1. Motor Control
   1. THEORIES
      1. Reflex Theory
         1. movement =result of a stimulus-response sequence of events/reflexes
         2. complex movements=chaining of many reflexes to produce finl outcome
      2. Hierarchial Theory
         1. CNS organized into 3 primary control levels: high, middle, low
         2. higher centers always assume control whenever the task demands are high
      3. Systems Theory
         1. motor control is result of cooperative actions of many interacting systs, working to accommodate the demands of the specific task
         2. Distributed model of control-large areas of CNS may be engaged for complex motor tasks while few centers are engaged for more discrete movements
   2. Motor Programming Theory
      1. Open-Loop Control System OLCS
         1. employs motor programs w/o influence of peripheral feedback or error detection processes
      2. Closed-Loop Control System CLCS
         1. employs feedback & a reference for correctness to compute error & initiate subsequent corrections
      3. Intermittent Control Hypothesis
         1. blends both OLCS and CLCS
      4. Generalized motor programs include both:
         1. Invariant characteristics
            1. unique feats of the stored code:
            2. relative force, relative timing, & order of components
         2. Parameters
            1. changeable feats. that ensure flexibility of motor programs & variations in movements from 1 performance to next:
            2. overall force & overall duration of movement
   3. Information-processing stages of movement control
      1. 1. Stimulus ID
      2. 2. Response Selection
         1. motor plan
      3. 3. Response Programming
         1. motor programming-turn motor plan into muscular action
   4. Def: an area of study dealing with the understanding of the neural, physical, and behavioral aspects of movement
2. Motor Learning
   1. THEORIES
      1. Theory of Motor Learning by Adams
         1. sensory feedback from ongoing movement is compared w/stored memory of the intended movement (perceptual trace) to prove CNS w/a reference of correctness & error detection. Memory traces are then used to produce an appropriate action & eval outcomes
      2. Schema Theory
         1. slow movements are feedback-based while rapid movements are program-based & proposed that schema were used for storage into memory
         2. Clinically: supports concepts that practicing a variety of movement outcomes would improve learning through the development of expanded roles/schema (-rule/concept/relationship formed on basis of experience)
         3. Recall Schema
            1. used to select & define the initial movement conditions
         4. Recognition Schema
            1. used to eval movement responses based on expected sensory consequences
   2. Stages
      1. 1. Cognitive
         1. what to do
      2. 2. Associative
         1. how to do
      3. 3. Autonomous
         1. how to succeed
   3. Strategies to enhance motor learning
      1. Precise demonstration (skilled & unskilled pt. models)
      2. Allow for trial & error in initial stage/practice; don't correct all errors
      3. Give guidance during early learning
      4. Prompt Pt. in early decision-making (self-monitoring/correcting)
      5. Strategy refinement where pt. is focused on proprioceptive feedback, the "feel of movement"
      6. During late stages of learning, incorp distractors (convo/dual tasks) to develop autonomous control
      7. Give Feedback
         1. Intrinsic vs Extrinsic feedback
         2. Concurrent vs Terminal feedback
         3. KR vs KP
         4. Frequent FB vs Varied FB
            1. Type of Varied feedback schedules:
            2. Summed Feedback
            3. given after a set # of of trials
            4. Faded Feedback
            5. given at first after every trial & then less frequently
            6. Bandwidth Feedback
            7. given only when performance is outside a given error range
            8. Delayed Feedback
            9. given after a brief time delay
         5. Clinical decisions about feedback incld:
            1. Type (mode)
            2. How much (intensity)
            3. Occurrence (scheduling)
      8. Practice, Practice, Practice
         1. Massed vs Distributed
            1. Massed
            2. sequence of practice & rest times practice time > rest time
            3. Considered if:
            4. motivation & skill levels are high and when pt has adequate endurance, attn, & concentration
            5. Distributed
            6. spaced practice intervals practice time =/<rest time
            7. Considered if:
            8. task itself is complex, long, high energy cost, pt has low motivation, short attn span, poor concentration or motor planning deficits, limited performance capabilities & endurance etc
            9. results in more learning per training time although training time is increased
         2. Blocked vs Random
            1. Blocked
