Bio-mechanical The understanding of kinaematics and kinesiology serves as the foundation for the biomechanical frame of reference.

The clinician views the limitations in occupational performance from a biomechanical perspective, analysing the movement to required to engage in occupation, Based on the principles of physics, the force, leverage and torque required to perform a task or activity are assessed. They also serve as the basis for intervention... The focus is on intervention addressing these basic client factors to improve occupational performance. Intervention may include exercises, splinting or other orthopaedic approaches, the outcome must reflect engagement in occupation.

Approach: Bio-mechanical Obj/ Aim Principles y Weight displacement y Encourage and reinforce development of a stable equilibrium by allowing equilibrium reactions

Techniques Weight displacement using activities Disturbance of centre of gravity Change height of centre of gravity

Posture

Works towards symmetry in the maintenance of posture y Rises sensory inputs for the experience of correct posture particularly proprioceptively by using techniques of percussion and/or compression which provide sensory feedback. y Reduce compensation until automatic adaptation is achieved. Muscular endurance y Resistance should be held to 50% or less for maximal strength for progressively longer periods of time. y Activity must be repetitious over a controlled number of times over duration of time. Intensity of the load or resistance. y The muscles need to be loaded to it maximum capacity of 20-30% to reach max muscle power to the point of exhaustion. y The force or resistance must exceed the capacity of that muscle in order to engage more motor units. Length of the contraction y Satisfactory contraction of the muscle fibres results in y

Use of symmetrical posture Positioning Compression Physical reinforcement Handling

Grading Centre of gravity above base: low-high Base of support: large-small, fixed moving External support: some-none Balance: Staticdynamic Static posture to dynamic posture. Positioning is graded from passive positioning to active correction and maintaining of posture. Less to more reinforcements

Activities which are moderately fatiguing, for progressively longer periods of time, with intervals to rest to allow metabolic recovery.

Increase the time of the session

Remediating the weakness. Intensity of the load or resistance. Length of the contraction Type of contraction Duration of contraction Rate of velocity of contraction Tempo of exercise Assistance or resistance

Alter weight applied Alter the point where the load is placed Alter the level of movement. Tired muscles should rest and not be overworked Excess and vigorous exercises can lead to further damage.

fatigue of the fibres thus more fibres are employed thus additional fibres will hypertrophy. Type of contraction y Weak muscles should be exercised to avoid wasting o Isometric exercises can be used to tighten and strengthen muscles o Isotonic exercises increase muscle strength by moving your weight. Duration of contraction y A sustained contraction increases the load on the muscle resulting in the activation of more motor units and ultimately in strengthening the muscle. Rate of velocity of contraction y A slower contraction produces more torque thus allowing more time for the recruitment of additional motor units resulting in strengthening of the muscle. Tempo of exercise y Increased tempo of the activity improves muscle power. Assistance or resistance y Strengthen in a gravity eliminated plane Positioning y Positioning of the joint in the optimal position could prevent the gradual advancement of contractures.(anti deformity positions) Slow passive stretches y Gentle stretches allows underlying soft tissue to adjust. By taking the stretch to the point of discomfort through external force. Stretching through activities y Participation in activities and the movements requires apply a slow stretch to the joints. And attention is focused away

Positioning Slow passive stretches Stretching through activities

from the affected joint. Muscular endurance y Resistance should be held to 50% or less for maximal strength for progressively longer periods of time. y Activity must be repetitious over a controlled number of times over duration of time. y Weight shifting or disturbance of centre of gravity leads to compensation with the innervated muscles to maintain postural control y Maintaining centre of gravity in an upright position over BOS to improve static balance y Aim for symmetry in the maintenance of a posture. Upright position requires activation of truck muscles to maintain the position against gravity y Moving a joint to a point of maximal stretch and holding that position allows connective tissue to adapt to the new requirements and adjust its length over time contractures. y Slow stretching with a slow improvement. The stretch must be maximal to the point of discomfort and held there for a few seconds. Weight displacement leads to eliciting equilibrium reactions through this the patient relearns balance Weight displacement using transfers Disturb centre of gravity using transfers and movement of limbs y Maximal to minimal assistance y Speed of displacement slow to fast y Static to dynamic balance Activities which are moderately fatiguing, for progressively longer periods of time, with intervals to rest to allow metabolic recovery. Increase the time of the session

Postural Control

Weight Shifting Disturbance of COG Repetition

Complexity of movement Speed Facilitation

Postural Alignment

Use of activities requiring symmetrical postures

Range of motion

Passive movement

Passive positioning to maintaining to activate correction of a posture. Resting to dynamic posture y Stretch to a point of discomfort and hold. y Increase the time spent in the position y Increase range daily

Balance

Muscle power

Through adding resistance, the muscle lengthens and contracts and muscle hypotrophy takes place.

