EVALUATION OF THE STAGES OF MOTOR CONTROL

The stages of motor control incorporate normal development processes and provide us
with a clinical framework of reference to evaluate and treat motor problems, becoming a
simple guide to understanding normal movement and its alterations.

1. MOBILITY: It is the ability to move from one position to another with independence and
safety. Ability to move the body while maintaining postural control.

Consists in:
 Ability to initiate movement with adequate muscle activation.
 Ability to move through the arc of motion requiring range of motion and flexibility.

When evaluating this stage we must observe if there are:

 Adequate arcs of movement, evaluating them passively and actively.
 Muscle function, observing movement patterns, tone and reflexes.

Various developmental activities can be used to assess mobility, including: limb patterns,
turning or repositioning, prone positioning, or lateral reaching.

By observing the patient, the Physical Therapist will determine if the patient can initiate
appropriate movement responses independently and complete the available range of
motion.

The key elements that the physiotherapist must observe and document are: - initiation and
control of movements - required sensory, motor and cognitive strategies and global
coordination - termination of movement - environmental restrictions.

2. STABILITY: Static postural control or static balance. Ability to maintain postural

stability and orientation with the center of mass (CDM) on the base of support (BDS) and
the body at rest. For example, the patient shows stability in sitting or standing if he is able to
maintain the posture with minimal sway, without loss of balance, or holding on with his
hands.

Stability requires:
 Balance
 Postural reactions

Maintaining a stable position in relation to gravity is also called static balance or static
postural reactions. Both righting and balancing reactions contribute to the ability to maintain
posture or body position.

Throughout the first year of life, the child learns to control posture in positions against gravity
and weight-bearing; As the posture becomes more against gravity, the child's base of
support becomes smaller and the center of gravity higher.
Three fundamental moments can be identified in the development of stability in the child:
 The development of head control.
 The development of the sitting position.
 The development of the standing position.

These three postures are responsible for static postural control and are a prerequisite for
dynamic movement control.

The development of stability is divided into two fundamental stages:

Tonic hold: Activation of postural muscles in a short arc against gravity or manual
resistance. The sensitivity of the neuromuscular spindle improves as a result of the
stimulation of gravity or resistance.
Co-contraction: “Almost simultaneous” contraction of the antagonists around a joint, to
maintain or function properly in weight-bearing postures. In the development of
cocontraction, the action of the postural extensors is of primary importance. The stretch
applied to the extensors activates both the primary and secondary endings, allowing co-
contraction of flexors and extensors around the joint. The neurophysiological mechanism of
co-contraction has not been clearly elucidated; it is believed that the tonic muscle, by
maintaining a lengthened position, activates its secondary endings and that they are the
ones that facilitate the antagonist muscles to contract.

When assuming weight-bearing postures, periarticular receptors are also activated, which
is considered a facilitating stimulus for the stabilizing muscles around the joint.

When evaluating stability:

- It should begin by observing the ability to maintain tonic strength. The patient is asked to
perform an isometric contraction of postural muscles against gravity or manual resistance.
It can be done by asking the patient to lie prone, in lateral decubitus or sitting. The
Physiotherapist evaluates how well the patient is able to maintain the response and
observes the quality of postural control, if the patient holds in a smooth and sustained
manner; If you do a discontinuous and abrupt hold, it is indicative of deficient or altered
control.

We must keep in mind that if the extensor muscles do not do this, we cannot expect them
to maintain the weight of the body in more demanding weight-bearing positions.

- Observe co-contraction in weight-bearing postures such as: head in the midline in a prone
position (co-contraction in the neck), prone on elbows, quadruped, sitting, kneeling,
standing.

The criteria that allow adequate stability to be qualified include: Ability to maintain a posture
without help or support, Ability to maintain the posture for an adequate time, Control posture
with minimal displacement.
The key elements that the therapist must observe and document are: - the base of support,
- the position and stability of the center of mass with the base of support, - the degree of
postural sway, - the degree of stabilization of the upper extremities or - the number of
episodes of loss of balance and direction, - the degree of external help required, - the risk of
falls.

3. CONTROLLED MOBILITY. Dynamic postural control or dynamic balance. It is the

ability to maintain postural stability and orientation with the center of mass over the base of
support while parts of the body are in motion. In controlled mobility, movement is added to a
posture. Some authors – Sullivan, Minor, Markos and Rood – define controlled mobility as
mobility superimposed on stability, that is, the movement of the proximal segment, while the
distal segment (hands, knees, feet) are fixed. The “Bobath” speak of dynamic postural
control that is acquired through well-coordinated movement patterns and appropriate pitch
changes.