            2. practice sequence org around 1 task performed repeatedly, uninterrupted by practice of any other task
            3. Random
            4. practice sequence in which a variety of tasks are ordered randomly across trials
            5. shown to have superior LT effects in terms of retention
         3. Practice order
            1. Blocked Order
            2. repeated practice of a task/group of tasks in order: 111222333
            3. benefit: produced improves early acquisition of skills (performance)
            4. Serial Order
            5. predictable & repeating practice order: 123123123
            6. Random Order
            7. nonrepeating & nonpredictable practice order 123321312
            8. benefit: produce better retention & generalizability of skills
         4. Mental Practice
            1. facilitates acquisition of motor skills
            2. when combo w/physical practice=increase in accuracy & efficiency of movements @ signif faster rates than physical practice alone
            3. considered for:
            4. pts. who fatigue easily & unable to sustain physical practice
            5. alleviating anxiety assoc. w/initial practice by previewing the upcoming movement experience
         5. Part vs Whole
            1. Part-whole practice
            2. most effective w/discrete or serial motor tasks that have highly independent parts
            3. not as effective for continuous movement tasks or complex tasks w/highly integrated parts
            4. Whole practice
            5. effective for continuous movement tasks
            6. effective for complex tasks w/highly integrated parts
         6. Transfer of Learning
            1. Bilateral transfer
            2. practice using contralateral (unaffected) extremity
            3. benefit: this initial practice enhances formation/recall of the necessary motor program, which can then be applied to the opp involved extremity
            4. Lead-up Activities
            5. simpler task versions of a req'd complex task
            6. subtasks are practiced in easier postures w/signif reduced DOF
            7. ie: practicing upright postural control in kneeling, half-kneeling or plantigrade b4 standing
         7. Closed vs Open Environments
   4. Measures of Learning
      1. Performance
      2. Retention
      3. Generalizability
         1. ability to apply a learned skill to the learning of other similar tasks
            1. ie learning to transfer form w/c to mat then apply that learning to other types of transfers: w/c to car; w/c to tub
      4. Resistance to contextual change
         1. adaptability req'd to perform a motor task in altered environmental situations
            1. ie walking w/cane on indoor level surface then apply that learning to new & variable situations: walking outdoors;on busy sidewalk
   5. Def: a set of internal processes assoc. w/practice/experience leading to relatively permanent changes in the capability for skilled behavior
3. Functional Skills
   1. Essential Functional skills=4 broad categories of motor skills:
      1. Mobility
      2. Stability
      3. Controlled mobility
      4. Skill
   2. Neurodevelopment Postures p. 482
      1. 1. Prone-on-elbows
      2. 2. Quadruped
      3. 3. Bridging
      4. 4. Sitting
      5. 5. Kneeling & half-kneeling
      6. 6. Modified plantigrade
      7. 7. Standing
4. Recovery
   1. 2 Main Types of Recovery
      1. Spontaneous Recovery
         1. resulting from repair processes immediately after insult
         2. influenced by return to fnx of undamged parts of brain w/resoln of temporary blocking factors (Diaschisis); takes 3-4 wks
      2. Function-Induced Recovery
         1. neural reorganization that occurs as a result of increased use of involved body segments in behaviorally relevant tasks
   2. Function-Induced Recovery (use-dependent cortical reorg)
      1. refers to the ability of the NS to modify itself in response to changes in activity & the environment
      2. Possible explanations
         1. Vicariance
            1. different & underutilized areas of the brain take over the fnxs of damaed tissue
         2. CNS backup or fail-safe systs
            1. the CNS has backup systs (parallel cortical maps) that become operational when the primary syst breaks down
            2. unmasking of new, redundant neuron pathways permits cortical map reorg & maintenance of fnx
            3. Substitution
            4. process where whole diff areas of the brain are also capable of becoming reprogrammed
      3. Constraint-Induced Movement Therapy (CI Therapy)
         1. mad research on CI therapy in pts following stroke
            1. demonstrated signif & large improvements of UE fnx
         2. is intense & task-specific
         3. limbs are max loaded to tolerance while movements are coordinated to stimulate actual walking
         4. 2 critical factors in its success:
            1. 1. The concentrated & repetitive practice of the involved UE
            2. ~6 hrs/day
            3. 2. Movement was restricted in the sound UE for up to 90% of waking hours