Resistance Repetition

y Moderate to minimal assistance y Minimal to maximal resistance y Amount of repetitions

To maintain or prevent limitations of ROM

y To increase ROM

TO increase muscle strength

TO increase endurance

TO improve static balance

positioning in a resting or functional position will avoid development of deformities, minimize oedema and maintain ROM gained Contraction of muscles help pump fluid out of the extremity (AROM) Positioning above the heart level aid venous return Through slow stretch the tissue surrounding a joint will adjust gradually, causing tight tissue to be lengthened which will increase ROM Through active, controlled contraction of muscles with a high frequency, the muscle strength of the muscles will be increased. (additional muscle cells are formed motor units are recruited) Moderately fatiguing activity (contractions against less than maximal resistance) for increasingly long periods of time with intervals of rest will increase muscle endurance Maintaing centre of gravity in an upright position over the baso of support to improve static balance

y y y y

Compression Positioning AROM PROM

y The degree of flexion or extension can be graded

y y

Active stretch Passive stretch (manual/orthot ic devices)

y y y

Force Speed Direction

y y

Active contraction Controlled contraction

y y y y

Intensity of load Duration of contraction Frequency Rate of velocity or contraction Period of time Intervals of rest

Less than maximal resistance applied over a period of time Rest intervals (metabolic recovery) Activities requiring weight shifting disturbanc e of centre of gravity Repetition

y y

y TO improve dynamic balance Weight shifting or disturbance of centre of gravity leads to compensation with the innervated muscles to maintain postural control

y y

Direction of displacement (anterior to lateral to posterior) Amount of displacement required Enlarge/decre ase base of support Amount of displacement Enlarge/decre ase base of support Increase/decr ease external objects used Weight of

external objects used Increase or decrease speed required

NDT Approach: NDT Obj/ Aims Muscle tone Reflexes Active movement Cognitive Postural Control Postural alignment Balance Coordination Principles y Bridging y Normalisation of tonus through elongation of the trunk muscles and dissociation of trunk and pelvis. y Weight bearing y Provides sensory input through joints though kinaesthetic proprioceptive input. y Postural adaptations occur due to the sensory input through the proximal joints, thereby normalizing tone increasing functioning of the distal joints. y Trunk rotation or dissociation y Helps incorporate rotational components of movement through the pelvic girdle, lumber and thoracic areas. y Handling of the key points of control produces changes in the tone therefore influencing Miss. Ns postural tone as well as control of her trunk. y Proper positioning y Encourages learning of normal movement patterns through kinaesthetic proprioceptive feedback. y Facilitates normal movement throughout the recovery process. y Increase postural tone by stimulating techniques, compression, static weight bearing, rhythmical stabilisation, fast movement, and resistance. Techniques Bridging Static weight bearing over the affected side. Compression Symmetrical patterns Resistance Sensory stimulation Work for head and trunk control and alignment. Work to activate up against gravity. Inhibition y Weight shifting y Non-static weight bearing y Side lengthening y Trunk rotation y Slow stretch y Inhibitory tapping y Shake y Normal movement y Slow Ice Facilitation y Weight shifting y Non-static weight bearing y Compression y Tapping: Sweep, alternating, pressure y Place and hold y Quick ice Grading Amount of resistance during weight bearing needs to be adjusted Inputs from the therapist Proximal control of trunk before distal control over extremities Control of extremities in weight bearing before spatial control Increase or decrease the amount of facilitation

Reflexes

Use sensory stimulation Work to activate up against gravity. Inhibition through TIP Integration Normal Movement Patterns Repetition y y

Activities which require the opposite movement than what is elicited by the reflex Activities requiring normal movement patterns Repetition

Coordination

Inco-ordination due to lesions of cortico-spinal systems may be improved by normalising tone and developing normal movement patterns.

Neuro-developmental Approach (NDT) Bobath Important aspects to remember: y

Position Support from the therapist Stimulus elimination Therapist facilitates to voluntary, independent, normal movement. Verbal input Normalising tone Gross-Fine Developing normal Gross-precise movement patterns manipulation Modulating reflexes Speed Accuracy Complexity Strength Rhythm Stability vs. mobility Grasp Handling object see Pedretti pg.770

Alignment of body segments requires a base of support ideal alignment results in optimal length tension relationships for muscle fibres increasing the potential for muscle activations leads to an increase in potential for muscle activation. P: proximal stability for distal mobility T: Tapping alternately 24 hour management with practise in between Normal sensation of movement, breaking into key components, using key points of control. Normal sensation of movement (mirror) - e.g. home programmes Breaking into key components self care is very important. Match expectations for retention and carry over to a patients physical cognitive and emotional capacities. Teach caregivers Use of physical handling Continue with verbal cues and use the environmental interaction Manual cues: key points of control leads to better physical movement and promotes motoric responses. Consistent with synergies to get normal movement patterns and inhibit the abnormal patterns

