Transcript Document

Motor Control and Motor
Learning Frames of
Reference
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68 year old, black male, married for 30
years
Job – caretaker in a church
Home – lives at the church in a basement
apartment
Suffered a left CVA, leaving right arm and
leg flaccid, speech slurred and dysarthric,
and is depressed
Concerns – his wife will not be able to
care for him and he will have to go to a
nursing home. He also cannot work so
they might have to go on welfare and may
not be able to afford their apartment
Medical history – hypertension for 9 years,
history of ulcers, had retinal surgery 6
years ago, no history of psychiatric illness
WALLY
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Mental and physical status –
 appears to be very neat, clean and well groomed.
 Inconsistent eye contact, especially when approached from
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the right side.
Motor ability is impaired and does not ambulate at this time.
Right arm and leg are flaccid and has right facial droop.
Slurred speech and difficulty finding words.
Affect is depressed since the injury.
Formal thought is confused and has perceptual deficits
which include visual disturbances, crossing the midline,
figure-ground difficulties, and severe right neglect.
Neurodevelopmental Therapy
Approach
• Movement control progresses from head to foot,
trunk to limbs, and from large to small
•It focuses on stability before mobility
•Goal is to regain control over primitive reflexes for
skilled voluntary movement.
How do you as Wally’s OT apply the
Neurodevelopmental Therapy Approach to his
ADL’s?
• Handling and Practice
•compensation is discouraged
• encourage Wally to use more of his affected sides for ADL’s
• Bathing
• Transferring himself from one location to another
• Dressing
• Feeding
Wally’s Functions & Disability
(using NDT perspective)
• Loss of selective movement control in his right arm
• abnormal tone on affected side (right side is flaccid)
• poor inhibition of primitive reflexes and/ or
nonfunctional movements
3 Goals to work on for Wally:
• Refining tone in his affected right side
• Regaining more movement in affected right side
• Strengthening fine motor skills and stability overall
Can you name a few common routines or tasks
you feel Wally should concentrate on?
1. Transferring (stability getting from wheelchair to
bed, or restroom)
2. Bathing
3. Dress
*Wally has been confused in his formal thoughts with
routines and ADL’s therefore, with practicing
certain tasks over and over, he will be able to
remember and master these tasks.
What recommendations would you give Wally’s
wife as far as carrying out NDT training?
• Make sure she is aware of what Wally is capable of.
• Have her encourage Wally to use more of his affected
side to strengthen bilateral movement
• Place items closer to his affected side to induce
spontaneous movement of his affected side
• Have Wally help her with various tasks and chores
around the house for strengthening his affected side
Motor Learning Approach
• A general rehabilitative approach to all forms of
movement abnormalities and disorders
•Holistic or systems approach
•Directly relates to specific task performance
•Aims at restoring functional movement using meaningful
tasks so that clients have the motivation to continue with
interventions
Wally’s function and disability using a
contemporary task perspective
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In a contemporary task perspective, functioning is defined within the
context of specific tasks and there is a gradual increase in the degrees
of freedom within which skilled movements are performed.
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Identifying specific tasks for Wally and defining function and disability
 Returning to work – impaired: Wally is unable to perform all the things
necessary for his prior occupation
 ADLs – functional : Wally still has use of his unaffected side and
through continued practice and support of the affected side Wally will
gradually regain function on the affected side
 Mobility - impaired : Currently Wally in unable to ambulate. He is in a
wheel chair and will eventually become mobile through the use of his
wheelchair as he continues to strengthen his transferring skills.
 Social participation – functional: Although Wally has some speech
difficulties, he is able to communicate and will continue to regain his
speech and language
What three tasks might Wally choose to
focus on as implied in the case?
Muscle strengthening
 Crossing the midline
 Establishing independence in activities
of ADLs
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 Dressing
 Bathing
 Transferring
What tasks would be priorities for Wally’s
wife for when he returns home?
Increasing his motivation
 Having Wally perform purposeful &
meaningful activities
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Describe the procedure you would use to
evaluate Wally’s ability to perform the task he
has chosen.
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Conduct evaluation during occupational &
role performance in natural settings
 Dressing at home
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Observe Wally performing functional tasks in
various contexts
 Transferring from wheelchair to bed, from toilet to
wheelchair, etc.
Use one of these as an example and
describe your approach in detail.
