PT 154 PT 154 Therapeutic Exercise 3 Theoretical underpinnings of therapeutic exercises and activities for neurological and developmental conditions. Edward James R Gorgon MPhysio PTRP Chair and Assistant Professor Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila
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PT 154 PT 154 Therapeutic Exercise 3 Theoretical underpinnings of therapeutic exercises and activities for neurological and developmental conditions. Edward.
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PT 154PT 154 Therapeutic Exercise 3Theoretical underpinnings of therapeutic exercises and activities for neurological and developmental conditions.
Edward James R Gorgon MPhysio PTRPChair and Assistant Professor
Department of Physical TherapyCollege of Allied Medical Professions
University of the Philippines Manila
WhatWhat impairs impairs movement?movement?
Path to Path to abnormal movementabnormal movement
Attempt to move
Obstacles to efficient movement
Compensatory movement strategy
Repeated practice of compensatory strategy
Learned use of compensatory strategy
Carr J & Shepherd R (Eds) (1987). A motor relearning programme for stroke (2nd ed), Rockville, Aspen.
Motor control theoriesMotor control theoriesA review of key concepts and applications
Reflex theoryReflex theory
■ Motor behaviors as a function of the presence or absence of controlling reflexes
■ Enhancing or reducing the effect of various reflexes during motor tasks
Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2nd ed). Baltimore, Lippincott Williams & Wilkins.
Hierarchical theoriesHierarchical theories
■ Motor behaviors as a result of loss of higher-level CNS control and subsequent exaggeration of normal reflexes and / or appearance of pathological reflexes
■ Inhibiting (or facilitating) reflex activity and regaining control by higher CNS centers over lower centers during motor tasks
Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2nd ed). Baltimore, Lippincott Williams & Wilkins.
Motor programming theoriesMotor programming theories
■ Motor behaviors as determined by abnormalities in central pattern generators and higher-level motor programs
■ Learning the correct rules for action and applying motor programs through available effectors
Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2nd ed). Baltimore, Lippincott Williams & Wilkins.
Systems theorySystems theory
■ Motor behaviors as a result of mechanical constraints in the body that shape the expression of NS control
■ Addressing musculoskeletal system impairments that impact upon overall motor control
■ Addressing interacting impairments among multiple body systems
Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2nd ed). Baltimore, Lippincott Williams & Wilkins.
Ecological theoryEcological theory
■ Motor behaviors as a function of the ability to satisfy or adapt movement to task and environmental requirements
■ Developing the ability to achieve functional tasks in multiple ways
■ Develop the ability to come up with best solutions for movement problems given existing limitations
Shumway-Cook A & Woollacott MH (2001). Motor control: Theory and practical… (2nd ed). Baltimore, Lippincott Williams & Wilkins.
Motor control theories Motor control theories – in contrast– in contrast
HIERARCHICAL theory SYSTEMS theory
Sensory stimuli determine posture
Separation of voluntary and reflex
Top-down control
Behaviors organized around task goals
Anticipatory, predictive control
Normal movement strategies
Horak F& Shumway-Cook A (1989).
Motor control theories Motor control theories –– in contrastin contrast
■ In terms of theory on motor skill acquisition
■ In terms of theory on dyscontrol
■ In terms of theory on function recovery following brain injury and issue of functional carryover
Motor control theories Motor control theories – in contrast– in contrast
HIERARCHICAL theory SYSTEMS theory
Inhibit abnormal tone
Integrate primitive reflexes
Fractionalize movement by breaking up muscle synergies
Effectively achieve task goals
Improve use of prior experience and anticipatory postural adjustments
Access appropriate and efficient movement patterns
Improve adaptability to context
Horak F& Shumway-Cook A (1989).
Skill learningSkill learningKey principles and critical variables principles and critical variables
SkillSkill defined defined
■ Consistently attaining an action-goal with some ECONOMY OF EFFORT
■ Involves an INDIVIDUAL SOLUTION to the problem of how to efficiently organize movement to produce an action-outcome consistently
■ Is TASK-SPECIFIC
Gentile (2000)
Skill learning Skill learning processesprocesses
■ Explicit learning processes
■ Implicit learning processes
Regulation of intersegmental force dynamics
Blending of successive movement components
Coupling of simultaneous components
Practice Practice is critical in motor learning
■ …practice, when properly undertaken, does NOT consist in repeating the means of solution of a motor problem time and again, but in the process of solving the problem time after time by techniques which we have changed and perfected from repetition to repetition… practice is a particular type of repetition without repetitionBernstein (1967)
■ Considered the most important determinant of learning
Practice Practice is critical in motor learning■ Preparation of the patient for practice
■ Distribution of practice
■ Variability of practice
■ Order of practice
■ Whole practice and part practice
■ Structure of the environment during practice
■ Mental practice
Patient preparationPatient preparation for practice for practice
■ Verbal instruction
■ Visual demonstration / illustration; patient’s observation of motion patterns
■ Manual guidance
■ Mental organization of movement timing
■ External focus vs internal focus
■ Visual scanning of “far” environment
Distribution Distribution of practiceof practice
■ Massed practice
■ Distributed practice
Variability Variability of practiceof practice
■ Blocked practice – early stage, complex, whole-body tasks?
■ Random practice – early stage, seated manipulative tasks?
Order Order of practiceof practice
■ Blocked order practice
■ Serial order practice
■ Random order
WholeWhole practice practice oror part part practicepractice??
■ Whole practice
■ Part –whole practice; progressive part practice
Classification of Classification of taskstasks
■ Discrete tasks
■ Serial tasks
■ Continuous tasks
Schmidt (1988)
Structuring the Structuring the environmentenvironment during during practicepractice
■ Regulatory conditions normally operative in the task
Accentuating regulatory conditions
Eliminating non-regulatory conditions
■ Level of biomechanical complexity
■ Level of information processing complexity
Classification of Classification of taskstasks Gentile (2000)
Classification of Classification of taskstasks Gentile (2000)
Feedback from the environment – correct performance
– errors to avoid
Organized and self-monitored (or semi-supervised) practice
Recording and illustration of progress in therapy
Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.
Intervention models Intervention models to improve to improve motor functionmotor function
Intervention modelsIntervention models – an overview
■ FUNCTIONAL / TASK-ORIENTED training model
Intervention modelsIntervention models – an overview
■ NEUROMOTOR DEVELOPMENTAL training model
Neurodevelopmental Treatment (NDT)
Proprioceptive Neuromuscular Facilitation (PNF)
Neuromuscular / Sensory stimulation techniques
Intervention modelsIntervention models – an overview
■ COMPENSATORY training model
Intervention modelsIntervention models – an overview
■ ECLECTIC training model
Required Required readingreading
■ O’Sullivan SB. O’Sullivan SB. Strategies to improve motor functionStrategies to improve motor function. In: . In: O’Sullivan SB & Schmitz TJ (2007). Physical rehabilitation (5O’Sullivan SB & Schmitz TJ (2007). Physical rehabilitation (5 thth ed). Philadelphia, FA Davis Company.ed). Philadelphia, FA Davis Company.