The just right level of the challenge is important: By grading use of manual cues (key points of control), you do not guide the client through new movements but facilitate learning. DO not overuse, reduce the challenge he must be actively involved Acquisition of movement:

y y

Movement practised in position can be carried over into other positions (eg. bridging in supine would be automatically used in midstance phase of gait) Practise specific to activity e.g. practise sport, or do flexion in functional movement picking up a cup (not only flexing) Adults are not expected to go through developmental milestones, but are only required to do what is functionally required for him/her in their life role

Neuroplasticity is the ability of the CNS to shape and renew self in response to practised activities Principles of management p774 (table 31-1) - Problem solving Principles y Retrain normal movement patterns (normal sensation of movement) y Therapist avoid abnormal movement patterns y Use activities and exercises that encourage normal movement patterns in trunk and extremities y Help the patient use existing motor control on the hemiplegic side for occupational performance y If the patient lacks strength /control develop compensations and adaptations to encourage the use of affected sides Techniques y use key points of control Facilitation techniques: give sensation of normal movement on hemiplegic side provide a system for relearning normal movement Stimulate muscles directly to contract: isometrically, eccentrically, isotonically y Practise movement y Teach ways to incorporate the affected side into functional tasks Inhibitory techniques: y Decrease abnormal muscle tone y Restore normal alignment in the trunk and extremities by lengthening spastic muscles y Stop unwanted movements and associated reactions y Teach methods for decreasing abnormal posturing of the arm and leg during task performance y (look at preparatory techniques, also example bridging)

Social Learning

Approach: Banduras Social Learning Obj/aims Principles Areas of Modelling occupation and A person forms a cognitive performance image of how certain skills. behaviours are performed through the observation of a model, and on subsequent occasions this coded information (stored in long term memory) serves as a guide for his action. Observational learning

Techniques y Social skills training y Assertiveness training y y y y y Modelling Practice Feedback Repetition Coaching

Grading

consists, of four processes, viz. Attentional processes, Retention Processes, Motor reproduction, Motivational processes (if positive reinforcement [internal external] is present the person performs modelled behaviour). Practice Instructing and modelling the desired behaviour is not enough. The client is given the opportunity to perform or practice the targeted behaviour in a simulated situation. Feedback Feedback should affirm or correct behaviour. A client could thus make mistakes in a protective environment where the errors have few negative consequences, and constructive feedback is available. Clients should be helped to make changes in their thought patterns and behaviour to improve their mental health. feedback should be: Objective and accurate Specific Corrective by providing suggestions or alternatives Positive or neutral for what the client does right. Coaching One way of getting a client to behave in a certain way is to give him or her clear instructions on what to do and why. If you want the client to lower his tone of voice inform him or her this in clear and unambiguous terms. Repetition Repeated practice and frequent feedback is important so that the necessary adjustments could be made. The principle is therefore; repeated brief trials, with immediate and frequent feedback. Motor Learning Approach: Motor Learning Aims/Obj Principles Techniques Grading

Facilitation of the development of postural control and also movement strategies that are needed to achieve a functional goal. Provide feedback: intrinsic, extrinsic, knowledge of results and knowledge of performance. o Practice a task for learning. (As a whole or in parts) Facilitates the development of postural control and also movement strategies that are needed to achieve a functional goal. Feedback contributes to motor learning process: Intrinsic feedback, extrinsic feedback, knowledge of results and knowledge of performance. Practicing a task is beneficial to learning. This may be practicing the task as a whole or parts.

y y

y y

Verbal instructions Demonstrating movement strategies Facilitation Practice

y y

y y

Verbal instructions Demonstrating movement strategies Facilitation Practice

Give less/more instruction

SI Approach: Sensory Integration Obj/Aims Principles y Bilateral y Positioning: integration y The otolith organ y Proproceptive receives information vestibular with regard to the input position of the head in space. The CNS y Posture processes this y Muscle tone stimulation and a y Cospecific response is contraction elicited. y Normalisation of tactile input

Techniques y Positioning of the head in different postures affects sensation of gravity. y Prone, supine, all fours, sitting, standing y Height of surface affects sensation of gravity and sense of security. y Support affects postural adaptations and sense of security. y Support of body (manually/ environment) y Base of support y Supporting surface

Grading y Positioning of head y Vertical Horizontal y Mid-positionlateral/diagonal y Inversion y Low-high y Total No support y Stable, unmovable, uneven/ raised surface- Stable, movable surface unstable, moveable, surface

Direction of linear

Movement and displacement: y Linear and angular movement stimulates the semi-circular canals. The CNS processes this stimulation and a specific response is elicited.

