Clinical Theories Motor Control (Missy)

Question 1

What neurologic rehabilitation model does the reflex motor control model follow?

Answer 1

1. neurotherapeutic facilitation

2. Contemporary task-oriented

Question 2

What neurologic rehabilitation model does the hierarchical motor control model follow?

Answer 2

1. neurotherapeutic facilitation

2. Contemporary task-oriented

Question 3

What neurologic rehabilitation model does the systems motor control model follow?

Answer 3

Contemporary task-oriented

Question 4

What neurologic rehabilitation model is NOT addressed by any of the motor control theories?

Answer 4

muscle reeducation

Question 5

What are the major principles of the muscle reeducation approach?

Answer 5

1. Control of individual m.s
2. No irradiation: Irradiation = ability of the m. that’s performing the action to generate more attention by being innervated by the surrounding m. contractions
3. Development of volitional control (conscious control)
4. Relies heavily on proprioception
5. Avoid secondary complications
6. Provide orthopedic support
7. Teach functional activities
8. Repetition –> Precision –> Speed –> Strength: a lot of rep, then start to move faster, then strengthen
   - first used on Polio (LMN), tried on UMN lesion and ineffective

Question 6

what are the limitations to the muscle re-education approach?

Answer 6

1. Cannot isolate m. actions in UMNL (abnormal patterns)
2. CNS plasticity is not accounted for
   - True UMN Lesions: essentially, doesn’t work well b/c most of these pts have difficulty isolating the m.; though does work for some
   - We don’t really use

Question 7

What are the assumptions we make in the neurotherapeutic facilitation approach?

Answer 7

1. Based on assumptions from both reflex and hierarchical theories of motor control
2. Abnormal mvmnts are from a disruption of normal reflex mechanisms
3. Control movement via Top-down regulation of chains of reflexes; occurs proximal to distal; Occurs head to toe
4. CNS is in charge and control has to be gained in the CNS
5. Brain controls movement not individual m.’s
6. Recovery is predictable

Question 8

What are the goals for neurotherapeutic facilitation approach?

Answer 8

1. Emphasis on sensory information that stimulates and drives normal movement patterns (facilitation and inhibition)
2. break up abnormal synergies
3. inhibit abnormal tone and primitive reflexes; Inhibition of primitive reflexes does not release normal movement
   - Pt is more passive w/these various techniques
   - Abnormal movements = a direct result of the lesion, rather than a response to the injury
   - Recovery of Fxn: can’t occur unless Higher Levels (cortex) regain control of Lower Centers (mid-brain and SC)

Question 9

What are the benefits of the neurotherapeutic facilitation approach?

Answer 9

1. Fxn’l skills will automatically return when abnormal movement patterns are inhibited and normal movement patterns are facilitated
2. Repetition of normal movement patterns will automatically transfer to fxn’l tasks
   - limitation = no consideration for fxn’l environment; need to consider what they can’t do and what it looks like when they leave the clinic

Question 10

What are the different neurotherapeutic facilitation approaches?

Answer 10

1. Brunnstrom Approach: Signe Brunnstrom (1966)
2. Rood Approach: Margaret Rood (1967)
3. Bobath Approach (NDT): Karl and Berta Bobath (1975)
4. PNF: Kabat and Knott (1954) and Voss et al (1985)
5. Sensory Integration PT: Jean Ayres (1972)

Question 11

Synergies occur at the SC level as the result of the hierarchal organization of the CNS; Designed to promote recovery in pts w/stroke; Pt’s relearn movement control through structured activities that promote normal function; Have pt use the synergies they have first, then move into more functional patterns of movement

Answer 11

Brunnstrom approach

• Controversial: primitive postural reflexes used to elicit voluntary movement to create overflow, to recruit involved musculature - synergy is obligatory in itself.. so how can it become voluntary?
• limitations to fxn’l and normal gait

Question 12

What is the flexion synergy of the UE?

Answer 12

• Scapular retraction/ elevation
• Shoulder abduction/ ER
• elbow flexion*/ supination
• wrist and finger flexion

Question 13

What is the extension synergy of the UE?

Answer 13

• Scapular protraction
• Shoulder adduction*/ IR
• elbow extension/ pronation*
• wrist and finger flexion

Question 14

What is the flexion synergy of the LE?

Answer 14

• Hip flexion*/ abduction/ ER
• Knee flexion
• Ankle DF/ Inv
• Toe DF

Question 15

What is the extension synergy of the LE?

Answer 15

• Hip extension/ adduction*/ IR
• Knee extension*
• Ankle PF*/ Inv
• Toe PF

Question 16

What are the Brunnstrom stages of motor recovery in stroke?

Answer 16

I: Flaccidity
II: Synergies, Some Spasticity - Minimal voluntary movements (spasticity and synergies start to develop)
III: Marked Spasticity - Voluntary control starts to develop (spasticity peaks)
IV: Out of Synergy, Less Spasticity - Some movement patterns out of the synergy begin (spasticity decreases)
V: Selective Control of Movement - More difficult movement combinations are learned
VI: Isolated/Coordinated Movement - Disappearance of spasticity; coordination becomes normal
- pt can stop at any of these stages and move to the next stage; may be linked to amnt of brain damage

Question 17

What’s the big takeaway from the Brunstrom approach?

