1. The Use of Meaningful Activity in Neurological Rehabilitation
An Occupational Therapy
Approach to Motor Control and Motor Learning
Heiko Lorenzen, Bc. of Health in OT
Döpfer School for Occupational Therapy
Cologne, Germany

2. Overview Introduction to Occupational Therapy Introduction to CIMT
Application of CIMT in Occupational Therapy
Case Example „Musician“
Discussion
Learned non-use: a phenomenon you might be familiar with if you work in neurological rehabilitation

3. Basic Assumptions in Occupational Therapy
„Occupation“ refers to all meaningful activities that make up an individual life
The engagement in occupations is associated with participation, health, well-being and quality of life
Occupational therapists aim to engage their patients in activities that are meaningful to them in order to facilitate participation

4. Occupational Therapy in Motor Control and Motor Learning
Motor control is the ability to fixate the body and to move the body (Gilmore & Spaulding 2001)
Motor learning refers to changes in movement behavior as a result of practice or experience (Gilmore & Spaulding 2001)
Occupational therapists make use of three different interventions in motor learning (AOTA 2008):
Preparatory methods
Use of purposeful (therapeutic) activities
Engagement in desired occupations
Fixate the body = postural control
I am going to present a therapy approach where all three stages build on each other and lead to effective motor learning after a stroke.

5. Introduction to the Constraint Induced Movement Therapy (CIMT)
CIMT is based on the learned disuse after the onset of neurological disorder

6. Development of learned disuse
(figure adapted from: brainworksrehab.com)
Injury / Stroke
Compensatory behavior
Less effective behavior strengthened
Positively reinforced
Unsuccessful motor attempts
Feelings of failure
Those who have treated stroke victims have known for a long time now that one of the biggest problems in recovery is “learned non-use.” This means that a person, because of a degree of paralysis, has learned not to use neurons and their associations that are intact and good to go, but aren’t being used and have withered. This is the biggest obstacle to the recovery from paralysis.
Behavior suppressed
Learned disuse of limb

7. Introduction to CIMT
The downward spiral of disuse leads to greater disability of the affected arm and hand (Wolf et al 2006)
Use it or lose it!
Affected limb needs to be „forced“ into activity
Typical CIMT program: 3 hours/day of therapy, 5 days/week for 4 weeks – 6 hours at home (Earley et al 2010)

8. Introduction to CIMT
Criteria for application of the CIMT method (Wolf et al 2006):
≥6 months post-stroke
No or mild cognitive impairments (MMSE ≥24)
Ambulatory without the use of assistive devices
≥45° shoulder flexion and abduction
45° external rotation at the shoulder
Full elbow extension
45° forearm supination and pronation
≥ 5° wrist extension
5° digital exension (specifically thumb, index + middle finger)
Ability to grasp and release a washcloth 3 times within 1 min.

9. Application of CIMT in Occupational Therapy
Application of preparatory methods
stretching of the affected upper extremity
joint mobilization
training the strength of the hand
taktile stimulation
Use of meaningful activity is a relatively new approach of CIMT and I mainly refer to a study conducted by Early et al (2010)

10. Application of CIMT in Occupational Therapy
Use of purposeful (therapeutic) activities
practicing to unscrew a bottle of water
practicing to use cutlery
practicing to grasp and move a table tennis racket
practicing the typical movements for playing a certain musical instrument
practicing to use a jig saw

11. Application of CIMT in Occupational Therapy
The chosen preparatory methods and purposeful activities need to match the demands of the desired occupation!

12. Application of CIMT in Occupational Therapy
Performance of meaningful activities (ideally within the own context)
using cutlery at home or in a restaurant
playing table tennis with a friend or in a club
playing the musical instrument
doing craftswork at home or at work

13. Case Example „Musician“ from Earley et al (2010)
52 year old woman, 4 years after left- hemispheric stroke
Decreased gait functions
Decreased strength and decreased use of the affected right upper extremity
Difficultuies in performing several basic ADL´s

14. Case Example „Musician“
Preparatory methods
Manual stretching of anatomic structures
Progressive resistive exercises
Weight bearing and joint compression
Performance of purposeful activities
Simulation of violin playing
Engagement in cooking activities
Arranging a photo album

15. Case Example „Musician“
Engagement in a variety of meaningful activities at home during 5 – 6 hours daily
After functional improvements and increased self-confidence this included also practicing to play her violin

16. Case Example „Musician“
Some of the results:
50% increase of grip strength and pinch strengh
Improvement of fine motor hand use measured with the Nine-Hole-Peg Test (intake score 28 s / discharge score 21 s)
4 years after the stroke and 1 month after the CIMT intervention the „musician“ returned to her role of playing the violin in a community symphony orchestra

17. Literature
American Occupational Therapy Association (AOTA) (2008) Occupational Therapy Practice Framework: Domain and Process (2nd ed.). American Journal of Occupational Therapy, 62,
Earley D, Herlache E, Skelton DR (2010) Use of occupations and activities in a modified constraint-induced movement therapy program: a musician´s triumph over chronic hemiparesis from stroke. American Journal of Occupational Therapy, 64,
Gilmore PE, Spaulding SJ (2001) Motor control and motor learning: implications for treatment of individuals post stroke. Physical & Occupational Therapy in Geriatrics, 20(1), 1-15
Townsend E, Polatajko H eds.(2007) Enabling occupation II: advancing an occupational therapy vision for health, well-being and justice through occupation. Ottawa: CAOT
Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D et al. (2006) Effect of constraint-induced movement therapy on upper extremity functions 3 to 9 months after stroke. JAMA, 296,

18. Thank you for your attention!
Heiko Lorenzen
Referent and Lecturer for Occupational Therapy
Referent for ICF in Neurological Rehabilitation
Referent for Fatigue Management
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