Linear acceleration and deceleration have an inhibitory effect on the CNS Angular acceleration and deceleration can have an inhibitory or facilitatory effect on the CNS Slow, even rhythmical movement has an inhibitory and integrating effect on the CNS. Fast, uneven, a rhythmical movement has an facilitating effect on the CNS

movement Direction of angular movement Nature of movementspeed, excursion, time Inhibitoryfacilitatory

Cognitive Behavioural Approach: Cognitive Behavioural Aims/Obj Principles y Postural y Demonstrations of the alignment correct posture in sitting. y Performance y Verbal feedback skills y Strengthen link between cognition and behaviour y Areas of occupation y Learn skills to handle life y Motivate patient to identify effect of thoughts on behaviour y Monitor and reflect thoughts, while learning new behaviour. y Create opportunity for implementation Techniques y Rewarding y Modelling/ imitation y Repetition and practice y Trial and error y Re-enforcing y Imitating y Modelling y Visual learning y Coaching y Association y Multi-sensory learning Grading y Decrease verbal feedback.

Psychosocial Interactive Approach: Psychosocial interactive Aims/Obj Principles All areas of 1. Instillation of hope occupation and Hope keeps the clients in performance the group and has an areas effect on other factors such as intrinsic motivation to participate in the group. Hope can be therapeutic in it self and often has a positive effect on the outcome of the session. Techniques 1. Hope 2. Universality 3. Imparting of information 4. Altruism 5. Socializing techniques 6. Imitative behavior 7. Interpersonal learning 8. Cohesion Grading Time Structuring Size Facilitation Activities Amount of information imparted

2. Universality The clients may have the sense that they are unique and different from everyone else because of their problems with play as well as in other performance areas. The group treatment session should make each child feel as they are part of the group and their individual problems should not play a role in the group. During this session, all the clients will be treated the same (with regard to discipline and receiving rewards etc.) It is important to accept each child but at the same time, the therapist must not play on their differences. The problems should be addressed as a whole and the clients should not be singled out individually if there is something wrong. This is done by setting up rules at the beginning of the session as not to pick on the clients later if they do anything wrong in the session. 3. Imparting information This involves the sharing of information within the group. Much of this information can be used by the other members of the group in their daily lives. This applies differently to clients groups. For our group sessions, imparting information is important to initially bind the group together. Getting to know the other clients in the group can help to minimise uncertainty and can facilitate the clients willingness to participate in the group. 4. Altruism

9. Catharsis 10. Corrective recapitulation of the primary family group 11. Existential factors

This is the ability to assist one another in a group setting and in the process, everyone can benefit. 5. Development of socialising skills During this session, the activities are structured and presented in such a way as to encourage interaction and communication with one another. 6. Imitative behaviour As the clients are placed in a group situation, they are given the opportunity to learn from each other. 7. Interpersonal learning The clients have an opportunity to learn from each other by making errors, identifying these mistakes and learning from what the other clients in the group say. This factor is important but presentation is important so as not to make the client feel that the others in the group are attacking her. Feedback needs to be encouraged. 8. Cohesion Building up relationships is a positive factor of group therapy. This relationship can be established between the clients and their peers in the group and/or between the clients and the therapists. This alliance and relationship can influence the outcome of the group as it is easier to receive feedback and trust someone that you have a relationship with. This group cohesion is important as the clients will be working together regularly and they need to be able to trust the therapists.

9. Catharsis This is the factor that involves the experience and expression of emotions and feelings (whether positive or negative). The clients will have to learn how to express their feelings in an acceptable manner. Educational

Aims/Obj y

Approach: Educational Principles y Give opportunity for verbal discussion take into account memory, interpretation, motivation and need of knowledge. y Use visual mediums, brochures, posters, take into account culture, language, literacy and distribution y Always use with other techniques.

Techniques Teaching Verbal discussion Visual mediums

Grading

Neuro-Physiological Approach: Neuro-Physiological Aims/Obj Principles Postural Control Indirect: y Inhibition of abnormal reflexes y Normalisation of tone y Motor re-learning Direct: y Weight shifting or disturbance of the centre of gravity leads to eliciting of equilibrium reactions. Through this the pt relearns equilibrium reactions. Techniques y Weight displacement using activities y Disturbance of centre of gravity y Change height of centre of gravity y Repetition Grading y Amount of displacement required y Centre of gravity above base: lowhigh y Base of support: large-small, fixed -moving y External support: some-none y Increase or decrease ROM in limbs. y Grade speed required. y Change direction of displacement.

