered what else was happening with the baby’s body. An infant’s constant eating and sleeping leads to some very chubby thighs. Does gravity make it hard for her to lift her legs once she starts putting on baby fat? To test this hypothesis, Thelen put 2-month-olds in torso-deep warm water in a large fish tank. Since heavy limbs would be buoyant underwater, she waited to see if the stepping resumed. “As predicted, our wet and slippery subjects all stepped like crazy,” says Thelen. “Before then, no one had thought about what the nervous system was moving—a pair of big, fat legs!” Thelen has experimented with treadmills, too, which also restored the lost stepping reflex. Held upright and placed on a special tabletop treadmill, babies were able to produce coordinated and alternating steps. Is this because the brain has finally matured enough to allow the baby to “walk”? Not in Thelen’s view. According to her dynamic systems theory, the baby is problem-solving, interacting with the treadmill—and the movement of the legs emerges.

Clinical Implications of Hierarchical Theory “When the influence of higher centers is temporarily or permanently interfered with, normal reflexes become exaggerated and so called pathological reflexes appear” …Brunnstrom, 1970 “The release of motor responses integrated at lower levels from restraining, influences of higher center, especially that of the cortex, leads to abnormal postural reflex activity”…Bobath, 1965 Brunnstrom, 1970: “When the influence of higher centers if temporarily or permanently interfered with normal reflexes become exaggerated and so called pathological reflexes appear” -pedal: of or relating to the foot Apedal: without Quadrupedal: on all 4 limbs Bipedal: on 2 limbs The walking or stepping reflex is present at birth; though infants this young can not support their own weight, when the soles of their feet touch a flat surface they will attempt to 'walk' by placing one foot in front of the other. This reflex disappears at 6 weeks as an automatic response and reappears as a voluntary behavior at around eight months to a year old. Thelen’s well-known fish tank experiment demonstrates her assertion that behavior emerges in movement. Newborn infants exhibit an early stepping reflex. When supported under the armpits with feet lowered to a table, a baby will take “steps.” This only lasts for a month or two. After that, it was thought that the reflex becomes inhibited by other parts of the brain as the baby matures. But was it really inhibited? Anyone who’s ever been around babies knows they kick—a lot. They kick when they’re happy, when they’re hungry, when they’re excited, when they’re mad. Lay a young baby down on a blanket or put her in an infant seat, and that baby will soon be flailing her little legs.Thelen noticed that all that kicking looked like stepping in a lying-down position. She wondered, How could the maturing brain exert an inhibitory influence in one posture but not in another? Thelen considered what else was happening with the baby’s body. An infant’s constant eating and sleeping leads to some very chubby thighs. Does gravity make it hard for her to lift her legs once she starts putting on baby fat? To test this hypothesis, Thelen put 2-month-olds in torso-deep warm water in a large fish tank. Since heavy limbs would be buoyant underwater, she waited to see if the stepping resumed. “As predicted, our wet and slippery subjects all stepped like crazy,” says Thelen. “Before then, no one had thought about what the nervous system was moving—a pair of big, fat legs!” Thelen has experimented with treadmills, too, which also restored the lost stepping reflex. Held upright and placed on a special tabletop treadmill, babies were able to produce coordinated and alternating steps. Is this because the brain has finally matured enough to allow the baby to “walk”? Not in Thelen’s view. According to her dynamic systems theory, the baby is problem-solving, interacting with the treadmill—and the movement of the legs emerges.

