Chapter 32: Traditional Sensorimotor Approaches to Intervention (test 1)

CNS control of movement

-movement results from interaction between UMN and LMN

-spinal motor neuron activity is modulated by segmental spinal circuitry and descending cortical an brainstem influences

-basal ganglia and cerebellum play a central role in motor control

-goal directed movement involves motivation, ideation, programming and execution

primary role of the limbic system

motivational urge, conation

clinical significance: poor initiation despite intact strength

primary role of the association cortices

ideation and movement strategies

clinical significance: impaired planning

primary role of the posterior parietal cortex

sensory integration for spatial movement

clinical significance: inaccurate reach/graps

primary role of the premotor cortex

orientation of body segments

clinical significance: inefficient strategies

primary role of the supplementary motor area

sequencing of movement

clinical significance: apraxia

primary role of the primary somatosensory cortex

sensory feedback for regulation

clinical significance: uncoordinated movement

primary role of the primary motor cortex

execution of movement

clinical significance: weakness, spasticity

primary role of the basal ganglia and cerebellum

timing and coordination

clinical significance: movement disorders

higher CNS level

structures: limbic system, and association areas

-limited focus on motivation

middle CNS level

structures: sensorimotor cortex, basal ganglia, cerebellum

- primary target of traditional approaches

lower CNS level

structures: brainstem, spinal cord

-execution-focused facilitation/inhibition

Assumption 1: reflexes as the basic unit of motor control

-reflexes are automatic, predictable responses to sensory stimuli

-normal in relay infancy

-volitional movement viewed as integration of reflexes

-CNS damage reduces movement variability

Assumption 2: hierarchical organization of motor control

-higher CNS centers regulate lower centers

-higher centers control volitional movement

- lower centers control reflexes movements

-damage leads to primitive movement patterns

which controls reflexes movements?

lower centers

which controls volitional movements

higher centers

implications for traditional sensorimotor interventions

-use of sensory stimulation to elicit movement

-therapeutic handling and positioning

-use of developmental postures to influence tone

Rood approach

-grounded in reflex and hierarchical models

-uses sensory stimulation and developmental postures to influence tone

key principles of the rood approach

-sensory input used to evoke motor responses

-techniques may facilitate or inhibit tone

-developmental postures used to influence tone

types of sensory stimulation in the rood approach

-slow rolling, neutral warmth, deep pressure, prolonged stretch (inhibitory techniques, decreases tone)

-tapping (facilitatory technique, tapping on the muscle belly)

use of developmental postures

-use of developmental sequences

-promote motor responses and influence tone

-do not directly increase function

T or F: rood techniques is used to reduce spasticity and prepare for FUNCTION

true

current clinical use of the rood approach

-used as adjunctive or preparatory interventions

-prepare client for purposeful activity

-not used as a standalone treatment

limitations of the rood approach

-sensory stimulation largely passive

-effect may be short-lasting and unpredictable

-limited engagement of volitional intent

Brunnstrom approach

-designed for individuals following cerebrovascular accident (CVA)

-grounded in reflex and hierarchical models of motor control

-views motor recovery as an "evolution in reverse"

theoretical foundations of the brunnstrom approach

-abnormal tone and reflective movement viewed as expected after CVA

- spasticity and reflexes considered necessary intermediate stages

-early abnormal movement is nor suppressed initially

stages of motor recovery after CVA (brunnstrom approach)

-stages guide intervention progression

synergy patterns and movement control(brunnstrom approach)

-flexor and extensor synergy patterns dominate early recovery

-synergy dominance interferes with isolated movement

-upper and lower extremities may show different dominant synergies

intervention principles in the brunnstrom approach

-primary emphasis on promoting movement

-progression from reflective to volitional control

-movement is encourages even if abnormal initially

use of reflexes and associated reactions (brunnstrom approach)

-reflexes and associated reactions may be used intentionally

-resistance applied to one side may increase tone on the opposite side

-strategy discontinued once volitional control is achieved

brunnstrom recovery stage of hand function: stage 1

arm function: Flaccidity is present and no movements of the limbs can be initiated

hand function: flaccidity

brunnstrom recovery stage of hand function: stage 2

arm function: The basic limb synergies or some of their components may appear as associated reactions or minimal

voluntary movement responses may be present.

Spasticity begins to develop.

hand function: Little or no active finger flexion.

brunnstrom recovery stage of hand function: stage 3 (peak of bell curve)

arm function: The patient gains voluntary control of the movement synergies, although full range of all synergy

components does not necessarily develop. Spasticity is

severe.

hand function: Mass grasp; use of hook grasp but no release; no voluntary finger extension; possible reflex extension of digits.

brunnstrom recovery stage of hand function: stage 4

arm function: Some movement combinations that do not follow the synergies are mastered, and spasticity begins to

decline.

hand function: Lateral prehension; release by thumb movement; semi-voluntary finger extension of digits, variable range.

brunnstrom recovery stage of hand function: stage 5

arm function: More difficult movement combinations are possible as the basic limb synergies lose their dominance over motor acts.

hand function: Palmar prehension; possibly cylindrical and spherical grasp, awkwardly performed and with limited

functional use; voluntary mass extension of the digits,

variable range.

brunnstrom recovery stage of hand function: stage 6

arm function: spasticity disappears and individual joint movements become possible

hand function: All prehensile types under control; skills improving; full range voluntary extension of the digits; individual finger movements present, less accurate than on the opposite side

proprioceptive neuromuscluar facilitaton (PNF) approach

-emphasizes developmental sequencing and balanced agonist-antagonist

-describes mass movement patterns that are diagonal for limbs and trunk

key features of the PNF approach

-uses diagonal movement patterns ro promote volitional movement

-incorporates sensory stimulation (tactile, auditory, visual) to elicit motor responses

-patterns used to facilitate coordinated movement across joints

PNF in OT practice

PNF patterns commonly embedded within functional

activities

• Object placement during tasks often reflects diagonal

movement patterns

• Example: reaching across midline during purposeful

activity

neuron-developmental treatment (NDT approach) aka Bobath

-based on normal development and moment patterns

LOOKING AT WHOLE BODY

-postural, alignment, pelvic, scapula

primary objective of neuron-developmental treatment

-Normalize muscle tone

• Inhibit primitive reflexes

• Facilitate normal postural reactions

• Improve quality of movement and relearn normal

movement patterns

intervention strategies in neuro-developmental treatment (NDT)

-Use of Handling techniques to influence movement

-Application of Inhibitory techniques to reduce

spasticity

-Weight bearing through the more affected limb

-Use of positions that encourage bilateral body use

contemporary use of NDT in OT

-Strategies applied within meaningful activities and occupations

- Avoidance of sensory input that may negatively affect muscle tone

- Ongoing revisions based on evidence related to motor learning

and CNS function

- Use of the NDT Practice Model in OT evaluation and intervention

Example of inhibitory techniques:

neutral warmth, deep pressure, prolonged stretch, weight bearing

Example of facility techniques

weigh bearing, tapping, quick stretch, resistance, vibration