Motivation Self Esteem Mood Eliciting Emotions

Large arm movements above the head in a circular motion activates the release of serotonin

y y y y

Big movements Physical Activity Increase heart rate Sun

in the blood stream which stimulates the limbic system, which results in an improved mood
y Physical activity leads to more oxygen being inhaled and thus transported to the brain, improve mood, motivation and activity level. Improve heart rate. Sun. y Integrate different scents into activities to elevate mood Weight shifting Disturbance of centre of gravity Repetition

y y y

Balance (in neuro patients)

Different olfactory scents have an effect on the limbic system and elevation of mood Weight shifting/disturbance of centre of gravity leads to eliciting equilibrium reactions through this the patient relearns balance

Static to dynamic Sitting to standing

Physiological Approach: Physiological Aims/Obj Principles Maintain soft Placing constant pressure on tissue integrity the skin especially at bony (PRESSURE prominences like the back of SORES) the head, the posterior aspects of the hips, the sacrum and the heels will cause the skin to become thinner and less elastic, until a sore is formed at that spot. By releasing pressure on the skin, sores will be prevented. Techniques Re-positioning or relieving pressure every 2 hours. Taking care of the skin by washing and properly dressing the skin Grading Grade the time between positioning

Motivation and Action

CREATIVE ABILITY Principle By making use of the just right challenge , maximum effort is facilitated and the current level of

Techniques Self-Differentiation Self-Presentation Appropriately grading the activity

Passive Participation

participation is challenged. By making use of activities that are meaningful to the patient, maximum effort is facilitated By facilitating active participation the client will experience task satisfaction

A meaningful 1-2 step activity Destructive, incidental constructive Participation is fleeting and therefore prompting and constant assistance is needed to sustain participation Physical assistance and constant supervision is required Effort is minimal and not sustained therefore the patient needs to constantly be brought back to the activity. Physical assistance, guidance and prompting is needed Presenting an activity that has an immediate effect ( wow effect). No norm compliance

A meaningful 3-4 step activity Explorative Patient is unsure during participation (therefore explorative action). Thus constant reassurance is needed throughout the session.

A meaningful 5-7 step activity Product Centred Participation varies and therefore some assistance is needed throughout the activity. Therapist needs to promote participation by example.

By facilitating maximum effort, the patients abilities will be challenged and the objectives will be improved

Effort is inconsistent and not maintained, exploration needs to be facilitated. Prompting and assurance is needed

Effort varies and therefore occasional guidance and prompting is necessary. Demonstrations and encouragement is needed Presenting an activity that allows a client to develop a skill. Introducing norms

By making use of an activity that produces a visually pleasing endproduct, task satisfaction and feelings of accomplishment can be facilitated

Presenting an activity that allows the client to present himself and explore the environment Basic tool handling Limited amount of norm compliance

Grading y y y y y By increasing the level of skill each activity requires By increasing the variety of activities and the different skills needed Increasing the demands to participate actively by decreasing incidental involvement Increase the intensity of emotions being elicited By grading the therapists feedback of the clients product according to the norm compliance expected

Approach: Motivation and action Aims/Obj Principles Present the just right challenge so that the client experiences success.

Techniques y Activity

Grading y Interaction with environment

y y

Client must exert maximum effort for success. Give him meaningful activities. Stimulate the childs interests and drive to participate. Allow the child to explore and master so that her motivation improves. Active involvement and task satisfaction is very important to remember. Elicit desire to handle material. Eliminate expectations therefore eliminating anxiety. Feeling of pleasure to be repeated often thereby realising it is good to do. Ensure a feeling of satisfaction following effort.

y y

increased Increase time to do task Interaction with others can be increased The number of steps in the task. Encourage concept formation. Increase with tool handling initiated.

Task Centered Approach: Task-centred approach Aims/Obj Principles All areas of Client Centred Focus occupation and y Elicited through active performance participation of the patterns client during treatment. Occupational Based Focus. y Use of functional tasks as the focus in treatment. y Select tasks that are meaningful and important to the client. y Analyze the characteristics of the tasks selected and the appropriateness for optimal intervention y Describe the movements used for task performance to the client for understanding y Analyze the movement patterns and functional outcomes of task performance according to client Person and environment y Identify the personal Techniques y Client Centred Focus y Occupational Based Focus y Person and environment y Practice and Feedback y General Treatment Goal Grading

and environmental factors that serve as major influences on occupational performance. Use natural objects and natural environments.

