Sensorimotor Approaches (Stroke)

Question 1

Producer of All Movement

Answer 1

Firing of motor neurons located in the anterior horn of the spinal cord. Directly innervate skeletal muscles.

** Basal Ganglia and Cerebellum in brain are also involved with motor control, and lesions here are associated with movement disorders.

Question 2

4 Processes related to flow of information to control movement:

Answer 2

1) Motivation
2) Ideation
3) Programming
4) Execution

Question 3

Motivation/Emotive Component of Movement

Answer 3

• Function of limbic system

* Motivational urge from limbic system to ideation by cortical association areas (lobes)

Question 4

Conation

Answer 4

Connection of knowledge and affective behavior (ie: ideation of movement in cortical areas transferring to movement)
• Represents intentional, deliberate, and goal-directed aspect of behavior
• Relates to individual’s reason for motor performance.

Question 5

Programming Component of Movement

Answer 5

• Cortical areas program movement strategy (plan) to meet movement goals
• Also involves premotor areas, basal ganglia, cerebellum

Question 6

Motor Program

Answer 6

Procedure or spatiotemporal order of muscle activation needed for smooth/accurate motor performance.

Question 7

Execution Component of Movement

Answer 7

• Motor cortex, cerebellum and spinal cord
• Concerned with activation of spinal motor neurons and interneurons that generate goal-directed movement and necessary postural adjustments

Question 8

Order of Movement Creation in Brain

Answer 8

1) Limbic System (detects need) >
2) Cortical Association Areas (receive sensory input needed) >
3) Association Cortex + Basal Ganglia + Lateral Cerebellum + Premotor Cortex (motor program) >
4) Motor Cortex (conveys to brain/spinal cord) >
5) Cervical Spinal Neurons (activate precise movement/PNS) + Brainstem/Cerebellum (adjust posture)

Question 9

Sensorimotor System

Answer 9

Structures of the brain that control movement, relying heavily on sensory feedback from exteroceptors/proprioceptors.

Question 10

Voluntary Movement Depends On:

Answer 10

• Knowing where body is in space
• Knowing where body intends to go in external space
• Knowing internal/external loads to overcome
• Formulating a plan to perform the movement
• Holding the plan in memory until execution

Question 11

Sensorimotor Cortex

Answer 11

• Integrating center of sensory/motor input
• Cortical areas immediately anterior and posterior to central sulcus

3 Principal MOTOR Regions (FRONTAL Lobe):

1) Primary Motor Area
2) Supplementary Motor Area
3) Premotor Area

2 Principal SENSORY Regions (PARIETAL Lobe):

1) Primary Somatosensory Cortex
2) Posterior Parietal Cortex

Question 12

Lesion in Posterior Parietal Cortex Leads to:

Answer 12

• Impairment of body image and it’s relation to extrapersonal space (inappropriate movement strategy results)
• Neglect of contralateral body segments (extreme case)

Question 13

Supplementary Motor Area

Answer 13

Planning of movement. Lesions here can result in apraxia, or also an inability to produce complex motor activities such as speaking, writing, buttoning, typing, etc.

Question 14

Primary Motor Area

Answer 14

Integrates info received from other areas of brain and generates descending command for execution of movement. Lesions here result in motor execution deficits (contralateral muscle weakness, spasticity, and poor isolation of movement).

Question 15

Lesions of Primary Somatosensory Cortex

Answer 15

Result in contralateral sensory loss, and uncoordinated movement (inability to register feedback).

Question 16

Sensorimotor Intervention Approaches

Answer 16

• Viewed as targeting motor planning and lower-level execution process with aim of reintegrating complete motor control hierarchy
• Client is taught motor strategies or compensatory mechanisms to adapt to deficits using SENSORY STIMULATION to elicit specific movement patterns
• Stimuli start as external and eventually become intrinsic to encourage voluntary motor control.
• Limitations because it does not actively engage client’s volitional intent to perform motor act.
• Includes Rood Approach, Brunnstrom Approach, Proprioceptive Neuromuscular Approach (PNF), and Bobath/Neurodevelopmental Treatment Approach.

Question 17

Reflex and Hierarchical Models of Motor Control (Sensorimotor Intervention)

Answer 17

View movement strategies along developmental continuum. Reflexes are normal responses from infancy in response to specific stimuli; form the basis of volitional (purposeful) movement.
• Motor control hierarchically arranged (higher centers of brain responsible for regulation/control of volitional movement, while lower levels regulate/control reflexive/automatic movement).
• Therefore, when CNS is damaged, lower levels take over (hence return to reflexive/unmoderated movement)
• These intervention approaches rely on sensory stimulation of muscles/joints to evoke motor responses, handling/positioning to effect muscle tone, and use of developmental postures to enhance ability to carry out movements.

