The Use of Meaningful Activity in Neurological Rehabilitation An Occupational Therapy Approach to Motor Control and Motor Learning

Heiko Lorenzen, Bc. of Health in OTDöpfer School for Occupational TherapyCologne, Germany

Overview

•Introduction to Occupational Therapy•Introduction to CIMT •Application of CIMT in Occupational

Therapy•Case Example „Musician“•Discussion

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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

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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

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Introduction to the Constraint Induced Movement Therapy (CIMT)

•CIMT is based on the learned disuse after the onset of neurological disorder

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Learned disuse of

limb

Injury / Stroke

Unsuccessful motor

attempts

Feelings of failure

Behavior suppressed

Development of learned disuse

Compensatory behavior

Less effective behavior

strengthened

Positively reinforced

(figure adapted from: brainworksrehab.com)

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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 + 5 – 6 hours at home (Earley et al 2010)

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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.

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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

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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

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Application of CIMT in Occupational Therapy

The chosen preparatory methods and purposeful activities need to match the demands of the desired occupation!

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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

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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

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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

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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

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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

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Literature• American Occupational Therapy Association (AOTA) (2008) Occupational Therapy

Practice Framework: Domain and Process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683

• 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, 735-744

• 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, 2095-2104

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Heiko Lorenzen •Referent and Lecturer for Occupational Therapy•Referent for ICF in Neurological Rehabilitation•Referent for Fatigue Management

Contact: heiko.lorenzen@web.de

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