Practice and Feedback y Structure practice of the task to promote motor learning. y Design the practice session to fit the type of task and learning strategies. y Provide feedback that facilitates motor learning and encourages experimentation with solutions to occupational problems. General Treatment Goal y Discover the optimal movement patterns for task performance. y Achieve flexibility, efficiency, and effectiveness in task performance. All areas, especially ADL Occupational performance emerges from the dynamic interaction between: 1. Person - Ms. C.M. 2. Environment - hospital 3. Occupation bed mobility, transfers, standing. Functional task activity, e.g. transferring and dressing

Adaptation Approach: Adaptation Aims/Obj Principles All areas of Changing the context occupation and y Changing factors performance (demands of task, tools) patterns that are external to the pt to improve occupational function. y Changing the context places low metaprocessing on the pt thus resulting in rapid improvements. Re-establishing habits and Techniques y Changing the context y Re-establishing habits and routines Repetition Consistency y Acquiring compensatory skills and strategies. Grading Increase-decrease repetition Increase-decrease adaptive tools

routines y Repetition and consistency performance of daily occupations occurs with little or no conscious attention. y Routines and habits let people expeditiously carry out frequently performed activities with minimal attention. Acquiring compensatory skills and strategies. y Teaching Pts new skills and strategies allow compensation for permanent or temporary impairments. y Pts need to appreciate the importance of the new skills and strategies, to be motivated for training, and recognizing opportunities in which the skill can be used. Behaviouristic Approach: Behaviouristic Aims/Obj Principles Learn behaviour based on previous experiences. Do not focus on thought, but focus on behaviour. Replace unacceptable behaviour with acceptable behaviour through conditioning. Break up new behaviour in to smaller components. Create opportunity where new behaviour can be displayed. Techniques Modelling Model behaviour on good behaviour of other. Desensitisation Gradual, uncontrolled, build up exposure to a sensitive situation. Behaviour modification Change unacceptable behaviour with contracts and goals reward/punishment. Chaining Gradual build up of actions to task completion. Biofeedback Feedback with chaining (relaxation therapy) Grading Grade familiar to unfamiliar stimuli and duration and frequency at which stimuli is presented.

Brunnstrom

Approach: Brunnstrom Aims/Obj Principles Active Movement Movement is required in Coordination stages called synergies. Muscle tone Use of active movement emphasizes voluntary movement. Components need to be practiced. Where there is no movement, make use of reflexes, associated reactions and tactile stimulation to facilitate movement.

Techniques Activities which elicit desired movement component or pattern during each stage.

Movement is regained by repetition of correct movement component or pattern. Making use of movements against resistance.

Facilitate movement by eliciting an association reaction or making use of reflexes when no voluntary movement is yet present Activities requiring repetition of desired movement. Activities that require movement against resistance.

Grading Mass patternsVoluntary control of isolated movementscoordinationimproved skill. Gross-fine movements Bilateral to unilateral movements Isometric- eccentricconcentric Sustained active movement Recovery stages.

Developed for individuals who sustained a cerebrovascular accident, the design draws strongly from both the reflex hierarchial models of motor control. Patients who sustained these accidents were described as going through evolution in reverse. Spastic or flaccid muscle tone and the presence of reflexive movements that may be evident after a CVI or as a part of the normal process of recovery and are viewed as necessary intermediate steps in regaining normal movement.

Stages:

These stages include the description of extension and flexor synergy patterns for the upper and lower limbs In the Brunstrom approach, emphasis is placed on facilitating the progress of the individual by promotion of movement, from reflexive to volitional. In the early stages of recovery, his may include incorporation of reflexes, and associated reactions to change tone and achieve movement. Example: To generate reflexive movements in the arm, resistance may be applied to the one side of the body to increase muscle tone on the opposite side. This technique is applied until the client demonstrates volitional control over the movement patterns. -Pedretti Assumptions and principles of Brunstrom movement therapy y y In normal motor development, spinal cord and brainstem reflexes become modified and their components rearranged into purposeful movement through the influence of higher centres Because reflexes and whole limb movement patterns are normal stages of development and because stroke appears to result in development in reverse, reflex and primitive movement patterns should be used to facilitate the recovery of voluntary movement post stroke Proprioceptive and exteroceptive stimuli can be used to evoke desired motion or tonal changes Recovery of voluntary movement procds in sequence from mass stereotyped flexor or extensor movement patterns to movements that combine features o the two patterns and finally to discrete movements of each joint at will(synergies) Synergies refer to patterned movements of the entire limb in response to a stimulus or to voluntary effort Newly produced correct motions must be practiced to be learned

