Motor Control and Motor

Learning Frames of
Reference
 WALLY
⦿ 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
⦿ Mental and physical status –
● appears to be very neat, clean and well groomed.
● Inconsistent eye contact, especially when approached from
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
⦿ 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.
⦿ 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
● 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
 Describe the procedure you would use to
evaluate Wally’s ability to perform the task he
has chosen.

⦿ Conduct evaluation during occupational &

role performance in natural settings
● Dressing at home
⦿ 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.
⦿ Dressing
● Teaching a set pattern for
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
 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

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

⦿ 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.
⦿ 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.
⦿ 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 Motor Learning
•Handling •Task oriented approach
•Use of facilitation and inhibition •Focus on assisting clients in
techniques developing the optimal motor and
•Placing hands at key points of cognitive strategies for achieving
control functional goals
•Using reflex-inhibiting •Remediation, adaptation, and
patterns/postures (RIPs) compensation are not separated,
•Considered preparatory but represent one holistic
treatment because it’s directed approach
toward establishing sensorimotor •Practice of needed skills in
performance components that natural settings
are prerequisites for occupational •Practicing whole tasks, not
performance. isolated parts
•Providing randomized practice
 Changes in environment and task demand in:

NDT Motor Learning

In Wally’s case, his task demands will Early stages of learning: Feedback is
change by taking him longer to do focused on movement outcome and
certain things such keeping things the critical features of the task and
neat, clean, and being well-groomed. environment (not on motor
performance)
Environment in the home will need to •Later stages: Clients are
be changed in order to have easier encouraged to self-evaluate their own
mobility when he’s in his wheelchair, movement performance and
transferring, and bathing. outcome by focusing on feedback
from their own body and environment
 Role of adaptation and compensation:

NDT Motor Learning

•Discouraged compensation with •Remediation (establish or restore),
one-handed strategies for task adaptation, and compensation are
performance as counterproductive not separated, but represent one
because it encourages learned holistic approach
neglect
•Compensation continues to be
discouraged, and use of hemi side
encouraged for performing activities
of daily living.
 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:
● 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