Limitations of Hierarchical Theory Environment and other non-CNS factors can affect movement, e.g. Thelen’s experiments showed that baby’s stepping response re- emerges with body weight support Normal adults exhibit lower level reflexes, e.g. flexor withdrawal Discussion. The walking or stepping reflex is present at birth; though infants this young can not support their own weight, when the soles of their feet touch a flat surface they will attempt to 'walk' by placing one foot in front of the other. This reflex disappears at 6 weeks as an automatic response and reappears as a voluntary behavior at around eight months to a year old. Thelen’s well-known fish tank experiment demonstrates her assertion that behavior emerges in movement. Newborn infants exhibit an early stepping reflex. When supported under the armpits with feet lowered to a table, a baby will take “steps.” This only lasts for a month or two. After that, it was thought that the reflex becomes inhibited by other parts of the brain as the baby matures. But was it really inhibited? Anyone who’s ever been around babies knows they kick—a lot. They kick when they’re happy, when they’re hungry, when they’re excited, when they’re mad. Lay a young baby down on a blanket or put her in an infant seat, and that baby will soon be flailing her little legs. Thelen noticed that all that kicking looked like stepping in a lying-down position. She wondered, How could the maturing brain exert an inhibitory influence in one posture but not in another? Thelen considered what else was happening with the baby’s body. An infant’s constant eating and sleeping leads to some very chubby thighs. Does gravity make it hard for her to lift her legs once she starts putting on baby fat? To test this hypothesis, Thelen put 2-month-olds in torso-deep warm water in a large fish tank. Since heavy limbs would be buoyant underwater, she waited to see if the stepping resumed. “As predicted, our wet and slippery subjects all stepped like crazy,” says Thelen. “Before then, no one had thought about what the nervous system was moving—a pair of big, fat legs!” Thelen has experimented with treadmills, too, which also restored the lost stepping reflex. Held upright and placed on a special tabletop treadmill, babies were able to produce coordinated and alternating steps. Is this because the brain has finally matured enough to allow the baby to “walk”? Not in Thelen’s view. According to her dynamic systems theory, the baby is problem-solving, interacting with the treadmill—and the movement of the legs emerges. Body Sense. Scientific America Frontier. (1:00-2:40, 5:10-7:30) http://vsx.onstreammedia.com/vsx/pbssaf/search/PBSPlayer?assetId=68932&ccstart=235620&pt=0&preview=undefined&entire=yes

Motor Programming Theories Concept of a central motor pattern or motor program Many studies found that movement is possible even in the absence of stimuli or sensory input Sensory inputs are not required to produce a movement but they are important in adapting and modulating the movement NGrillner’s spinal cat studies, 1981 Neuronal networks in the spinal cord can be activated to produce a locomotor rhythm in the absence of sensory inputs and descending control from the cortex Dimitrijevic et al. (1980’s): epidural spinal cord stimulation can elicit step-like EMG activity and locomotor synergies in paraplegic subjects with chronic SCI Spinal cat: cat with spinal cord transection CPGs can be activated by stimuli applied to the paws, neurotransmitters to the transected spinal cord, electrical stimulation applied to the spinal cord, or brainstem locomotion center (mesecephalic locomotor center) Review article: Evidence for a Spinal Central Pattern Generator in Humans MILAN R. DIMITRIJEVIC1,3,*, YURI GERASIMENKO2, MICHAELA M. PINTER3 http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1998.tb09062.x/abstract Abstract: Non-patterned electrical stimulation of the posterior structures of the lumbar spinal cord in subjects with complete, long-standing spinal cord injury, can induce patterned, locomotor-like activity. We show that epidural spinal cord stimulation can elicit step-like EMG activity and locomotor synergies in paraplegic subjects. An electrical train of stimuli applied over the second lumbar segment with a frequency of 25 to 60 Hz and an amplitude of 5-9 V was effective in inducing rhythmic, alternating stance and swing phases of the lower limbs. This finding suggests that spinal circuitry in humans has the capability of generating locomotor-like activity even when isolated from brain control, and that externally controlled sustained electrical stimulation of the spinal cord can replace the tonic drive generated by the brain. http://jp.physoc.org/content/587/15/3795/F1.small.gif

General setup for studies of locomotion in cats with spinal lesions http://libproxy.umflint.edu:5185/doi/pdf/10.1146/annurev-neuro-061010-113746 With complete lesion of the spinal cord at T13, cats are positioned with their forelimbs standing on a platform fixed above the belt while the hindquarters are free to walk on the moving treadmill. With a partial lesion, the cat is free to walk with all four limbs on the treadmill. Rossignol, 2011

