CHP 12 neurological intervention

contemporary task-oriented approaches for motor control training

• principles

  • occupational performance emerges from interaction of multiple systems (personal & performance, etc.)

  • behavioral changes represent attempt to compensate and achieve functional goal

  • use varied strategies

  • top-down approach (look at occupational performance first)

• interventions focus on

  • adjusting to role and performance limitations

  • creating optimal environment

  • use of functional task and occupational based activities

  • practice, practice, practice

  • adapt and remediate

Carr and Shepherd’s Motor Relearning Program (MRP)

• person is active participant whose goal is to relearn effective strategies for performing functional movement

• postural adjustments and limb movements linked

• skill development does not follow developmental sequence

• intervention focus

  • general strategies for solving motor problems NOT individual movements (problem solve rather than memorize)

• successful task relearning = activities performed automatically and efficiently

  • compensatory strategies limits functional recovery > repeated use can cause further limitations and abnormal movements

motor learning principles

• learning is contingent on type of task being learned

  • discrete, continuous, serial, closed (task w/planned movements > bowling), open (driving), variable motionless, consistent motion

• law of practice refers to performance changing linearly with amount of time spent in practice

  • massed (rest < practice), distributed (practice = rest), blocked, random, whole (dressing), part (don/doff shirt)

• key feature of practice is information learner receive about attempts to learn (trial/error, feedback)

  • inherent/intrinsic, augmented/extrinsic, concurrent (during), terminal (end), immediate (after), delayed, knowledge of results (you did this much), knowledge of performance (next time keep your shoulders back, but good job)

motor learning stages

1. skill acquisition

   • cognitive stage, occurs during initial instruction and practice of skill

     • teach back, demonstrate, highlight key points, select appropriate feedback and task, reflection, adapt

2. skill retention

   • associative stage, involves carryover as individual demonstrate newly acquired skill after initial practice

     • practice, feedback, structure

3. skill transfer

   • autonomous stage, individual demonstrates skill in new context

     • practice, feedback, structure

factors to promote generalization of motor learning

• capacity of intrinsic feedback

• high knowledge of performance feedback

• low extrinsic > knowledge of results

• practice in variety of natural settings and conditions

• whole task practice

near transfer

• alternate form of initial task

• very similar to initial task but has minimal changes in task parameters

• near > intermediate > far > very far transfer

sensorimotor approaches

• utilized for CNS dysfunction

• general principles

  • controlled movement preceded by stereotypic reflex response

    • facilitation and inhibition patterns

  • sensory input regulates motor output (need sensation for movement)

  • centralized motor programs determine muscle activation patterns (cortex > middle brain > SCI)

    • higher level and lower level centers; higher level > lower

  • damage to higher control centers release primitive reflexes and movement patterns from inhibition

  • lower level integration (SCI) occurs by higher level righting and equilibrium responses

• includes

  • neurodevelopmental tx approach (NDT)

  • proprioceptive neuromuscular facilitation (PNF)

  • Brunnstrom’s approach

  • Margaret Rood’s approach

neurodevelopmental treatment approach (NDT)

• Bobath technique

• focus is on improving quality of movement through

  • normalization of movement patterns

  • integration of both sides

  • establishment of ability to weight bear and weight shift

  • establishment of normal righting and equilibrium patterns

• primary intervention is handling

• principles

  • normalization of postural and limb tone is prerequisite to normal movement

    • eliminate tone abnormalities (hypo-hypertonia, flaccidity, spasticity, etc.)