   3. Effects of Environment on Recovery of Fnx
      1. there's evidence that pts recovering from stroke who were treated on an acute stroke unit demonstrated better recovery & functional outcomes than pts who received comparable amt of PT while on a general medical unit
      2. Carr & Shepherd argue that poor recovery after stroke may be partially explained by improverished & nonchallenging environments (hospitals & rehab environ) that many individs recovering from stroke are exposed to
5. FRAMEWORK FOR INTERVENTION
   1. Intervention Strategies
      1. Compensatory Training Strats
         1. Substitution; Adaptation; Assistive/Supportive Devices
      2. Neuromotor Strats/TherEx
         1. Neuromotor training; Developmental Activities; Balance, Coordination, Postural Training; Gait/locomotor Training; Strength, Power, Endurance; Relaxation Training
      3. Functional Training Strags
         1. Task-Specific Training; Behavioral Shaping; Environment Enrichment
      4. Motor Learning Strats
         1. Feedback: KP, KR; Practice: Type, Sequence, Order; Transfer Training; Problem Solving
   2. Functional Training
      1. not eligible:
         1. lack voluntary control or cognitive fnx; early stages TBI recovery; Stroke etc
      2. prerequisities:
         1. basic head & trunk stability during upright positioning
      3. Functional Task Analysis Worksheet p. 248
      4. Task-Oriented Training Strats to Promote Function-Induced Recovery p. 489
   3. Neuromotor Development Training
      1. includes developmental activities training, motor training, movement pattern training, and NM education or reeducation
      2. technique that involves the affected body segments targeted for training while compensatory movements by intact segments aren't allowed
      3. Hands-on approach is used to stimulate, guide, or assist movement for correct performance
      4. 2 Most Popular Approaches in current use:
         1. 1. Neurodevelopmental Treatment (NDT)
            1. Emphasizes the use of Feedback & Feedforward mechanisms to support postural control
            2. Pt. learns to control posture & movement thru sequence of progressiely more challenging postures & activities
            3. uses "Handling Techniques & Key Points of Control" directed @ supporting body segments & assisting the pt in achieving active control
            4. Sensory stim (facilitation & inhibition via proprioceptive & tactile inputs) is used
            5. postural alignment & stability are FACILITATED
            6. Excessive tone & abnormal movements are INHIBITED
         2. 2. PNF
         3. NM/Sensory Stimulation Techniques
            1. Facilitation techniques include:
            2. Facilitation; Activation; Inhibition
            3. the combo of spina inputs & supraspinal inputs acting on AMN will determine whether a muscle response is facilitated, activated, or inhibited
            4. General Guidelines:
            5. 1. several inputs applied simultaneously produce the desired motor response owing to spatial summation w/in the CNS, whereas a single stimulus may not
            6. 2. Repeated app of same stimulus may produce the desired motor response owing to temporal summation, whereas a single stimulus may not
            7. Contraindicated for:
            8. pts w/hyperactivity; whereas inhibition/relaxation techniques are of benefit
            9. Facilitation techniques aren't appropriate for pts who demonstrate adequate voluntary control
   4. Compensatory Training
      1. is early resumption of functional skills using uninvolved segments for fnx
      2. Central tenets of this approach:
         1. 1. Concept of substitution
         2. 2. Concept of adaptation: modification of task & environment
      3. splinter skills-skills acq'd in manner inconsistent w/skills the individ already possesses & can't be easily generalized to other task variations or other environments
      4. May be only realistic approach possible when:
         1. recovery is limited or the pt presents w/signif impairments & functional lims w/little/no expectation for additional recovery
   5. Integrating Approaches=Best
6. Intervention Strategies to Improve Motor Control
   1. Strength, Power, Endurance Training
      1. Muscle Strengthening
         1. Benefits:
            1. increased production of max force due to changes in neural drive & changes in muscle
            2. Increased connective tissue tensile strength & bone mineral density
            3. Improved body composition in terms of BMR of lean to fat
            4. Improved RT, functional performance & sense of well-being
      2. Exercise Prescription incld:
         1. Mode of exercise; Intensity; Frequency; Rest interval; Duration
      3. Basic Principles of Effective Strengthening Programs incld:
         1. Overload Principle
            1. 80% MVC
         2. Specificity Principle
            1. training effects are specific to the mode of exercise stress imposed on the execising m.