Question 18

Rood Approach

Answer 18

Sensorimotor intervention approach:
• Use of sensory stimulation to evoke motor response
• Use of developmental postures to promote changes in muscle tone

Sensory stimulation has potential to either inhibit or facilitate muscle tone. Can use slow rolling, neutral warmth, deep pressure, tapping, and prolonged stretch as stimuli. Also move client through developmental sequences.

Limited success due to short-lasting nature of stimuli.

Question 19

Brunnstrom (Movement Therapy) Approach

Answer 19

Sensorimotor intervention approach:
• For individuals who had sustained a CVA
• Draws from reflex and hierarchical models
• Views spastic/flaccid muscle tone and reflexive movements as part of recovery toward volitional movement
• Stages of motor recovery (1-6) from flaccidity to individual joint movements.
• Emphasis placed on promotion of movement from reflexive to volitional
• Example: resistance applied to one side of body to increase muscle tone on opposite, affected side in order to facilitate reflexive movement until client demonstrates volitional control over the movement pattern.

Question 20

Proprioceptive Neuromuscular Facilitation Approach (PNF)

Answer 20

Sensorimotor intervention approach grounded on reflex/hierarchical model of motor control.
• Major emphasis on developmental sequencing of movement and balanced interplay betw agonist/antagonist in producing volitional movement
• MASS MOVEMENT PATTERNS and postures for limbs and trunk (DIAGONAL in nature) used to promote movement
• Tactile, auditory, visual stimulation actively incorporated to promote motor response
• Example: client asked to reach into bag on left side to retrieve objects to be placed into cabinet on right side.
• Successful in increasing ROM and stretching tight muscles
• May reduce falls in older adults.
• May be used as preparatory activity or applied within performance of a task.
• Used for conditions such as Parkinson’s, SCI, arthritis, stroke, TBI and hand injuries.
• Can reduce sensory deficits in CVA pts

Question 21

Neurodevelopmental Treatment (NDT) Approach

Answer 21

Sensorimotor intervention approach based on normal development and movement.
• Drawn from hierarchical model of motor control
• To normalize muscle tone, inhibit primitive reflexes, and facilitate normal postural reactions
• Goal to improve quality of movement and relearn normal movement patterns
• Employ numerous techniques: handling; use of inhibitory techniques (diminish impact of spasticity); weight bearing over affected limb; using positions that encourage bilateral use; and avoidance of sensory input affecting muscle tone.
• Many of the techniques are used within context of purposeful activities.

Question 22

Client Factors Addressed by PNF

Answer 22

• Posture
• Mobility
• Strength
• Effort
• Coordination

Question 23

How PNF is Administered by Therapist

Answer 23

Facilitation techniques are superimposed on movement patterns and postures through therapist’s
• MANUAL CONTACTS
• VERBAL COMMANDS
• VISUAL CUES

Uses CERVICOCAUDAL and PROXIMODISTAL direction in tx. Head, neck, trunk come before extremities. (Postural control is key!)

Address movement in BOTH directions to avoid any neglected abilities (ie: getting up but also sitting down; dressing and undressing).

May be preparatory method, or applied within the performance of a task.

Used for: Parkinson’s, SCI, Arthritis, CVA, TBI, and Hand Injuries.

Question 24

Reciprocal Inhibition

Answer 24

Theoretical model used to explain benefits of PNF. Neuromuscular reflex that inhibits opposing muscles during movement. Example: contract elbow flexors, then elbow extensors are inhibited. This is the idea behind active stretching and a component of PNF stretching.

Question 25

Synergy Patterns

Answer 25

Primitive movements that dominate reflex and voluntary effort when spasticity is present after CVA. Interferes with coordinated voluntary movement such as eating, dressing and walking.

FLEXION Synergy Pattern: Scapular retraction, shoulder abd and ext rotation, elbow flexion, forearm supination, wrist/finger flexion. Hip flex, abd, ext rotation, knee flex, ankle dorsiflexion.

EXTENSION Synergy Pattern: Scapular protraction, shoulder add and int rotation, elbow ext, forearm pronation, wrist/finger flexion. Hip ext, add, and int rotation, knee ext, ankle plantar flex/inversion, toe flexion.

Question 26

PNF Balance betw Antagonist Muscles

Answer 26

Observe where imbalance exists, and then facilitate the weaker component. If client shows flexor synergy, extension should be facilitated. (Think of bed positioning, keeping affected limbs in opposite position of synergy pattern.) In the presence of spasticity, first inhibit spasticity, then facilitate antagonistic muscles, reflexes and postures.

