IPHREHAB :OCCUPATIONAL THERAPIST ASSESSMENT AND INTERVENTION FOR MOTOR LEARNING

IPHREHAB

Assessment

• OCCUPATIONAL THERAPIST Assessment includes:

1. Dynamic evaluation, watching client during occupational performance, including responses to cues.
2. Collaboration with client to determine occupational problems and priorities.
3. Evaluation of person, task, & context, to determine appropriate OT interventions.

Assessment

• OT evaluations may incorporate manual muscle tests, range of motion, strength & endurance tests, which directly relate to problems with specific task performance.
• Sensory & perceptual evaluations stem from client-identified problems with those aspects of task performance.
• Cognitive evaluations may further clarify difficulties with awareness, goal identification, motor planning, and generalization of learning.

INTERVENTION

• Client-centered role/task selection
• Discussion of OT assessment results
• Collaboration which includes therapeutic use of self in determining and/or raising level of client self-awareness
• Imparting information on current evidence with regard to a choice of approaches
• Practice of needed skills in natural settings

Motor Learning Interventions

• Prevention of injury/dysfunction through splinting, positioning, educating, & sensitization to relevant environmental cues.
• Promoting function through individualized task problem-solving & collaborative experimentation about the best way to accomplish the task.

• Practicing whole tasks, not isolated parts.
• Providing skill practice in varied contexts during daily routines.
• Providing randomized practice (changing parameters or circumstances).
• Providing intermittent feedback during task performance or summarized at end.
• Encouraging self-evaluation & error detection (both KP & KR).

Interventions

• Modify task demand in order to achieve task goal (use e-mail instead of telephone to communicate with others; use alarm to remember next step).
• Modify contextual factors in order to achieve task goal (use bolsters to position for active movement in playing a game).

Intervention: Constraint-Induced Movement Therapy

• Contemporary variation of task-focused approach for stroke survivors (1 year post-stroke).
• Consists of “constraining” nonaffected arm, forcing use of affected limb for performing daily tasks. 
• In 2-week experiment, “constrained” group showed significantly greater motor skills, carry over to life tasks, and maintenance of gains in 2-year follow-up.
• Original study replicated (Blanton & Wolf, 1999) shows that 20% to 25% of clients with chronic stroke symptoms may benefit from this approach.

Please make your own copy of article. Focus on distinctions made between traditional & contemporary OT approaches. 

IPHREHAB : MOTOR LEARNING , FUNCTION AND DYSFUNCTION AND CHANGE WITH MOTIVATION

IPHREHAB


FUNCTION & DYSFUNCTION

• Gentile (1992): early & late stages of learning
• Fitts & Posner (1967):

1. Cognitive stage of motor learning (understanding of task, experimentation)
2. Associative stage: refined practice
3. Autonomous stage: skill relatively automatic
4. Example: child learning to climb stairs

Function 

• Degrees of freedom: refers to gradual increase in smoothness of performance of skilled movement. Example: using a hammer.
• Specific definitions for function & dysfunction have not been defined in occupational therapy (Kaplan & Bedell, 1999). 
• Definition of dysfunction in OT must include all three components: person, environment, & occupation.

CHANGE & MOTIVATION

• Holistic approach: OT ALWAYS incorporates practice of perception and movement within the context of SPECIFIC TASKS. 
• Client centered: Motivation comes naturally when clients and/or families set priorities for tasks to be accomplished & goals to be achieved. 
• Systems approach begins with role performance, considering the best combination of remediation, adaptation, & compensation in order to promote client-identified level of functioning to fulfill desired roles.

Change

• Change occurs through learning process.
• Recovery may be:

1. Spontaneous, without benefit of intervention
2. Forced recovery, function gained through therapeutic intervention, such as – example?
3. Adapted or functional recovery, attained through altering methods or contexts within which client accomplishes a task

Postulates of Change, cont.

• Defined in Pediatrics by Kaplan & Bedell. Motor skills more likely to improve when:

1. Match between child’s ability, task, & context.
2. Child understands expectation & receives clear guidance
3. Independent problem-solving encouraged
4. Just right challenge (zone of proximal development).