            2. the training efects from an isometric protocol are specific to the exercising muscle & the point in the range that the muscle is holding
         3. Cross Training
            1. program incld variety of training elements: isometric, concentric, eccentric, & endurance
            2. used to place broadest possible demands on the NM syst & overcome effects of specificity
         4. Reversibility Principle
            1. failure to sustain benefits of strength training if mm. aren't regularly used in a maintenance program of resistance or function exercises
      4. Exercise Types
         1. OCK & CKC
         2. Plyometric Training
         3. Progressive Resistive Exercise (PRE)
            1. Con: the weight selected is determined by the amt that can be lifted by the muscle @ the weakest pt of ROM
         4. Isokinetic Training
            1. Benefits:
            2. Provides accommodating resistance throughout ROM; Speed of movement can be predetermined
         5. PNF
            1. Pro: offers functionally based, synergistic movements
            2. Stretch during PNF
            3. applied in lengthened range to assist in initiation of contraction & throughout range as needed to sustain contraction
            4. Approximation during PNF
            5. applied to assist extensor paterns
            6. Traction during PNF
            7. applied to assist flexor patterns
            8. Specific Techniques Appendix B pp. 514-516
         6. Benefits of Functional Training (unlike straight planes of motion & isolated movements: PRE & Isokinetic Training
            1. Improved: Coordination of mm.; Postural Control & Bal; Muscle Extensibility & Flexibility
            2. Develop Control of synergistic muscle groups acting in multiple axes & planes of movements
            3. Fosters control of varying types & combos of muscle contractions that are used interchangeable during normal movement
            4. Maximizes intrinsic sensory input (somatosensory, vestibular, visual)
      5. Endurance Training
         1. 60-70% VO2 max
         2. 3days/wk or alternate days '
      6. MAXIMIZING TANSFER GAINS TO FUNCTIONAL SKILLS
         1. must combo strength training protocols w/task-specific ptractice
            1. match strength training protocol to the reqs of the functional task in terms of ROM achieved & type magnitude, & speed of contraction
   2. Flexibility Exercises
      1. Techniques:
         1. ROM Exercises
            1. AROM; AAROM; PROM
         2. Muscular Stretching
            1. Types:
            2. Manual or Mechanical
            3. Static Stretching
            4. Ballistic Stretching
            5. high-load, short-duration
            6. Facilitated Stretching
            7. PNF Facilitated Stretching Techniques incld: (appendix B p.516)
            8. Hold-Relax
            9. Contract-Relax
            10. Active Contraction
            11. is superior to static & ballistic stetching!