Question 27

How sensory input from therapist leads to motor learning (PNF):

Answer 27

Example: Therapist cues verbally (input 1), “Reach for the cup,” which causes client to look up (input 2) toward the movement, to touch (input 3) the cup. Motor learning occurs when these external cues no longer needed.

External input may also be in the form of joint approximation (contact) from the therapist (ie: through shoulders and pelvis of client with apraxia while standing for a task), or stretch (stretching finger extensors to facilitate object release); so client learns how normal movement feels.

Question 28

Verbal Mediation in PNF

Answer 28

Auditory feedback to facilitate motor performance. Clients say aloud the steps required for a movement and to help learn to perform it. Studies show it helps client retain sequence of steps.

Question 29

Visual Stimuli in PNF

Answer 29

Visual stimuli assist in initation/coordination of movement. Ensure client tracks in direction of movement. Can position activities (or therapist!) to facilitate movement in a certain direction. ie: Therapist may stand diagonally in front of client to facilitate forward direction.

Question 30

Tactile System in PNF

Answer 30

Most efficient stimuli to build cognitive and emotional experiences. Feel movement patterns that are coordinated and balanced.

Question 31

Part-Task vs. Whole-Task Practice

Answer 31

Part-Task: Using parts of the task in order to learn the whole task (practice parts where difficulties lie). (ie: lifting leg to get into tub for bathing)

Whole-Task: The entire task, such as bathing. Composed of multiple parts that can be broken out to practice separately.

ALSO:
Step-Wise Procedures: Emphasis on part of the task during performance of the whole.

Question 32

PNF Assessment

Answer 32

• Follows sequence of proximal to distal
1) First, vital and related functions considered (breathing, swallowing, speaking, facial/oral musculature, and visual-ocular motor
2) Head and neck are second, as they affect UEs (check dominance of tone, alignment, stability/mobility)
3) Upper Trunk
4) UEs
5) Lower Trunk
6) LEs
• Ends with observation of self-care/ADLs performance

Question 33

Considerations of PNF Assessment

Answer 33

• Is there need for more stability/mobility?
• Balance betw flexors/extensors?
• Able to move in all directions?
• Major limitations (ie: weakness, spasticity, contractures)
• Able to assume/maintain postures?
• Are inadequacies more proximal or distal?
• Sensory input with best response (auditory, visual, or tactile?)
• Techniques of facilitation with best response?

Question 34

Diagonal Patterns in PNF

Answer 34

Mass movement patterns observed in most functional activities. Can be recognized in ADLs, and helps identify areas of deficiency. Two diagonal motions for each major part of body:
• head and neck
• upper and lower trunk
• extremities

Each diagonal pattern has flexion/extension component, together with rotation/movement away from or toward midline.

Question 35

Head, Neck and Trunk Diagonal Patterns in PNF

Answer 35

1) flexion with rotation to the right or left
2) extension with rotation to the right or left

These proximal patterns combine with extremity diagonals.

Question 36

Upper and Lower Extremity Diagonal Patterns in PNF

Answer 36

Three movement components at reference point of shoulder or hip joint:

1) flexion and extension
2) abduction and adduction
3) external and internal rotation

Shorter descriptions: D1 (flexion/extension) and D2 (flexion/extension)

Question 37

UE D1 - Flexion

Answer 37

Unilateral PNF Diagonal Pattern: Shoulder flexion-adduction-ext rotation.
• Scapula elevation, abd, rotation
• Shoulder flexion, add, ext rotation
• Elbow flexion or extension
• Forearm supination
• Wrist flexion to radial side
• Finger flexion, adduction; thumb adduction

Examples: hand-to-mouth motion in feeding; tennis forehand; combing hair on left side of head with right hand; rolling supine to prone.

Question 38

UE D1 - Extension

Answer 38

Unilateral PNF Diagonal Pattern: Shoulder extension-abduction-interal rotation.
• Scapula depression, add, rotation
• Shoulder ext, abd, int rotation
• Elbow flexion or extension
• Forearm pronation
• Wrist extension to ulnar side
• Finger extension/abd; thumb palmar abduction

Examples: pushing car door open from inside; tennis backhand stroke; rolling prone to supine.

Question 39

UE D2 – Flexion

Answer 39

Unilateral PNF Diagonal Pattern: Shoulder flexion-abduction-ext rotation.
• Scapula elevation, add, rotation
• Shoulder flexion, abd, ext rotation
• Elbow flexion or extension
• Forearm supination
• Wrist extension to radial side
• Finger extension, abd; thumb extension

Examples: combing hair on right side of head with right hand; lifting racquet in tennis serve; backstroke in swimming.