Central Pattern Generator (CPGs) F flexor motoneurons E extensor motoneurons DC dorsal columns DRG dorsal root ganglion CPGs can be activated by stimuli applied to the paws, neurotransmitters to the transected spinal cord, electrical stimulation applied to the spinal cord, or brainstem locomotion center (mesecephalic locomotor center) http://libproxy.umflint.edu:5185/doi/pdf/10.1146/annurev-neuro-061010-113746 General framework of locomotor control. This scheme shows a lumbar spinal segment (L3-L4) with gray and white matter. In the gray matter,. The specialized interneurons activate flexor (F) and extensor (E) motoneurons. Some interneurons are under the influence of the CPG and respond to various inputs in a phase-dependent manner. Other interneurons are outside this zone of influence but receive various inputs as well. Descending inputs and sensory afferents can reach different types of interneurons. The main descending pathways coursing through the dorsolateral funiculus (DLF) are the cortico- and rubrospinal tracts. The reticulo- and vestibulospinal tracts are found in the ventrolateral funiculus (VLF). Other pathways are defined mainly by the type of neurotransmitters released, such as norepinephrine (NE), serotonin (5-HT), glutamate (GLU), or local circuits releasing GABA or acetylcholine (Ach). Sensory afferents originate from muscle or skin and project to the spinal cord through mono-, di-, and polysynaptic pathways. Abbreviations: DC, dorsal columns; DRG, dorsal root ganglion. Grillner’s spinal cat studies, 1981 Neuronal networks in the spinal cord can be activated to produce a locomotor rhythm in the absence of sensory inputs and descending control from the cortex Dimitrijevic et al. (1980’s): epidural spinal cord stimulation can elicit step-like EMG activity and locomotor synergies in paraplegic subjects with chronic SCI Evidence for a Spinal Central Pattern Generator in Humans MILAN R. DIMITRIJEVIC1,3,*, YURI GERASIMENKO2, MICHAELA M. PINTER3 http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1998.tb09062.x/abstract Abstract: Non-patterned electrical stimulation of the posterior structures of the lumbar spinal cord in subjects with complete, long-standing spinal cord injury, can induce patterned, locomotor-like activity. We show that epidural spinal cord stimulation can elicit step-like EMG activity and locomotor synergies in paraplegic subjects. An electrical train of stimuli applied over the second lumbar segment with a frequency of 25 to 60 Hz and an amplitude of 5-9 V was effective in inducing rhythmic, alternating stance and swing phases of the lower limbs. This finding suggests that spinal circuitry in humans has the capability of generating locomotor-like activity even when isolated from brain control, and that externally controlled sustained electrical stimulation of the spinal cord can replace the tonic drive generated by the brain. http://jp.physoc.org/content/587/15/3795/F1.small.gif Rossignol, 2011

Evidence of a Motor Program: Central Pattern Generator (CPGs) CPGs are spinal networks capable of generating bilateral rhythmic movements, such as swimming or walking, in the absence of descending and sensory inputs CPGs are network of interneurons that alternatively activate flexors and extensors on one side, and coordinate with CPGs on the other side http://libproxy.umflint.edu:5185/doi/pdf/10.1146/annurev-neuro-061010-113746 With complete lesion of the spinal cord at T13, cats are positioned with their forelimbs standing on a platform fixed above the belt while the hindquarters are free to walk on the moving treadmill. With a partial lesion, the cat is free to walk with all four limbs on the treadmill.

Motor Programming Theories Motor programs are Hardwired and stereotyped neural connections such as central pattern generators (CPGs) Abstract rules for generating movements at the higher level Motor program can be activated by sensory stimuli or by central processes

Motor Programming Theories Writing Sign your name with your dominant hand, then with your non-dominant hand. (Try it with your foot too!) Are there similarities in the signatures written using different body parts?

Limitations of Motor Programming Theories Does not consider that the nervous system must deal with both musculoskeletal and environmental variables to produce movements e.g. identical neural commands to elbow flexors can produce different movements depending on the initial position of the arm and the force of gravity Try shaking your hand at the wrist on a horizontal plane and then a vertical plane.

Clinical Implications of Motor Programming Theories Movement problems are caused by abnormal CPGs or higher level motor programs It is important to help patients relearn the correct rules for action Focus on retraining movements that are critical to a functional task, not just specific muscles in isolation

Systems Theory: Bernstein’s Degree of Freedom Problem How does the CNS select a solution from an infinite number of possibilities for a task? Solution Higher levels activate lower levels while lower levels activate synergies, i.e. groups of muscles that are constrained to act together as a unit The same central command can result in different movements. Conversely, different commands can produce the same movement. Bernstein's "degrees-of-freedom“ problem: How can an organism with thousands of muscles, billions of nerves, tens of billions of cells, and nearly infinite possible combinations of body segments and positions ever figure out how to get them all working toward a single smooth and efficient movement without invoking some clever "homunculus" who has the directions already stored?