         3. Joint Mobilization
   3. Strategies to Manage Tone
      1. Strats for Managing Hypertonia
         1. Interventions to manage spasticity (appendix C pp. 518-519):
            1. Prolonged Icing
            2. Prolonged Stretch
            3. Inhibitory Pressure
            4. Neutral Warmth
         2. Rhythmic Rotation (appendix B p. 516)
            1. highly effective exercise technique that can be used to reduce hypertonicity & increase ROM
      2. Serial Casting
         1. In combo w/stretching=effective in reducing hypertonicity, improve ROM & reducing deformity
         2. Used When:
            1. traditional techns fail & pt. is at risk for development of contractures & deformity, or demonstrates ineffective movement patterns or severe limitations in hygiene & skin care
         3. Changed every 5-7 days
         4. Contraindicated in pts. with:
            1. Severe heterotropic ossification (HO); muscle rigidity; Skin conditions such as open wounds, blisters/abrasions; Impaired Circulation & Edema; Uncontrolled HTN; Unstable intracranial pressure; Pathological inflamm conditions; Those at risk for Compartment Syndrome or Nerve Impingement; Those w/long-standing Contractures (>6-12 mos)
      3. Modalities
         1. NMES
            1. to reduce spasticity & improve motor fnx
         2. TENS
            1. to improve motor fnx & reduce tone in pts w/UMN syndrome
         3. EMG BIOFEEDBACK
            1. to relax spastic mm. by monitoring m. activity of during slow, passive stretch
      4. Strats for Managing Hypotonia
         1. Quick Stretch
         2. Tapping
         3. Resistance
         4. Approximation
         5. Positioning
         6. Strengthening exercises that don't overload the weak, hypotonic mm. are indicated
            1. interventions designed to improve postural stability in functional positions
         7. NMES
   4. Postural Control Training
      1. Strats to Improve Static Postural Control
         1. Neuromuscular/sensory Stimulation Techniques
         2. Rhythmic Stabilization
         3. PNF technique of Stabilizing Reversals (Slow Reversals)
            1. for pt w/hyperkinetic disorders: ataxia, athetosis
         4. Using Therabands or wts to enhance proprioceptive loading & contraction of stabilizing muscles
         5. Aquatic Therapy
         6. Neuromuscular fixed-support strategies to improve standing control
            1. Ankle Strategies
            2. standing on wobble board/foam roller w/flat side down progressing to flat side up
            3. Hip Strategies
            4. pt. instructed to move upper body forward & backward while standing on foam roller. Tandem standing or tandem on foam roller-to recruit lateral hip strats
         7. Anticipatory Postural Adjustment exercises
            1. prior knowledge serves as an important source of info in initiating correct postural pattern
      2. Strats to Improve Dynamic Postural Control
         1. any WB postures
         2. Quick stretch
         3. Tapping
         4. Light tracking resistance
         5. Manual contacts
         6. Dynamic Verbal Commands
         7. PNF extremity patterns
            1. Dynamic Reversals (Slow Reversals)
            2. Repeated Contractions
            3. Rhythmic Initiation
            4. Combo of Isotonics (Agonist Reversals)
         8. TherEx Ball activities
         9. Stepping Strategies
      3. Postural Awareness Training
         1. PT interventions should focus first on improving specific musculoskeletal impairments then on postural reeducation w/demonstration
         2. Categories/Types
            1. COM Control Training
            2. focus on obtaining symmetrical, balanced WB
            3. PRACTICE VOLITIONAL BODY SWAY
            4. it assists pt in developing accurate perceptual awareness of LOS, an important component of overall CNS internal model of postural control
            5. Posturography Feedback Training
            6. Force-platform devices are used to measure forces & provide COP biofeedback or posturography feedback
            7. comp analyzes data & provides feedback concerning sway path & COP position on a visual monitor
            8. used to shape sway movements to enhance symmetry & steadiness
            9. Effective/indicated for pts who
            10. demonstrate probs in force generation
            11. bal retraining using this training doesn't automatically transfer to fnal skills like gait
      4. Strats to Improve Safety
         1. High risk activities likely to result in falls:
            1. Turning; Sit-to-stand transfers; Reaching & Bending over; Stair Climbing
         2. COMPENSATORY TRAINING STRATEGIES
            1. Maintain adequate BOS @ all times
            2. Widening BOS when turning or sitting down