Answer 17

1. Where synergy patterns came from
2. Idea of stages of motor recovery
3. Where you see spasticity and synergies peak

Question 18

Focus of approach is on functional sequence (seen in normal infant development); Approach developed stages for motor control as far as transitional mobility; hands on contrived techniques came from this approach

Answer 18

Rood approach

Question 19

What are the stages of motor control in the rood approach?

Answer 19

1. Transitional Mobility - moving from one position to another
2. Static Postural Control (stability) - can pt maintain position w/a fixed BOS and body not in motion
3. Dynamic Postural Control (controlled movement) - moving in and out of that position (not from one position to another though)
4. Skill - highest level of motor behavior – can pt consistently perform these and can it carry over to function?
   • Example:
5. Transition to Quadruped from Sitting
6. Maintain Quadruped (stability)
7. Forward UE Reach in Quadruped (dynamic) - Shift weight, etc
8. Creeping (functional skill – moving forward in that position)

Question 20

Uses sensory stimulation to accomplish facilitation or inhibition to get desired movement; approach is focused on NMJ

Answer 20

Contrived techniques of the Rood approach

- m spindles (facilitation), GTO (inhibition)

Question 21

Approach:
Dysfunction = Abnormal postural reflexes; Loss of higher level postural reactions
Approach put pts in reflex-inhibiting or tone-inhibiting postures to get Normal upright posture and Development sequence positions (next slide)
- Very hands-on approach (“these PT’s good w/their hands”)
- Concept: How do you facilitate normal movement?

Answer 21

Bobath approach: NDT

Question 22

What is the developmental sequence of the Bobath approach?

Answer 22

1. Rolling
2. Prone on elbows
3. Prone on hands
4. Hooklying
5. Bridging - Hooklying, bridging good for gait b/c working all those m.s
6. Quadruped
7. Sitting
8. Tall kneeling – both knees on surface
9. Half kneeling – one on surface, other leg foot on surface and hip flexed
10. Modified Plantigrade - Having both your hands on something
11. Standing
12. Walking

Question 23

What are the proximal points of control when doing NDT? Distal points?

Answer 23

• Proximal: Head, spine, shoulders, pelvis
• Distal: Toes and ankles, fingers and wrists
• start proximally, as pt gains more control, move distally

Question 24

The goal of the bobath approach is to carry over to function and environment. how is this achieved?

Answer 24

1. Working out of reflexes
2. Varying activity level according to the level of difficulty the pt can handle
3. Varying the context in which the activity occurs
4. Carry over into function (most recent addition to this approach)

Question 25

What are the basic concepts/ ideas of the Bobath approach?

Answer 25

1. Cannot superimpose normal movement on abnormal tone
2. WB before NWB – why?
   - Ex: putting wt through the arms (quad, standing, sitting w/arms to the side)
   - Reasoning: helps if there is a lot of tone or spasticity, you can get prolonged stretch in a WB position
   - This approach would say work on that first before going to NWB activities
3. Slow to fast
   - Ex: moving/out of positions, providing resistance w/your hands in diff positions
4. Working Proximal to Distal
5. Isometric –> Eccentric –> Concentric
6. Aim for the highest LOF
   - Clinical Example: Pt w/more severe impairments – getting them in a more secure position (sitting, standing if safe) to assist w/increasing alertness of pt; Some pt’s participate more/less than others – helps keep pt more engaged

Question 26

What are the goals of NDT?

Answer 26

1. Inhibit abnormal tone/ spasticity
2. Facilitate/ promote normal movement/ tone
3. Gain independent control
4. Apply to function

Question 27

Rotational and diagonal movement patterns of multiple joints; Used to improve motor control and facilitate maximal contraction; Use manual contacts to produce a motor response; Address specific problems – strength, lack of stability, flexibility, coordination

Answer 27

Proprioceptive Neuromuscular Facilitation (PNF)

- Controversy is that we move in many different patterns, not just the PNF patterns

Question 28

Goal-directed functional tasks instead of focusing on m.’s – pt goes through this, and trying to get them to carry it over to function; Pt. is active in problem solving for efficient movement; Maintains focus on active learning; PT is aimed toward helping pts learn a variety of techniques in order to complete the task; Environment: Practicing the task in a closed controlled environment, then in open environments; Less hands on techniques; Focusing more on contrived techniques

Answer 28

Task oriented approach
- Result of the systems theory of motor control = Control of movement relies on goal-directed, functional tasks instead of a focus on m.’s or movement patterns

Question 29

What assumptions are made by the task oriented approach?

Answer 29

1. Abnormal movements result from impairments in one or more systems controlling behavior
2. Observed movements are a result of both the injury AND the efforts of the remaining systems to compensate for the injury and remain functional
3. Compensatory strategies may not be optimal but can be functional - Balance between do we teach these or still try to rehab?
4. Use the uninvolved side to compensate for the injury
5. Substitution
6. Adaptation