Question 40

UE D2 – Extension

Answer 40

Unilateral PNF Diagonal Pattern: Shoulder extension-adduction-internal rotation.
• Scapula depression, abd, rotation
• Shoulder extension, add, int rotation
• Elbow flexion or extension
• Forearm pronation
• Wrist flexion to ulnar side
• Finger flexion/add; thumb opposition

Examples: pitching a baseball; hitting a ball in tennis serve; buttoning pants on left side with right hand.

Question 41

LE D1 – Flexion

Answer 41

Unilateral PNF Diagonal Pattern: Hip flexion-add-ext rotation.
• Hip flexion, add, ext rotation
• Knee flexion or extension
• Ankle/foot dorsiflexion with inversion and toe extension

Examples: kicking soccer ball; rolling supine to prone; putting on sock with legs crossed.

Question 42

LE D1 – Extension

Answer 42

Unilateral PNF Diagonal Pattern: Hip ext-abd-int rotation
• Hip ext, abd, int rotation
• Knee flexion or extension
• Ankle/foot plantar flexion with eversion and toe flexion

Examples: putting leg into pants, rolling prone to supine.

Question 43

LE D2 – Flexion

Answer 43

Unilateral PNF Diagonal Pattern: Hip flex-abd-int rotation
• Hip flexion, abd, int rotation
• Knee flexion or extension
• Ankle/foot dorsiflexion with eversion and toe ext

Examples: karate kick; drawing heels up during breaststroke swimming

Question 44

LE D2 – Extension

Answer 44

Unilateral PNF Diagonal Pattern: Hip ext-add-ext rotation
• Hip ext, add, ext rotation
• Knee flexion or extension
• Ankle/foot plantar flexion with inversion and toe flexion

Examples: push-off in gait; kick during breaststroke swimming; long sitting with legs crossed.

Question 45

Symmetric Patterns (PNF)

Answer 45

Bilateral Diagonal Pattern in PNF. Paired extremities perform similar movements at same time. Bilateral symmetric UE patterns facilitate trunk flex/ext.

Examples: pushing off a chair to stand (bilateral symmetric D1 extension); reaching to lift large item off high shelf (bilateral symmetric D2 flexion)

Question 46

Asymmetric Patterns (PNF)

Answer 46

Bilateral Diagonal Pattern in PNF. Paired extremities perform movements toward one side at same time, facilitation trunk rotation. May be performed with the arms in contact.

Examples: Putting on a left earring (left arm in D2 flexion, right arm in D1 flexion); zipping left-side zipper (right arm in D2 ext, left arm in D1 ext).

Question 47

Reciprocal Patterns (PNF)

Answer 47

Bilateral Diagonal Pattern in PNF. Paired extremities move in opposite directions simultaneously, either on same diagonal or in combined diagonals. When combined diagonals, a stabilizing effect occurs on head/neck/trunk. When high-level balance needed for activity, reciprocal patterns with combined diagonals come into play with one extremity in D1 ext and other in D2 flex.

Examples of COMBINED: pitching in baseball; sidestroke in swimming; walking on narrow walkway with one extremity in diagonal flex/other in diagonal ext.

Examples of SAME: D1 in arm swing during walking, facilitating trunk rotation.

Question 48

Combined Movements of UEs and LEs (PNF)

Answer 48

Interaction of upper and lower extremities during movement. Results in:

1) Ipsilateral patterns (extremities on same side move in same direction at same time—more primitive/shows lack of bilaterality)
2) Contralateral patterns (extremities on opp sides move in same direction at same time)
3) Diagonal Reciprocal patterns (contralateral extremities move in same direction at same time while opposite contralateral extremities move in opposite direction).

Intervention goal is to move from 1 (least developed) to 3 (most developed).

Examples: Crawling and Walking.

Question 49

Total Patterns (PNF)

Answer 49

Developmental postures are called total patterns of movement and posture. Require interaction betw proximal (head/neck/trunk) and distal (extremity) components. Use of these patterns improves ability to assume/maintain postures, which helps all areas of occupation.

Examples: developing lower total patterns of movement like rolling, lying-to-sitting before sustaining a sitting posture; Reach for object in supine and place it in side-lying posture; reinforcing wrist extension by leaning forward while wiping tabletop.