            3. Widening BOS in direction of expected force (ie in direction of wind)
            4. If Greater Stability is Needed:
            5. Instructions on lower COM
            6. Wearing shoes w/low heels & rubber-soles for better gripping to increase friction btwn body & support surface
            7. use of an AD
   5. Sensory Training
      1. Characteristics of Sensory Receptors
         1. Slow Adapting vs Fast Adapting Receptors
            1. Slow Adapting receptors such as: jt receptors, GTOs & muscle spindles
            2. used more in monitoring & regulating postural responses
            3. Fast Adapting receptors such as: touch receptors
            4. generally more effective in initiating dynamic movements
         2. Slow Velocity vs High Velocity Movements
            1. Slow Velocity Movements
            2. afferent stimuli can contribute to movement responses
            3. High Velocity Movements
            4. there's sufficient time to allow for afferent info to effect motor control (open skills)
      2. Deafferentated Limbs
         1. PT must focus on forced training of sensory-deficit limbs even though pt may have little interest in moving it
      3. can be used to sharpen C& heighten perceptions & assist in reorganizing the CNS
      4. Training Strats for Sensory Loss
         1. Sensory Stimulation Techniques
         2. Sensory Integration Training
            1. the use of enhanced, controlled sensory stim in context of a meaningful, self-directed activity in order to elicit adaptive behavior
            2. Goals:
            3. improve sensory discrimination: ID of specific stimuli, intensities, & localization of stimuli
            4. improve perception: selection, attn, & resposne to sensory inputs w/appropriate use of info to gen specific motor responses
         3. Sensory Reeducation
            1. used successfully to improve sensor fnx in pts w/peripheral nerve damage
      5. Training Strats for Balance
         1. 3 Sources of inputs utilized to maintain balance:
            1. Somatosensory Inputs
            2. proprioceptive & tactile inputs from feet & ankles
            3. Visual Inputs
            4. Vestibular Inputs
         2. Examination to ID pt's use of inputs to maintain bal:
            1. Clinical Test for Sensory Interaction & Balance (CTSIB)
         3. Use of Compensatory Training
            1. if more than 1 of the major sensory systs are impaired, compensatory shifts are generally inadequate & bal deficits are pronounced
         4. Augmented Feedback (to assist training)
            1. verbal commands; light-touch finger contact; biofeedback cane w/auditory signals; limb load monitor
   6. Gait & Locomotion Training
      1. Basic reqs for walking:
         1. establishment of a rhythmic stepping pattern
         2. body support & propulsion in intended direction
         3. dynamic postural control
         4. ability to adapt to changing task & environmental demands
      2. Interventions
         1. First directed at improving function of individual gait components
         2. Then shift to improving synergistic control of muscles & flexibility through functional training activities
         3. Lead-Up/Preambulation Activities to improve strength, ROM, & control necessary for gait:
            1. Bridging
            2. Sit-to-stand
            3. Static & Dynamic postural control activities in:
            4. kneeling
            5. half-kneeling
            6. modified plantig rade
            7. *stepping first in modified plantigrade & then in standing
            8. standing
      3. Task-Specific Training
         1. What should be done:
            1. Prevent further indirect impairments (weakness, decreased endurance, loss of mobility etc)
            2. Practice weight shifting, stabilization of stance limb or advancement of dynamic limb
            3. practice walking under supportive conditions using // bars or ADs
            4. then stand-by guarding w/hands off approach asap
            5. walking w/a variety of walking patterns: forwards, backwards,sidewards, side stepping, cross stepping, braiding gait
            6. then further progressions
            7. provide resistance
            8. control for speed: use marching music
            9. practice on varying surfaces
            10. eyes open vs closed
            11. moving head R & L; up & down to vary vestibular inputs
            12. walking w/directional changes
            13. dual task training
            14. obstacle courses to challenge control
            15. stair climbing w/various step number
            16. Lead-Up Activities for Stair climbing:
            17. Sit-to-Stand transfers
            18. Standing weight shifting activities
            19. Stepping activities
      4. Locomotor Training Using BWSTT