Clinical Theories Motor Control (Missy) Flashcards
What neurologic rehabilitation model does the reflex motor control model follow?
- neurotherapeutic facilitation
2. Contemporary task-oriented
What neurologic rehabilitation model does the hierarchical motor control model follow?
- neurotherapeutic facilitation
2. Contemporary task-oriented
What neurologic rehabilitation model does the systems motor control model follow?
Contemporary task-oriented
What neurologic rehabilitation model is NOT addressed by any of the motor control theories?
muscle reeducation
What are the major principles of the muscle reeducation approach?
- Control of individual m.s
- No irradiation: Irradiation = ability of the m. that’s performing the action to generate more attention by being innervated by the surrounding m. contractions
- Development of volitional control (conscious control)
- Relies heavily on proprioception
- Avoid secondary complications
- Provide orthopedic support
- Teach functional activities
- 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
what are the limitations to the muscle re-education approach?
- Cannot isolate m. actions in UMNL (abnormal patterns)
- 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
What are the assumptions we make in the neurotherapeutic facilitation approach?
- Based on assumptions from both reflex and hierarchical theories of motor control
- Abnormal mvmnts are from a disruption of normal reflex mechanisms
- Control movement via Top-down regulation of chains of reflexes; occurs proximal to distal; Occurs head to toe
- CNS is in charge and control has to be gained in the CNS
- Brain controls movement not individual m.’s
- Recovery is predictable
What are the goals for neurotherapeutic facilitation approach?
- Emphasis on sensory information that stimulates and drives normal movement patterns (facilitation and inhibition)
- break up abnormal synergies
- 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)
What are the benefits of the neurotherapeutic facilitation approach?
- Fxn’l skills will automatically return when abnormal movement patterns are inhibited and normal movement patterns are facilitated
- 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
What are the different neurotherapeutic facilitation approaches?
- Brunnstrom Approach: Signe Brunnstrom (1966)
- Rood Approach: Margaret Rood (1967)
- Bobath Approach (NDT): Karl and Berta Bobath (1975)
- PNF: Kabat and Knott (1954) and Voss et al (1985)
- Sensory Integration PT: Jean Ayres (1972)
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
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
What is the flexion synergy of the UE?
- Scapular retraction/ elevation
- Shoulder abduction/ ER
- elbow flexion*/ supination
- wrist and finger flexion
What is the extension synergy of the UE?
- Scapular protraction
- Shoulder adduction*/ IR
- elbow extension/ pronation*
- wrist and finger flexion
What is the flexion synergy of the LE?
- Hip flexion*/ abduction/ ER
- Knee flexion
- Ankle DF/ Inv
- Toe DF
What is the extension synergy of the LE?
- Hip extension/ adduction*/ IR
- Knee extension*
- Ankle PF*/ Inv
- Toe PF
What are the Brunnstrom stages of motor recovery in stroke?
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
What’s the big takeaway from the Brunstrom approach?
- Where synergy patterns came from
- Idea of stages of motor recovery
- Where you see spasticity and synergies peak
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
Rood approach
What are the stages of motor control in the rood approach?
- Transitional Mobility - moving from one position to another
- Static Postural Control (stability) - can pt maintain position w/a fixed BOS and body not in motion
- Dynamic Postural Control (controlled movement) - moving in and out of that position (not from one position to another though)
- Skill - highest level of motor behavior – can pt consistently perform these and can it carry over to function?
• Example: - Transition to Quadruped from Sitting
- Maintain Quadruped (stability)
- Forward UE Reach in Quadruped (dynamic) - Shift weight, etc
- Creeping (functional skill – moving forward in that position)
Uses sensory stimulation to accomplish facilitation or inhibition to get desired movement; approach is focused on NMJ
Contrived techniques of the Rood approach
- m spindles (facilitation), GTO (inhibition)
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?
Bobath approach: NDT
What is the developmental sequence of the Bobath approach?
- Rolling
- Prone on elbows
- Prone on hands
- Hooklying
- Bridging - Hooklying, bridging good for gait b/c working all those m.s
- Quadruped
- Sitting
- Tall kneeling – both knees on surface
- Half kneeling – one on surface, other leg foot on surface and hip flexed
- Modified Plantigrade - Having both your hands on something
- Standing
- Walking
What are the proximal points of control when doing NDT? Distal points?
- Proximal: Head, spine, shoulders, pelvis
- Distal: Toes and ankles, fingers and wrists
- start proximally, as pt gains more control, move distally
The goal of the bobath approach is to carry over to function and environment. how is this achieved?
- Working out of reflexes
- Varying activity level according to the level of difficulty the pt can handle
- Varying the context in which the activity occurs
- Carry over into function (most recent addition to this approach)
What are the basic concepts/ ideas of the Bobath approach?
- Cannot superimpose normal movement on abnormal tone
- 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 - Slow to fast
- Ex: moving/out of positions, providing resistance w/your hands in diff positions - Working Proximal to Distal
- Isometric –> Eccentric –> Concentric
- 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
What are the goals of NDT?
- Inhibit abnormal tone/ spasticity
- Facilitate/ promote normal movement/ tone
- Gain independent control
- Apply to function
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
Proprioceptive Neuromuscular Facilitation (PNF)
- Controversy is that we move in many different patterns, not just the PNF patterns
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
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
What assumptions are made by the task oriented approach?
- Abnormal movements result from impairments in one or more systems controlling behavior
- Observed movements are a result of both the injury AND the efforts of the remaining systems to compensate for the injury and remain functional
- Compensatory strategies may not be optimal but can be functional - Balance between do we teach these or still try to rehab?
- Use the uninvolved side to compensate for the injury
- Substitution
- Adaptation
