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

Edward James R Gorgon MPhysio PTRPChair and Assistant Professor

Department of Physical TherapyCollege of Allied Medical Professions

University of the Philippines Manila

WhatWhat impairs impairs movement?movement?

Path to Path to abnormal movementabnormal 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.

Motor control theoriesMotor control theoriesA review of key concepts and applications

Reflex theoryReflex 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.

Hierarchical theoriesHierarchical 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

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

Motor programming theoriesMotor 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

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

Systems theorySystems 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

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

Ecological theoryEcological 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

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

Motor control theories Motor control theories – in contrast– 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).

Motor control theories Motor control theories –– in contrastin 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

Motor control theories Motor control theories – in contrast– 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 prior experience and anticipatory postural adjustments

Access appropriate and efficient movement patterns

Improve adaptability to context

Horak F& Shumway-Cook A (1989).

Skill learningSkill learningKey principles and critical variables principles and critical variables

SkillSkill defined 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)

Skill learning Skill learning processesprocesses

■ Explicit learning processes

■ Implicit learning processes

Regulation of intersegmental force dynamics

Blending of successive movement components

Coupling of simultaneous components

Practice Practice is critical in motor learning

■ …practice, when properly undertaken, does NOT consist in repeating the means of solution of a motor problem time and again, but in the process of solving the problem time after time 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

Practice 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

Patient preparationPatient preparation for practice for practice

■ Verbal instruction

■ Visual demonstration / illustration; patient’s observation of motion patterns

■ Manual guidance

■ Mental organization of movement timing

■ External focus vs internal focus

■ Visual scanning of “far” environment

Distribution Distribution of practiceof practice

■ Massed practice

■ Distributed practice

Variability Variability of practiceof practice

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

■ Random practice – early stage, seated manipulative tasks?

Order Order of practiceof practice

■ Blocked order practice

■ Serial order practice

■ Random order

WholeWhole practice practice oror part part practicepractice??

■ Whole practice

■ Part –whole practice; progressive part practice

Classification of Classification of taskstasks

■ Discrete tasks

■ Serial tasks

■ Continuous tasks

Schmidt (1988)

Structuring the Structuring the environmentenvironment during during practicepractice

■ Regulatory conditions normally operative in the task

Accentuating regulatory conditions

Eliminating non-regulatory conditions

■ Level of biomechanical complexity

■ Level of information processing complexity

Classification of Classification of taskstasks Gentile (2000)

Classification of Classification of taskstasks Gentile (2000)

Mental Mental practicepractice

■ Theoretical underpinnings

■ Always combined with physical practice (!)

■ When appropriate to use

■ When inappropriate to use

Speed Speed andand accuracy accuracy inin practicepractice

■ As near-normal performance as possible

Transfer of learning Transfer of learning with practicewith practice

■ Bilateral transfer

■ Use of lead-up activities

Feedback Feedback facilitates motor learning

■ Mode of feedback

■ Augmented feedback

■ Precision of feedback

■ Intensity of feedback

■ Schedule of feedback

Mode Mode of feedbackof feedback

■ Internal feedback

■ External (augmented) feedback

Augmented Augmented feedbackfeedback

■ Knowledge of results (KR)

■ Knowledge of performance (KP)

Precision Precision of feedbackof feedback

■ General focus feedback

■ Specific focus feedback

Intensity Intensity ofof feedbackfeedback

■ Constant (frequent) feedback

■ Intermittent (varied) feedback

Schedule Schedule ofof feedbackfeedback

■ Immediate feedback vs delayed feedback

■ Concurrent feedback vs terminal feedback

Summary feedback

Faded feedback

Bandwidth feedback

Phases Phases of skill learningof skill learning

Recall PT 152 unit Physiology of motor learning and memory

■ Fitts and Posner’s stages of motor learning*

Cognitive stage; Associative stage; Autonomous stage

■ Neo-Bernsteinian stages of motor learning

Novice stage; Advanced stage; Expert stage

■ Gentile’s stages of motor learning

Getting the idea of movement Getting the idea of movement stage; FixationFixation / / diversificationdiversification stage

Phases Phases of skill learningof skill learning

■ Early phase of skill learning

“Getting the idea of movement” stage

■ Later phases of skill learning

Fixation / diversification stage

Initial phase Initial phase of skill learningof skill learning

■ Setting the task goal

Selecting the functional task

Promoting self-efficacy and avoiding “goal confusion”

■ Structuring the environment

Using normal regulatory conditions

■ Promoting selective attention

Using an external focus and accentuating regulatory conditions

Observing, mentally organizing, visually scanning

Initial phase Initial phase of skill learningof skill learning

■ Planning the movement

General advice on movement organization

Whole practice, unless task is naturally “breakable”

Typical-performance speed and accuracy

Mental practice

■ Performing the movement

Avoiding interferences: cues, feedback, manual guidance

Initial phase Initial phase of skill learningof skill learning

■ Augmented feedback

Unambiguous

Intermittent

Knowledge of results

Knowledge of performance

■ Decision making

Modify task?

Modify environment?

Later phases Later phases of skill learningof skill learning

■ Organizing practice by structuring the environment

Use of different types of tasks

Use of random practice

Increased practice time to increase movement efficiency

■ Organizing practice using an effective practice schedule

Use of distributed practice, unless fatigue is of little significance

Mental practice

■ “Fading” augmented feedback

Terminal feedback using KP or KR

The patient as an active learnerThe patient as an active learner Some basic concepts and guidelines

The patient as an The patient as an active learneractive 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)

The patient as an The patient as an active learneractive learner

■ 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.

The patient as an The patient as an active learneractive learner

■ 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

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

The patient as an The patient as an active learneractive learner

■ 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

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

Intervention models Intervention models to improve to improve motor functionmotor function

Intervention modelsIntervention models – an overview

■ FUNCTIONAL / TASK-ORIENTED training model

Intervention modelsIntervention models – an overview

■ NEUROMOTOR DEVELOPMENTAL training model

Neurodevelopmental Treatment (NDT)

Proprioceptive Neuromuscular Facilitation (PNF)

Neuromuscular / Sensory stimulation techniques

Intervention modelsIntervention models – an overview

■ COMPENSATORY training model

Intervention modelsIntervention models – an overview

■ ECLECTIC training model

Required Required readingreading

■ O’Sullivan SB. O’Sullivan SB. Strategies to improve motor functionStrategies to improve motor function. In: . In: O’Sullivan SB & Schmitz TJ (2007). Physical rehabilitation (5O’Sullivan SB & Schmitz TJ (2007). Physical rehabilitation (5 thth ed). Philadelphia, FA Davis Company.ed). Philadelphia, FA Davis Company.