Other terms used to refer to this ability to maintain control while the body is in motion are
dynamic balance and stability in motion.

Motor control progresses from static to dynamic, motor skill functions require a balanced
interaction between static and dynamic control.

The evaluation of controlled mobility should focus on the observation of postural responses
during movement, through observing:

- Weight changes or movements in a posture. The patient is placed in the weight-bearing

position and is asked to move or move slowly in different directions: lateral, anteroposterior,
diagonal, rotation. The Physiotherapist observes that the movement is smooth,
coordinated and in the appropriate arc.

It should be taken into account that moving within a posture promotes the development of
balance reactions. When the patient cannot move, balance in the posture, impaired
balance reactions should be suspected.

- Stato-dynamic control must also be observed: the ability to shift the weight on one side
and leave the other limb free for dynamic activities. For adequate statodynamic control,
very good balance reactions are required.

The key elements that the therapist must observe and document are: - degree of postural
stability maintained by the loaded segments, - degree and extent of control of dynamic
movements, - level and type of assistance required (e.g., verbal commands, manual
contacts, guided movement).

4. SKILL. Ability. It is the ability to habitually execute coordinated movement sequences for
exploration and interaction with the physical and social environment. The proximal
segments stabilize while the distal segments are free to perform skilled functions (e.g.
manipulation or transportation).
Dexterity can also be defined as coordinated movement, characterized by discrete distal
function superimposed on proximal stability. Dynamic stability of the trunk and proximal
joints is maintained during the activities performed by the individual.

Examples of skill activities are:

 Oromotor function, chewing, swallowing, language.
 Manual function: closing and manipulation.
 Wandering.

Skill is a response organized into a sequence of goal-oriented activities that effectively uses
feedback to produce coordinated movement.

The individual who has normal dexterity is one who moves with precise control, for
example, when dressing or feeding; that maintains movement sequences for prolonged
periods, for example: walking, running; and that can also adequately combine different
sequences of movement, for example: walking and reaching for an object at the same time.

Skill assessment can be carried out using activities from the sequence:

- Change of decubitus or “rolling”. Observe how it does it, if there is coordination and
control and interaction of the different segments (flexion, rotation, extension). A segmental
roll should be expected, shoulder before hip or vice versa. A block rolling pattern (shoulder
and hip at the same time) is indicative of lack of control or hypertonia.

- In lateral decubitus, an indication of skill is the simultaneous counter-rotation of the trunk.

- In the upper limbs, the degree of manual control must be observed along with the postural
control that the proximal part must have. For example: asking the patient to perform
dressing activities, buttoning, writing, etc. Also ask for bimanual activities.

- In ambulation activities, the evaluation of skill includes the evaluation of gait: determinants,
base of support, reciprocal movements of the trunk and upper limbs. Variations in the
walking pattern: stopping, starting at different speeds, walking in different directions,
backwards, forwards, to the side, stairs, etc.

The key elements that the physiotherapist must observe and document are: - response
orientation and direction of movements (correct response), - precision, control and
consistency of movements (continuous and appropriate motor adjustments, stability), -
control of speed and synchronization of movements, which include reaction time and
movement time, - economy of effort.

Motor skills can be discrete, continuous or serial. Kicking a ball is an example of a skill with
pauses, with a recognizable beginning and end. Walking is a continuous skill (with no
recognizable beginning or end) and playing the piano is a serial skill (a series of discrete
actions put together). A skilled person is able to easily adapt movements to the specific
environments in which they occur. The mobility skill performed in a stable, unchanging
environment is called a closed motor skill, while the mobility skill practiced in a variable,
changing environment is called an open motor skill. A skilled person is also able to perform
simultaneous mobility tasks (dual-task control), for example, walking while holding or
manipulating an object.

BIBLIOGRAPHY:

O'SULLIVAN S. Physical rehabilitation. Volume I. Ed. Paidotribo. 2013.

O´SULLIVAN S., Schmitz T. Physical Rehabilitation assessment and treatment.

Secon edition. FA Davis Company. Philadelphia. 1988. Translation of the
Physiotherapist JULIA JUDITH RIVERA G. UIS teacher.