IPHREHAB : MOTOR LEARNING FROM PAST TO PRESENT

IPHREHAB

 MOTOR LEARNING FROM PAST TO PRESENT

• Aim is to replaces Motor Control (NDT, etc.) as a more evidence-based approach to all forms of movement disorders across the lifespan (CP, TBI, CVA, etc.)
• Backdrop for Task Oriented approach defined by Horak (1991), Shumway-Cook & Woolacott (2001) and Mathiowetz, Bass Haugen & Flinn (in Trombly & Radomsky, 2002). 

Basic Assumptions

Motor Control – It is the ability to regulate and/or direct the mechanisms essential to movement (Shumway-Cook & Woolacott, 2001). AKA “neuromaturational” or “hierarchical” or “bottom up” theories of re-acquisition of voluntary movement.

Motor learning – Set of processes associated with practice or experience leading to relatively permanent changes in the capacity for producing skilled action (Shumway-Cook & Woollacott, 2001). Combines neuroscience with  systems & learning theory.

Assumptions, cont.

• Based in principle of neural plasticity – the ability of the nervous system to modify neural connections to perform more efficiently.
• Short term (working memory) – needed for learning new movements 
• Long term (save/retrieve) – needed for lasting change
• Motor learning occurs naturally during task performance (supports a task focused approach)

Systems Theory

1. Systems approach includes a consideration of :

• Client factors: health condition, dysfunction or damage, age, gender, etc.
• Occupations: meaningful or preferred tasks
• Environment: all relevant contexts.

1. Systems include sensorimotor, psychosocial, cognitive, and performance contexts (physical, socioeconomic & cultural characteristics of the task itself and the broader environment) (Mathiowetz & Bass Haugen, 1994).
2. Consistent with occupation-based models

IPHREHAB : SENSORY AND MOTOR LEVEL OF DERMATOME

IPHREHAB

A dermatome is a patch of skin that is innervated by a given spinal cord level. Figure 2 is taken from the ASIA classification manual, obtainable from the ASIA web site. Each dermatome has a specific point recommended for testing and shown in the figure. After injury, the dermatomes can expand or contract, depending on plasticity of the spinal cord.

C2 to C4. The C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle (the horizontal bone that goes to the shoulder. C4 covers the area just below the clavicle.

C5 to T1. These dermatomes are all situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the lateral aspects of the hand, and T1 covers the medial side of the forearm.

T2 to T12. The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

L1 to L5. The cutaneous dermatome representating the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

S1 to S5. S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

Ten muscle groups represent the motor innervation by the cervical and lumbosacral spinal cord. The ASIA system does not include the abdominal muscles (i.e. T10-11) because the thoracic levels are much easier to determine from sensory levels. It also excludes certain muscles (e.g. hamstrings) because the segmental levels that innervate them are already represented by other muscles.

Arm and hand muscles. C5 represents the elbow flexors (biceps), C6 the wrist extensors, C7 the elbow extensors (triceps), C8 the finger flexors, and T1 the little finger abductor (outward movement of the pinky finger).

Leg and foot muscles. The leg muscles represent the lumbar segments, i.e. L2 are the hip flexors (psoas), L3 the knee extensors (quadriceps), L4 the ankle dorsiflexors (anterior tibialis), L5 the long toe extensors (hallucis longus), S1 the ankle plantar flexors (gastrocnemius).

The anal sphincter is innervated by the S4-5 cord and represents the end of the spinal cord. The anal sphincter is a critical part of the spinal cord injury examination. If the person has any voluntary anal contraction, regardless of any other finding, that person is by definition a motor incomplete injury.

It is important to note that the muscle groups specified in the ASIA classifications represent a gross over simplication of the situation. Almost every muscle received innervation from two or more segments.

In summary, the spinal cord segment serve specific motor and sensory regions of the body. The sensory regions are called dermatomes with each segment of the spinal cord innervating a particularly area of skin. The distribution of these dermatomes are relatively straightforward except on the limbs. In the arms, the cervical dermatomes C5 to T1 are arrayed from proximal radial (C5) to distal (C6-8) and proximal medial (T1). In the legs, the L1 to L5 dermatomes cover the front of the leg from proximal to distal while the sacral dermatomes cover the back of the leg.