  • loss of postural control > overuse of uninvolved side and limited fxnal movement

  • avoidance of movements and activities that increase tone

    • associated reactions (nonfxnal and involuntary changes in uninvolved limb position & tone) should be avoided

  • inhibition of primitive reflexes and abnormal postural and limb movements

proprioceptive neuromuscular facilitation (PNF)

• superimposed movements (diagonals) and posture focusing on sensory stim from manual contacts, visual cues, and verbal commands

  • goal directed ax w/facilitation techniques; reversing movements

• D1 flexion/extension and D2 flexion/extension

  • diagonal patterns and mass movements during fxnal activities

  • cross midline and rotary movement

• principles

  • neuromuscular mechanisms can hasten with stimulation of proprioceptors

  • early motor behavior is dominated by reflex ax; mature motor behavior supported by integrated postural reflexes

    • spontaneous movement; extreme flexion to extension

  • developing motor behavior expressed in orderly sequence

    • shifts btw flexor or extensor dominance

    • locomotion depends on reciprocal contractions

PNF D1 and D2 patterns

D1 = shopping cart

D2 = Disco

• D1 flexion (EX: comb left side of heat w/R arm, reach for cup in UR cabinet w/LE) (shopping cart dance)

  • scap: abduct, up rotate

  • shoulder: flex, add, ER

  • elbow: flex

  • forearm: sup

  • wrist: flex, radial

  • finger/thumb: flex, add

• D1 Extension (EX: reach for R arm rest w/RUE; place cup in dishwasher, reach back to wash RLE w/RUE)

  • scap: add, down rotate

  • shoulder: ext, abd, IR

  • elbow: ext

  • forearm: pro

  • wrist: ext, ulnar

  • finger/thumb: ext, abd

• D2 flexion (EX: raising hand to ask Q; reaching for cup in front you; fist pump)

  • scap: add, up rotate

  • shoulder: flex, abd, ER

  • elbow: ext

  • forearm: sup

  • wrist: ext, radial

  • finger/thumb: ext, abd

• D2 extension (EX: wash L thigh w/RUE; putting on seatblet, don belt)

  • scap: abd, down

  • shoulder: ext, add, IR

  • elbow: flex

  • forearm: pro

  • wrist: flex, ulnar

  • finger/thumb: flex, abd

Brunnstrom’s movement therapy

• focused on facilitating recovery through specific sequence that promotes movement from reflexive to volitional

  • focus on developing movmt in hemiplegia

• stages

  • I: flaccid, no vol movement

  • II: synergies and spasticity

  • III: incr spasticity and beginning of vol movmt in synergy

  • IV: decr spasticity and vol move beginning move out of syngery

  • V: spasticity continues to decr, vol movmt more complex w/out synergistic pattern

  • VI: spasticity almost gone, isolated vol movmt

  • VII: normal movement

Margaret Rood’s Approach

• sensorimotor control is developmentally based and tx must begin at current level

• four phases of motor control

  • reciprocal inhibition/innervation

    • early mobility pattern primarily a reflex governed by spinal and supraspinal centers (protective, stepping reflex)

  • co-contraction

    • simultaneous contraction of agonist and antagonist that provides stability in static pattern

      • prolonged holding of object, standing at concert, prop arm to stand

  • heavy work/mobility superimposed on stability

    • proximal muscles contract and move and distal segments are fixed

      • downward dog to upward dog, stance phase in gait

  • skill

    • highest level of control and combines stability and mobility

    • consist of stabilized proximal segment w/distal segment move in space

      • changing lightbulb, writing on chalk board kicking ball

• ontogenic motor patterns: sequence of motor development

  • supine withdrawal

  • rollover

  • prone extension

  • neck co-contraction

  • prone on elbows

  • quadruped

  • standing

  • walking

modified Ashworth scale (MAS)

• measures resistance to passive movements of joint which is not exclusive to measure of spasticity

  • evaluation of hypertonia and spasticity

  • velocity dependent stretch reflexes

• standardized extension time: one second duration

• PROCEDURE

  1. full PROM

  2. document max ext & flex

     1. find full range and divide by 4 for quadrants

  3. quick stretch in direction opposite of pull for 1 sec x3

  4. document point of catch/angle manifestation

• DOCU:

  • muscle group tested and rating

  • EX: R elbow flexors: MAS 2

MAS scoring

• 0: no increase in muscle tone; normal muscle tone

  • full range

• 1: slight increased tone, catch & release, minimal resistance @ end of range

  • 4th quarter

• 1+: slight increased in tone, catch > minimal resistance throughout remainder (less than half)

  • 3rd quarter

• 2: more marked increase in muscle tone through most ROM, affected parts move easily

  • 2nd quarter

• 3: considerable increase in muscle tone, PROM difficult

  • 1st quarter

• 4: affected part rigid

  • cant get range

reflex testing

• utilized to evaluate involuntary stereotyped responses to particular stimulus

  • may be present since fetal life or re-emerged after brain injury

• response = positive

• common reflexes tested

  • grasp: pressure at palm of hand > finger flex

  • flexor withdrawal: stim at sole of foot > flex of stimulated leg

  • ATNR: flex extended leg while opposite leg is flexed > ext of opposite leg w/add and IR

  • STNR: flex head followed by head etx > flex of head result in flex of arms/ext of legs and vice versa

  • tonic labyrinthine: prone to supine > prone = flex of arm/legs and supine = ext of arm/legs

intention tremor

worsening of action tremor as limb approaches target in space

dysmetria

• undershooting (hypometria) or overshooting (hypermetria) of target

dyssynergia

breakdown in movement resulting in joints being moved separately to reach desired target as opposed to moving in smooth trajectory

decomposition of movement

dysdiadochokinesia

impaired ability to perform rapid alternating movements

(patty cake on thighs)

rigidity

• increased resistance to passive movement throughout the range

• may be..

  • cogwheel: alternative contraction/relaxation of muscles being stretched

  • lead pipe: consistent contraction throughout range

akinesia

• inability to initiate movements

  • kinesia = movments

athetosis v dystonia v chorea

• athetosis: dyskinetic condition includes inadequate timing, force, and accuracy of movements in trunk/limbs; movements are writhing and worm like

• dystonia: involuntary sustained distorted movement or posture involving contraction of groups of muscles

• chorea: involuntary movements of face and extremities which are spasmodic and short duration

  • huntingtons!

  • hemiballismus: unilateral chorea > violent, forceful movements of proximal muscles

assessment of GHJ inferior subluxation

• allow person arm to dangle into gravity

• palpate space underneath acromion process with index finger

• compare intact side and document width of pace in terms of finger breadths

using orthosis for neuro pts

• prevent deformities and contractures (CVA, CP, etc)

• control spasticity

• correct malalignment

• compensate for weakness

• provide support

cock-up orthosis

• supports wrist in 10-20 ext to prevent contractures

• allows digits to function

• volar or dorsal

bobath finger spreader (abduction orthosis)

• soft orthosis positions digits and thumb in abduction to reduce tone

rood cone

• based on Rood’s inhibitory principles of sustained deep pressure

• utilized to reduce flexor spasticity in hand

orthokinetic orthoses

• utilizes tactile input (elastic bandages) to facilitate and/or inhibit appropriate muscle group

any static orthosis that is used to decrease tone in neuro hand pts may…

cause hand deformity

• increase w/severity of spasticity

• use with cautions and frequently monitor

• consider fabricating orthosis w/wrist separate from fingers to reduce sustained flexor that could increase tone

• SaeboStretch good option for minimal to moderate tone

overhead suspension sling

• incorporates arm support that is supported by sling and suspended by overhead rod

• can be used for exercises or to engage in functional task

• candidates

  • proximal weakness w/ muscle grades in 1/5 to 3/5 range

    • EX: ALS, guillain-barre, MD

balanced forearm orthoses

• mobile arm supports or ball-bearing forearm orthoses

• consists of arm trough, proximal and distal arms, and support bracket that can be placed on w/c or table

• allows person with weak proximal musculature to utilize available control of trunk and shoulder to engage in functional tasks for exercise

shoulder slings

• utilized to support flaccid arm after neurologic insult for short and controlled periods of time