Question 50

Procedures Essential to PNF Approach

Answer 50

PNF techniques superimposed on movement and posture.
• Verbal commands
• Visual cues
• Manual contacts (therapist’s hands on client)
• Stretch (helps innervate the stretched muscle)
• Traction (facilitates joint receptors by separating surfaces; promotes movement and “pulling” motion)
• Approximation (facilitates joint receptors by compression surfaces; promotes stability and “pushing” motion)
• Maximal Resistance (stronger muscles/patterns reinforce weaker components; to obtain maximal effort on part due to movement against resistance)

Question 51

Techniques Directed to Agonist (PNF)

Answer 51

• REPEATED CONTRACTIONS: repetition of activity for motor learning and dev of strength, ROM, endurance. Voluntary movement facilitated with stretch and resistance, using isometric/isotonic contractions (CONTRACT-RELAX method – CR). Repeated contraction against force then relaxing/stretching increases muscle length.
• RHYTHMIC INITIATION: improves ability to initiate movement (common in Parkinson’s or apraxia). Voluntary relaxation, passive movement, repeated isotonic contractions of agonistic pattern. Command used: “Relax and let me move you,” then “Now you do it with me.” May add resistance after repetitions. Allows patient to feel the pattern before active movement.

Question 52

Reversal of Antagonist Techniques (PNF)

Answer 52

• CONTRACT-RELAX-ANTAGONIST-CONTRACT (CRAC) Method: contraction of antagonist to facilitate weaker agonist.
• SLOW REVERSAL: Isotonic contraction of antagonist followed by isotonic contraction of agonist. Overcomes rigidity, improves balance of antagonists, increase ROM/strength.
• STABILIZING REVERSALS: Alternating isotonic contractions opposed by enough resistance to prevent motion. Increases stability, balance, muscle strength.
• RHYTHMIC STABILIZATION: Increases stability by eliciting simultaneous isometric contractions of antagonistic muscle groups. Repeated isometric contractions leading to increased circulation (can cause breath-holding). Can result in Co-Contraction if client not allowed to relax. Manual contacts applied on agonist and antagonist with simultaneous resistance; client asked to hold contraction against resistance, then without relaxing, manual contacts switched to opposite surfaces. Improves postural control, muscle balance, endurance.

Question 53

Relaxation Techniques (PNF)

Answer 53

• HOLD-RELAX: Same sequence as contract-relax, but involves isometric contraction of antagonist followed by relaxation then active movement into agonistic pattern. Helpful in presence of pain.

SLOW REVERSAL-HOLD-RELAX: Isotonic contraction followed by isometric contraction, relaxation of antagonistic pattern, and then active movement of agonistic pattern. Best when client can move the agonist actively. Can increase ROM.

RHYTHMIC ROTATION: Therapist passively moves body part in desired pattern; when tightness felt, therapist rotates part slowly/rhythmically in both directions. Decreases spasticity and increases ROM.

Question 54

Neurodevelopmental Treatment (NDT) Basis of Approach

Answer 54

The inhibition of released and exaggerated abnormal reflex action, the counteraction of abnormal patterns, and the facilitation of more normal automatic voluntary movements.

Question 55

NDT Intervention Approaches

Answer 55

• Facilitation
• Mobilization
• Practicing motor skills of certain activities
• Practicing activities themselves
• Teaching caregivers how to position the client

Question 56

NDT Evaluation

Answer 56

1) Top-down approach; Begin with occupational history interview.
2) Observe client performing occupations
3) Assess level of assistance, amount of movement present, and quality of movement/postural control.

Assess:
• Ability to maintain postural alignment needed for occupation
• Typical motor skills needed for activities that will be addressed
• Client’s alignment/movement while performing basic motor skills for everyday activities (ie: reaching, sit-to-stand, transferring)
• Underlying impairments contributing to dysfunction (changes in muscle strength, tone, activation and/or sensory processing)

Question 57

NDT Intervention

Answer 57

Emphasis on efficient and functional movement, minimizing compensations. Includes facilitation of normal motor performance skills involved in a task as well as practice of tasks themselves with manual guidance/handling. Any compensations stress incorporating the hemiplegic side. Emphasis on neutral/symmetric alignment during activities.

Intervention structure sequence:
Preparation > Movement (graded handling/key points of control) > Function (learned movement into occupation)

Question 58

Closed-chain vs. Open-chain Patterns of Movement (NDT)

Answer 58

In NDT, limb movements grade from closed-chain to open-chain patterns.

Closed-Chain: Distal part of joint/chain of joints is fixed while proximal part moves (weight bearing on arm combined with movement over base of support).

Open-Chain: Joints are all moving freely.

Question 59

EBP and Neurodevelopmental Treatment (NDT)

Answer 59

Evidence in at lower level for NDT (not much evidence available to support). Mixed results. Best to consider all factors contributing to function and integrate all resources into intervention.