y y

y y

Practise within the context of daily activities enhances the learning process

Basic limb synergies: y y y they may occur reflexively or s early stages of voluntary control when spasticity is present when movement is initiated a movement of one joint all muscles that are linked in synergy with each movement automatically contract causing a stereotyped movement pattern upper extremity-flexor synergy: is composed of scapular retraction and/or elevation shoulder abduction and external rotation elbow and forearm supination position of the fingers is variable (elbow component flexion is the strongest component of the flexor synergy). flexor synergy can be evoked when no movement exists by applying resistance to shoulder elevation or elbow flexion of the uninvolved upper extremity. upper extremity -extensor synergy: scapular protraction shoulder horizontal adduction and internal rotation elbow extension forearm pronation and variable wrist and finger motion (the pectoralis major is the strongest component of the extension synergy. pronation is the next strongest ) upper extremity flexor synergy usually develops before extension synergy. when both synergies are developing and spasticity is marked the strongest components of the flexion and extension synergies sometimes combine to produce the typical upper extremity posture rotated, with elbow flexed forearm pronated and the wrist and fingers flexed the lower limb flexor synergy is composed of hip flexion, abduction and external rotation, knee flexion; dorsiflexion and inversion of the ankle and dorsiflexion ot the toes. (hip flexion is the strongest component) lower limb-extensor synergy:

Compensatory

Approach: Compensatory Aims/Obj Principle Energy Compensatory methods help conservation to maximize function.

Technique Teaching compensatory methods can help Mr. C.L. save energy when he participates in activities.

Grading Amount of assistance given

Humanistic Approach: Humanistic Aims/Obj Principle y Responsibility lies with the patient to reach answers y Reflection of emotion y Patient centred give patient control y Empathy Therapeutic relationship Affolter Approach: Affolter Aims/Obj Principle Tactile-kinaesthetic system is key to problem solving. The therapist must try to involve entire body to challenge posture and upper extremities Effective problem solving leads to learning and independence Patient must experience learning situations and interact with the environment, explore. Technique Guiding (maximal, moderate, minimal assist) Grading Grade the amount of assistance Technique y Congruence y Active listening y Encouragement Support Grading y The amount of input from the therapist y The amount and depth of problems to be solved

Mistakes allowed during treatment

Provide tactilekinaesthetic info during the session

The patient must experience learning situations and interact with the environment to learn

Use tactile system

Effective problem-solving in turn leads to learning and independence and information processing

Presenting tasks that involve problemsolving (that the patient experiences in everyday life/ ADL) Provide with a challenge
Allow the patient to make mistakes and thus solve problems

By physically guiding the patients hands and body in functional activities, the patient can process stimulation without extra stimuli

Non-verbal guiding maximal assistance (heavy) Moderate assistance Minimal assistance (light) Guide until you can reduce assistance Regular speed of guidance (not too fast or too slow)

Tactile-kinaesthetic input

Only patients hand comes into contact with the object being manipulated Guide movement along whole support surface

To challenge posture and upper extremities Developing sensory motor skills prove a foundation for the development of complex cognitive and perceptual skills (link to principle 1)

Involve the whole body Tactile, kinaesthetic, proprioceptive and vestibular stimulation Non-verbal guidance/feedback Repetition Always guarantee success. Do not let the patient fail, but mistakes can be made and corrected Allow the patient to initiate the task

Main focus is perceptual and cognitive improvement through problem solving in the environment. It is a functional and meaningful approach. It can be used for patients who have aphasia and apraxia, who do not rely on verbal / visual cues) According to Willard and Speckman, Barbara Zoltan
Sensory Stimulation FOR PATIENTS ON TONE!! Approach: Sensory stimulation Aims/Obj Principle Orientation, y Each stimulus is provided attention, with a desired motor memory response in mind. y The range of stimuli provided can be: tactile, vestibular, olfactory, kinaesthetic, proprioceptive, auditory, visual and gustatory. y Stimulus with an emotional significance to the patient, will most likely elicit a response. y Patients response may be slow because CNS processing is slowed or prevented by the damage. ROOD APPROACH y y y y Originally developed for CP Uses sensory stimulation to recover motor control Applied to wide variety of motor control problems Normal motor control emerges from the use of reflex patterns present at birth As these patterns are used and generate sensory stimuli in purposeful activity, they support voluntary control at a conscious/cortical level The patterns are however under unconscious subcortical control Basic movement patterns does not require conscious attention which can instead be directed to the goal/purpose of the task, thus organization of motor control makes for efficiency in motor tasks Different muscles have different responsibilities Rood classified muscles into 1) Light work muscles - Primary function = movement -Voluntarily controlled 2) Heavy work muscles -primary function = stabilization -reflexively controlled THUS different types of nervous system control THUS respond differently to sensory stimulation

Technique y Pleasant and unpleasant, familiar and unfamiliar stimuli are presented. y Wait for a response or repeat stimulus

Grading Grade familiar to unfamiliar stimuli and duration and frequency at which stimuli is presented.