Systems Theory: Bernstein’s Degree of Freedom Problem Viewed body as a mechanical system, involving the interaction between mass, external force (e.g. gravity), internal force “Coordination of movement is the process of mastering the redundant degrees of freedom of the moving organism” (Bernstein, 1967) Imagine lifting your arm to shoulder height and then relaxing your muscles. Then imagine shaking your hand vigorously just at the wrist. The actual movements produced— your arm drops in the first example and your lower and upper arm vibrate in the second—are not all controlled by your nervous system. As your body parts move, they generate inertial and centripetal forces and are subject to gravity. The same muscle contraction may have different consequences on your arm depending on the specific context in which the contractions occur.

Systems Theory: Latash’s Principle of Abundance Synergy is a task-specific covariation of elemental variables with the purpose to stabilize a performance variable, i.e. minimize errors of a performance variable Reaching: joint rotation angle stabilize hand position Grasping: individual finger force stabilize total grasp force Standing stability: postural muscle activation  stabilize COP Motor synergies are neural organizations of elemental variables that stabilize a performance variable over time.

Systems Theory: Latash’s Principle of Abundance A muscle belongs to more than one synergy. Within a synergy, each muscle has a unique weighting factor that specifies the level of activation of that muscle within that synergy. Synergies assure small variability of the performance variable while allowing relatively large variability of each elemental variable Synergies do not eliminate the degrees of freedom, but to ensure flexible and stable performance of a task. http://www.sph.umd.edu/KNES/faculty/jkshim/neuromechanics/publications/Papers/2005%20%5BMarin%20Drinov%20Academic%20Publishing%20House%5D%20Synergies%20that%20stabilize%20and%20destabilize%20action.pdf Mark L. Latash, Halla Olafsdottir, Jae Kun Shim, Vladimir M. Zatsiorsky (2005). Synergies that stabilize and destabilize action. In: Gantchev N. (Ed.) From Basic motor control to functional recovery – IV, pp. 19-25, Marin Drinov Academic Publishing House: Sofia, Bulgaria.

Postural perturbation study: each muscle may be activated to a different degree by each muscle synergy http://jn.physiology.org/content/93/1/609.full.pdf A: muscle synergy composition for the case where 4 synergies are chosen. Note that each muscle may be activated to a different degree by each muscle synergy. Percentages shown represent the percent total VAF accounted for by activation of each synergy. Ting, 2005

Dynamic Systems Theory: Principle of Self-Organization Movement emerges as a result of interacting elements. No needs for specific neural commands or motor programs. Variability of movement is normal. Optimal amount of variability allows for flexible, adaptive strategies to meet the environmental demand Control parameter is velocity in this case. Movements emerge when a critical change in one of the systems, i.e. a control parameter, reaches a critical value. Gait patterns are different from walk to trot to gallop (anyone who knows how to ride a horse here??? Does your horse change its gait patterns when it goes from slow to fast?)

Dynamic Systems Theory: Principle of Self-Organization Control parameter is velocity in this case. Movements emerge when a critical change in one of the systems, i.e. a control parameter, reaches a critical value. Gait patterns are different from walk to trot to gallop (horse in this case) A new movement emerges when a control parameter reaches a critical value

Limitation of Systems Theory Nervous system is fairly unimportant How do we apply mathematics and body mechanics to clinical practice? Used a lot of calculations which is not practicle in the clinic

Clinical Implications of Systems Theory Body is a mechanical system. Consider musculoskeletal factors underlying a patient’s movement problem Changes in movements may not necessarily result from neural changes, e.g. faster vs. slow gait, speed during sit to stand Encourage the patient to explore variable movements Muscle extensibility and joint mobility contribute to how the body moves. Think: How will joint contracture and muscle tightness affect the forces a muscle can generate? How do you position your patient to perform a sit to stand? Which is easier? “Toes under the knees” vs. “heels under the knees”? Manipulating control parameters (e.g. physical or dynamic characteristics) to help patients regain control of movements e.g. compare fast, slow gait and arm swing e.g. speed during sit to stand

Ecological Theory: Gibson’s Perception-Action Coupling Action is specific to the task goal and the environment Perceptual information of the environmental factors relevant to the task goal is necessary to guide the action Limitations: ↓ emphasis on nervous system Again, another rather abstract theory. However, finally they start to pay attention to “perception” and its link to “action”. Animals, including us, move around with a purpose. How we define this purpose depends on our perception of the world.