  • long term use may be detrimental

  • prevents traction injuries during upright ax (flaccid arm will begin to sublux!!! use sling for support when moving about)

• types:

  • arm pouch: supports weight of arm holds arm in flexor pattern; short periods

    • only use during fxnal mobility and transfers

  • shoulder saddle: supports distal weight of arm with forearm cuff; worn under clothes; allows elbow flex/ext

  • hemi shoulder: arm supported with humeral cuff; allows elbow flex/ext and distal fxn

  • GivMohr: supports distal weight of arm; allows elbow flex/ext; pictured

oral motor dysfunctions

• may result in speech impairments (dysarthria), swallowing impairments (dysphagia), drooling, facial asymmetry, etc.

• evaluate each stage

  • pre oral: food set up, sensory awareness of food, food to mouth

  • oral-preparatory: open mouth, muscles of mastication, bolus in oral cavity, bolus formation

  • oral stage: lips, buccal muscles, and tongue propel bolus

  • pharyngeal: swallow reflex, laryngeal elevation, soft palate elevation, pharyngeal peristalsis

  • esophageal: propulsion of bolus through esophagus

signs of aspiration (6)

• change in color due to airway obstruction

• prolonged coughing

• gurgling voice, extreme breathiness, loss of voice

• nasal drip

• profuse drooling

• fever

swallowing stages (5)

1. pre-oral or anticipatory stage

   • voluntary; psychological, social, environmental, cultural, emotional aspects of eating

2. oral-preparatory stage

   • voluntary; food to mouth, salivation, mastication, bolus formation

3. oral stage

   • voluntary; lips, cheeks, tongue move bolus to pharynx

4. pharyngeal stage

   • involuntary; swallow response, vocal cords close, elevation of structures

5. esophageal stage

   • involuntary; bolus enters esophagus, peristalsis

primitive reflexes impacting oral motor function

• rooting reflex

  • test: stroke from corner of mouth along cheek to ear > head turns and tongue protrusion

• jaw jerk (phasic bite reflex)

  • test: tap center of mandible 1-2 times > jaw closes/opens

  • fxn: allows for jaw movements of eating

• bite reflex (tonic bite reflex)

  • test: tongue depressor placed btw upper and lower teeth > strong closure of mouth

  • fxn: present when unable to chew foods, utensil use is difficult

• ATNR

  • test: rotate head 90 > limb ext on face side, flex on skull side

• STNR

  • test: flex head then ext head > flex of head = flex arms & ext of legs; ext of head = ext of arms & flex of legs

testing CNIII

• oculomotor n

• pupil size, pupillary reflex, visual tracking

testing CNIV

• trochlear n

• visual tracking, smooth pursuit

testing CNVIII

• vestibulocochlear n

• tuning fork, balance

testing CNIX

• glossopharyngeal n

• gag and swallow reflex

• taste to posterior tongue

testing CNXI

• spinal accessory n

• shoulder (sternocleido, trap m) testing

testing CNXII

• hypoglossal n

• stick out tongue

oral motor interventions

• direct therapy for strategies and eating techniques

  • modification of food consistency, amount, placement

    • slow oral transit time > cold & sour bolus

    • weakness > soft solids & thick fluids to posterior mouth

    • delayed swallow > high flavor foods

    • reduced laryngeal elevation > mendelsohn & supraglottic

  • postural interventions!!