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Dressing
 Teaching a set pattern for
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dressing
Giving cues to distinguish right,
left, front & back
Lay out clothing in order which
you will put them on
Sit down while dressing
Put the affected limb into the
piece of clothing before the
unaffected arm or leg
How would summarize an intervention plan for
Wally using the motor learning approach?
Practice dressing, bathing, transferring
in a natural setting
 Practice whole tasks, not isolated parts
 Provide feedback
 Encourage self-evaluation & error
detection
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NDT vs. Motor Learning:
Similarities and differences in descriptions of occupational
problems and goals for Wally
Both NDT & Motor Learning Theory rely on the plasticity of the brain to rewire and make new
connections so that Wally will eventually be able to ambulate and use his right side again.
DIFFERENCES
Neurodevelopmental
Theory
 Occupational dysfunction is characterized by the inability to control one’s own
motor movements.
 Goals to therapy include trunk stability, increased independence in self-care, and
restoration of safe mobility.
 NDT focuses on establishing sensorimotor components that are prerequisites for
occupational performance.
Motor
Learning Frame
 Three stages of function: cognitive, associative and autonomous stage. Function
defined within context of specific tasks.
 The goal is to restore functional movement by developing optimal motor and
cognitive strategies.
 Recovery is reached when the person is restored to their previous level of
abilities as before the accident.
Similarities and differences in approach to
evaluation
NDT
Motor Learning
Initially occurs in clinical setting
Conduct in natural setting during
normal occupation and role
performance
Involves both observation and
handling to determine
function/limitations
May rely on self-report or caregiver
report to determine functional capacity
Responses to input are evaluated as
well as posture and movement
sequences
Attributes of person, environment, and
task are evaluated
Selective control of arms and legs is
evaluated segment by segment
Observe same task within various
contexts
SIMILARITIES
•Collaborative approach with client and family to
determine occupational problems and priorities
How would you use each approach to deal with
Wally’s motivational issues
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NDT assumes that training and practice will produce
improvements without intentional effort of the client’s
part. Therefore, Wally’s participation in activities that
are meaningful to him will be his motivation.
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Motor Learning frame selects tasks that are
challenging and meaningful to the client, and that are
identified by the client themselves. We would ask
Wally what types of things most important to him and
go from there.
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In both cases, we will most likely be working on tasks
that will enable him to go back to work so he and his
wife do not have to go on welfare or lose their house.
Differences in intervention strategies and
techniques:
NDT
•Handling
•Use of facilitation and inhibition
techniques
•Placing hands at key points of
control
•Using reflex-inhibiting
patterns/postures (RIPs)
•Considered preparatory
treatment because it’s directed
toward establishing
sensorimotor performance
components that are
prerequisites for occupational
performance.
Motor Learning
•Task oriented approach
•Focus on assisting clients in
developing the optimal motor
and cognitive strategies for
achieving functional goals
•Remediation, adaptation, and
compensation are not
separated, but represent one
holistic approach
•Practice of needed skills in
natural settings
•Practicing whole tasks, not
isolated parts
•Providing randomized practice
Changes in environment and task demand in:
NDT
In Wally’s case, his task demands
will change by taking him longer to
do certain things such keeping
things neat, clean, and being wellgroomed.
Environment in the home will need
to be changed in order to have
easier mobility when he’s in his
wheelchair, transferring, and
bathing.
Motor Learning
Early stages of learning: Feedback
is focused on movement outcome
and the critical features of the task
and environment (not on motor
performance)
•Later stages: Clients are
encouraged to self-evaluate their
own movement performance and
outcome by focusing on feedback
from their own body and
environment
Role of adaptation and compensation:
NDT
•Discouraged compensation with
one-handed strategies for task
performance as counterproductive
because it encourages learned
neglect
•Compensation continues to be
discouraged, and use of hemi side
encouraged for performing
activities of daily living.
Motor Learning
•Remediation (establish or restore),
adaptation, and compensation are
not separated, but represent one
holistic approach
Which approach would you use with Wally, and why?
We would use NDT because Wally has abnormal
movement and tone (right arm and leg flaccid) and
must be inhibited before normal movement can be
restored.
 His disability include:
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 Loss of postural control and selective movement control
 Abnormal on the affected side
 Associated reactions (bilateral movement are not good)
 Poor inhibition of primitive reflexes
 Sensory disturbances