Clinical Implications of Ecological Theory Individual is an active explorer of the environment for learning Individual discovers multiple ways to solve movement problems in environment Fundamental to the play-based therapy for pediatric patients Again, another rather abstract theory. However, finally they start to pay attention to “perception” and its link to “action”. Animals, including us, move around with a purpose. How we define this purpose depends on our perception of the world. Baby Sense. Scientific America Frontier. (1:00-2:40, 5:10-7:30) http://vsx.onstreammedia.com/vsx/pbssaf/search/PBSPlayer?assetId=68932&ccstart=235620&pt=0&preview=undefined&entire=yes

Discuss at your table group What are the assumptions of movement control underling each of these treatment approaches? http://www.youtube.com/watch?v=mCiBehv_FOw&feature=related http://www.youtube.com/watch?v=r5o5S-9zGpE

Neurologic rehabilitation approaches

Motor control models Neurologic rehabilitation models Reflex Contemporary task-oriented Neurotherapeutic facilitation Muscle reeducation Hierarchical Systems Motor control models Neurologic rehabilitation models Nowadays NDT approach has changed a great deal. In essence, it is more like “motor learning and motor control”, instead of the NDT 20 years ago. However, continuing using the same name is sometimes confusing. Muscle reeducation Polio Reflex-based Neurofacilitation Approaches Brunnstrom, Bobath-Neurodevelopmental treatment (NDT), PNF Top-down control of movement (i.e. corticalization) Abnormal movement is a direct result of neural lesion Recovery requires higher centers regain control Inhibit abnormal movement patterns to facilitate return of motor skills Repetition of normal movement patterns will automatically transfer to functional tasks

Muscle Reeducation Change function at the level of muscle Vera Carter, a practitioner beginning her work with muscle treatment of polio patients in Australia in the early 1930’s http://www.hshsl.umaryland.edu/images/resources/historical/kendall/carter.jpg Kendall Historical Collection

Assumptions of Neurofacilitation Approaches Abnormal movement is a direct result of the neurologic lesion Inhibit abnormal movement patterns to facilitate the normal movement patterns will lead to the return of functional skills Repetition of normal movement patterns will automatically transfer to functional tasks Normal movement control requires top-down control, a process of “corticalization” Following a neurologic lesion, abnormal movement is caused by Disruption of normal reflex mechanisms Release of lower level reflexes Recovery of normal function requires higher centers regain control

Reflex- and Hierarchical Based Neurofacilitation Approaches Brunnstrom, Rood, Proprioceptive neuromuscular facilitation (PNF), Bobath’s neurodevelopmental treatment (NDT) Retraining motor control through “techniques” to facilitate and/or inhibit different movement patterns e.g. PNF UE D1 Flexion/Extension http://davisplus.fadavis.com/kisner/Chap ter06.cfm Nowadays NDT approach has changed a great deal. In essence, it is more like “motor learning and motor control”, instead of the NDT 20 years ago. However, continuing using the same name is sometimes confusing.

Task-Oriented Approach (motor control of motor learning approach) System approach has several different names with similar concept. This is the norm and what is in the practice guidelines nowadays. Patients practice in a variety of ways to accomplish the task goals, rather than practice movement patterns.

Task-Oriented Approach Movement is organized around a behavioral goal and is constrained by the environment Patients learn by actively attempting to solve the movement problem rather than by repetitively practicing normal patterns of movement. e.g. RIC constraint-induced movement therapy camp http://www.youtube.com/watch?v=NhLs h1SW4Ak Movements in patients with neurologic conditions emerge from the best mix of the systems remaining to participate.

Moving forward “….currently available evidence of dose– response relationships in motor learning, time-dependency of neuronal and functional recovery, and task specificity of treatment effects….…the lack of evidence as well as major changes over time in our understanding of underlying mechanisms about stroke recovery, which do not concur with the obsolete and constantly changing assumptions used to explain the Bobath Concept…”Kollen, 2009 http://stroke.ahajournals.org/content/40/4/e89.full.pdf+html Kollen BJ, Lennon S, Lyons B, et al. The Effectiveness of the Bobath Concept in Stroke Rehabilitation. Stroke. April 1, 2009 2009;40(4):e89-e97.