    • chin tuck, supraglottic swallow, mendelsohn’s maneuver

• indirect therapy not including bolus practice

  • thermal (cold) stimulation to swallow receptors

  • reflex facilitation

  • strengthening and coordination of oral movements

  • positioning

constraint induced movement therapy (CIMT)

• task-oriented approach for neuro pts with control of wrist and digits

  • BP injuries

• criteria for affected side

  • 20 ext of wrist and 10 ext of each digit

  • 10 ext of wrist, 10 abd of thumb, 10 ext any 2 other digits

  • able to lift washrag off tabletop using any type prehension then release it

• major components

  • massed practice and shaping of affected limb w/repetitive fxnal ax

    • 3-6hrs a day; shaped ax for increasing difficulty

    • environmental/task modifications allowed to enhance performance

    • contemporary motor learning principles (random, variable, natural, problem solving)

  • restraint of less affected UE to prevent use

  • transfer package: adherence based behavioral method to promote transfer to ADL training (logs, contracts, homework, etc.)

ayres sensory integration

• inherent neural organization of sensory information creates pathways for increasing mature and effective adaptive responses

• interventions…

  • aim to modify regulatory state without having lasting neurophysiological impact

  • are tailored sensory experiences and sensory tools that support function

  • may be passive or active

    • passive: weighted vest during class, steamrollers in prone

    • active: alternative seating, fidget toys, chew toys

  • should not disrupt routine

  • may or may not be playful

  • group based or individualized

  • equipment used is minimal w/no training required

• assumptions

  • plasticity of CNS

  • therapeutic environment = just right challenge + sensory motor learning experiences + active problem solving + mature adaptive responses

  • higher cortical processing dependent on organization of sensory info at lower brain centers

  • adaptive responses!! allow adequate modulation and supports optimal development

sensory integration and praxis tests (SIPT)

• measures sensory integration skills that are associated w/learning disabilities, emotional disorders, and minimal brain dysfunction

• standardized; 4-8.11yrs

• seventeen tests

  • address tactile processing, vestibular-proprioceptive processing, visual perception, and practicability

DeGangi-Berk test of sensory integration (TSI)

• standardized; 3-5yrs

• measures sensory integrative fxn with focus on vestibular system

• three areas:

  • bilateral motor coordination, postural control, reflex integration

test of sensory functions in infants

• standardized; 1-18mos

• assess level of sensory responsiveness to variety of sensory stimuli

sensory processing measure (SPM)

• elementary school aged children

• measures sensory processing, praxis, and social participation across different environments

• assesses all 7 senses

  • visual, auditory, tactile, olfactory-gustatory, proprioceptive, and vestibular behaviors

Ayres sensory integration intervention OT role

• control sensory input that is child driven and play based

• create environment to facilitate active participation for just right challenge

• ensure registration of meaningful sensory input

• balance structure and freedom (tap into inner drive of child)

• gradually introduce new activities and grade up

• promote organized adaptive responses

general sensory integration intervention principles

• grade and apply appropriate sensory combo

  • firm pressure and resistance > light touch

  • linear movement > angular

  • slow movement > rapid

• combo of stimuli must be used to elicit adaptive response for effective intervention

  • starting point

• closely monitor response to stimuli and adhere to precautions (hyper/hypo responses)

tactile interventions

• modulation/responsiveness

  • self-applied stimuli is more tolerable than passive

  • use firm pressure

  • use controlled sensory activities with simultaneous tactile and vestibular-proprioceptive input

  • start w/slow linear and deep pressure

  • apply tactile stimuli in direction of hair growth

  • follow tactile stimuli with joint compression

• discrimination

  • deep touch to hands and body

  • usually simultaneously with deficits in motor planning

  • graded ax requiring discrimination

proprioception interventions

• modulation/responsiveness

  • firm touch, pressure, joint compression, traction

  • resistance to active movement for learning force for task

  • use various body positions (yoga, obstacle courses, etc.)

  • slow linear movement, resistance, and deep pressure

  • use adaptive techniques (weight vests)

• discrimination

  • all above w/activities requiring ability to grade force or effort of movements

vestibular interventions

• modulation/responsiveness

  • grade type and rate of movement

  • slowly introduce linear movement with touch pressure in prone and provide resistance to active movement

    • gravitational insecurity!

  • use linear vestibular stimuli to increase spatial orientation

  • use rapid rotary and angular movements with deceleration/acceleration to increase ability to distinguish pace of movement (semicircular canals)