y -

y y y

Following CNS damage the normal sequence of reflex development and learned voluntary motor control did not occur thus abnormal tone Used to assist patient to move voluntarily Used to prepare the patient for active participation in purposeful activities Application

y y y

Identify the highest developmental motor pattern that the person can do with ease Treatment begins with the next level at which person most struggle Physical response to sensory stimulation, psychological factors (individuals emotional state and perceived significance) THUS!! Holistic perspective to achieve maximal motor control

Approach: Rood OBJECTIVE/AIM -To obtain normal motor control -To normalize m.tone

PRINCIPLE Appropriate sensory stimulation could elicit specific motor responses: -Normalize muscle tone by using sensory stimuli to evoke an appropriate muscle response -Begin with persons current developmental level to progress through the normal sequence of motor development -Focus attention on the goal/purpose of an activity (because all movement is essentially purposeful) -Provide opportunities for repetition to reinforce learning

TECHNIQUES To evoke muscle response (facilitatory) -sensory stimuli (e.g. applying ice, brushing and stroking the area over muscles) -proprioceptive stimuli (e.g. manual joint compression, quick stretching, tapping, pressure applied by therapist , resistance to movement) Tech to inhibit muscles: -sensory stimuli (slow rhythmic movement, neutral warmth, maintained stretching) -olfactory, gustatory, auditory and visual stimuli can be used to facilitate or inhibit (used when voluntary control in minimal and abnormal tone and reflexes are present)

GRADING Sequential progression -evoking muscle response with sensory stimuli -using obtained responses in developmentally appropriate patterns of movement -purposeful use of movements in activity Normal developmental sequence of motor behaviour to be followed

Comparison of key treatment strategies used in the traditional sensory motor approaches

Carr and shepherd y y y y Principles of motor learning guide the therapist structuring the therapeutic environment to maximise the patients recovery of motor function Framework on which approach is based include dynamical systems theory of motor control, the plasticity of CNS and maladaptive biomechanical changes that occur after CNS injury Active and passive mobility is introduced early to prevent and decrease muscle stiffness and shortening Therapeutic environment is very important, and is established to facilitate relearning of effective strategies for performing functional movement

Therapist as coach: y The patient therapist relationship is active, collaborative mentoring with regards to motor performance

Goals: y y Encourage performance of most important mechanical features within a given category of a motor task Discourage behavioural adaptations with limited effectiveness

Treatment teaching-learning process y y The patient must have a clear understanding of the motor goal and strategies appropriate/ not appropriate for reaching a goal The patient is asked to routinely describe/ demonstrate with another body segment if necessary, the specific movements required to achieve a task. This gives the therapist a clear understanding of what the patient thinks they are being asked to do. Instructions are then modified accordingly. Carr and Shepherds approach use individual as active participant whose major goal in rehabilitation is to relearn effective strategies for performing functional movement Patients practise tasks that require mild variations in movement patterns during successive repetitions Limb movement s and postural adjustments are always learned simultaneously and in the context of task performance Whole task performance is emphasized rather than [practising component parts Practise is critical to motor skill development because patients learn heat they practise thus important that patient s do not use compensatory movement strategies during daily activities outside therapy (see evaluation and treatment planning pg 506 Tromley 5th) Carr and Shepherds treatment focus: Standing up and sitting down Balance Walking Reach and manipulation

y y y y y

Approach: Rood OBJECTIVE/AIM

PRINCIPLE

TECHNIQUES

GRADING

Early introduction to active and passive mobility prevents and decreases muscle stiffness and shortening An optimal therapeutic environment facilitates relearning of effective strategies for functional movement Performance of most important mechanical features within a movement guides motor relearning of that movement A clear concept of the motor strategy ensures effective motor learning A clear concept of the task end project ensures an effective motor learning

Practise is critical to motor skill development because patient s learn with practise Repetition: successive repetitions to relearn he effective strategies for performing movement Oral instructions: words kept to minimum The most important aspect of the movement is identified on which the patient must concentrate during task performance Provide and object goal (not abstract directions) Visual demonstration Provided the therapists own performance of task with focus on 1-2 components most important to the patients development of control Photos or pictures can also be used to indicate the essential task component A very effective strategy with regards to sequential tasks, eg rising from supine to sitting Manual guidance: Helps to clarify model of action by passively guiding the patient through the path of

Whole task performance preferred above practising component parts of task

movement physically resisting or constraining inappropriate movement eg. When sitting down, the therapist gives manual guidance behind shoulders to reinforce the concept that patients must move body forward to achieve necessary hip and knee flexion Accurate, timely feedback Quality of performance is very important It helps the individual to learn strategies to repeat and which to avoid Only provide positive feedback for accurate movement/ improvement not effort.