Intro Thera III

7/30/2019 Intro Thera III

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PT 154 Therapeutic Exercise 3Theoretical underpinnings of therapeutic exercises and activities forneurological and developmental conditions.

Presented by:Maria Christina M. Gutierrez, PTRPUniversity of BatangasCollege of Allied Medical Sciences


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Motor Control

Stages

Stimulus Identification

Response Selection

Response Programming


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What impairs movement?


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Path to abnormal movement

Attempt to move

Obstacles to efficient movement

Compensatory movement strategy

Repeated practice of compensatory strategy

Learned use of compensatory strategy

Carr J & Shepherd R (Eds) (1987). A motor relearning programme for stroke (2nd ed), Rockville, Aspen.


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Motor control theoriesA review of key concepts and applications


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Reflex theory

Motor behaviors as a function of the presence or absence of

controlling reflexes

Enhancing or reducing the effect of various reflexes during

motor tasks

Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical (2nd ed). Baltimore, Lippincott Williams & Wilkins.


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Hierarchical theories

Motor behaviors as a result of loss of higher-level CNS control

and subsequent exaggeration of normal reflexes and / or

appearance of pathological reflexes

Inhibiting (or facilitating) reflex activity and regaining control by

higher CNS centers over lower centers during motor tasks



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Motor programming theories

Motor behaviors as determined by abnormalities in central

pattern generators and higher-level motor programs

Learning the correct rules for action and applying motor

programs through available effectors



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Systems theory

Motor behaviors as a result of mechanical constraints in the

body that shape the expression of NS control

Addressing musculoskeletal system impairments that impact

upon overall motor control

Addressing interacting impairments among multiple body

systems



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Ecological theory

Motor behaviors as a function of the ability to satisfy or adapt

movement to task and environmental requirements

Developing the ability to achieve functional tasks in multiple

ways

Develop the ability to come up with best solutions for

movement problems given existing limitations



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Motor control theories in contrast

HIERARCHICAL theory SYSTEMS theory

Sensory stimuli determine

posture

Separation of voluntary and

reflex

Top-down control

Behaviors organized around

task goals

Anticipatory, predictive

control

Normal movement strategies

Horak F& Shumway-Cook A (1989).


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Motor control theoriesin contrast

In terms of theory on motor skill acquisition

In terms of theory on dyscontrol

In terms of theory on function recovery following brain injury

and issue of functional carryover


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Motor control theories in contrast

HIERARCHICAL theory SYSTEMS theory

Inhibit abnormal tone

Integrate primitive reflexes Fractionalize movement by

breaking up muscle

synergies

Effectively achieve task goals

Improve use of priorexperience and anticipatory

postural adjustments

Access appropriate and

efficient movement patterns

Improve adaptability to

context

Horak F& Shumway-Cook A (1989).


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Skill defined

Consistently attaining an action-goal with some ECONOMY OF

EFFORT

Involves an INDIVIDUAL SOLUTION to the problem of how to

efficiently organize movement to produce an action-outcome

consistently

Is TASK-SPECIFIC

Gentile (2000)


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Practice is critical in motor learning

practice, when properly undertaken, does NOT consist in

repeating the means of solutionof a motor problem time andagain, but in the process of solving the problem time aftertime by techniques which we have changed and perfected

from repetition to repetition

practice is a particular type of repetition without repetitionBernstein (1967)

Considered the most important determinant of learning


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Practice is critical in motor learning

Preparation of the patient for practice

Distribution of practice

Variability of practice

Order of practice

Whole practice and part practice

Structure of the environment during practice

Mental practice


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Patient preparation for practice

Verbal instruction

Visual demonstration / illustration; patients observation of

motion patterns

Manual guidance

Mental organization of movement timing

Externalfocus vs internalfocus

Visual scanning of far environment


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Distribution of practice

Massed practice

Distributed practice


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Variability of practice

Blocked practice early stage, complex, whole-body tasks?

Random practice early stage, seated manipulative tasks?


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Orderof practice

Blocked order practice

Serial order practice

Random order


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Whole practiceorpart practice?

Whole practice

Partwhole practice; progressive part practice


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Classification oftasks

Discrete tasks- Beginning and end points are clearly defined

Serial tasks- Composed of a number of discrete skills whose

integrated performance is crucial for goal achievement

Continuous tasks- Beginning and ending points are arbitrary

Schmidt (1988)


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Classification oftasksGentile (2000)


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Classification oftasksGentile (2000)


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Mental practice

Theoretical underpinnings

Always combined with physical practice (!)

When appropriate to use

When inappropriate to use


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Speed and accuracy inpractice

As near-normal performance as possible


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Transfer of learning with practice

Bilateral transfer

Use of lead-up activities


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Feedback facilitates motor learning

Mode of feedback

Augmented feedback

Precision of feedback

Intensity of feedback

Schedule of feedback


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Mode of feedback

Internal feedback

External (augmented) feedback


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Augmented feedback

Knowledge of results (KR)

Knowledge of performance (KP)


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Precision of feedback

General focus feedback

Specific focus feedback


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Intensity offeedback

Constant (frequent) feedback

Intermittent (varied) feedback


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Schedule offeedback

Immediate feedback vs delayed feedback

Concurrent feedback vs terminal feedback

SummaryfeedbackFadedfeedback

Bandwidthfeedback


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The patient as an active learnerSome basic concepts and guidelines


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The patient as an active learner

Involves ACTIVE PRACTICE of everyday tasks instead of

passive receiving of therapeutic intervention

Involves being given the opportunity to practice tasks as much

as possible (e.g., practice outside the clinical setting)


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Configuring the organizational structure for active learning

Function of staff, role of patients, and interaction of these

Clarifying policies and procedures (e.g., via drawing up contracts)

Promoting autonomy and responsibility in patients consistently

Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.


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Configuring the physical structure for active learning

Architecture / design of therapy workspaces

Providing suitable materials to enable intra-clinical practice

Providing suitable materials to enable extra-clinical practice



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Active learning through independent practice

Explicit (written / illustrated / diagrammed / recorded) instructions

Feedback from the environment correct performance

errors to avoid

Organized and self-monitored (or semi-supervised) practice

Recording and illustration of progress in therapy



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Intervention models to improvemotor function


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Intervention models an overview

FUNCTIONAL / TASK-ORIENTED training model


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NEUROMOTOR DEVELOPMENTAL training model

Neurodevelopmental Treatment (NDT)

Proprioceptive Neuromuscular Facilitation (PNF)

Neuromuscular / Sensory stimulation techniques


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COMPENSATORY training model


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ECLECTIC training model


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Required reading

OSullivan SB. Strategies to improve motor function. In:OSullivan SB & Schmitz TJ (2007). Physical rehabilitation (5th

ed). Philadelphia, FA Davis Company.

Intro Thera III

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