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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
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WhatWhat impairs impairs movement?movement?
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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.
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Motor control theoriesMotor control theoriesA review of key concepts and applications
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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.
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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.
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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.
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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.
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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.
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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).
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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
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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).
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Skill learningSkill learningKey principles and critical variables principles and critical variables
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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)
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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
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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
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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
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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
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Distribution Distribution of practiceof practice
■ Massed practice
■ Distributed practice
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Variability Variability of practiceof practice
■ Blocked practice – early stage, complex, whole-body tasks?
■ Random practice – early stage, seated manipulative tasks?
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Order Order of practiceof practice
■ Blocked order practice
■ Serial order practice
■ Random order
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WholeWhole practice practice oror part part practicepractice??
■ Whole practice
■ Part –whole practice; progressive part practice
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Classification of Classification of taskstasks
■ Discrete tasks
■ Serial tasks
■ Continuous tasks
Schmidt (1988)
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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
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Classification of Classification of taskstasks Gentile (2000)
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Classification of Classification of taskstasks Gentile (2000)
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Mental Mental practicepractice
■ Theoretical underpinnings
■ Always combined with physical practice (!)
■ When appropriate to use
■ When inappropriate to use
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Speed Speed andand accuracy accuracy inin practicepractice
■ As near-normal performance as possible
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Transfer of learning Transfer of learning with practicewith practice
■ Bilateral transfer
■ Use of lead-up activities
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Feedback Feedback facilitates motor learning
■ Mode of feedback
■ Augmented feedback
■ Precision of feedback
■ Intensity of feedback
■ Schedule of feedback
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Mode Mode of feedbackof feedback
■ Internal feedback
■ External (augmented) feedback
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Augmented Augmented feedbackfeedback
■ Knowledge of results (KR)
■ Knowledge of performance (KP)
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Precision Precision of feedbackof feedback
■ General focus feedback
■ Specific focus feedback
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Intensity Intensity ofof feedbackfeedback
■ Constant (frequent) feedback
■ Intermittent (varied) feedback
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Schedule Schedule ofof feedbackfeedback
■ Immediate feedback vs delayed feedback
■ Concurrent feedback vs terminal feedback
Summary feedback
Faded feedback
Bandwidth feedback
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Phases Phases of skill learningof skill learning
Recall PT 152 unit Physiology of motor learning and memory
■ Fitts and Posner’s stages of motor learning*
Cognitive stage; Associative stage; Autonomous stage
■ Neo-Bernsteinian stages of motor learning
Novice stage; Advanced stage; Expert stage
■ Gentile’s stages of motor learning
Getting the idea of movement Getting the idea of movement stage; FixationFixation / / diversificationdiversification stage
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Phases Phases of skill learningof skill learning
■ Early phase of skill learning
“Getting the idea of movement” stage
■ Later phases of skill learning
Fixation / diversification stage
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Initial phase Initial phase of skill learningof skill learning
■ Setting the task goal
Selecting the functional task
Promoting self-efficacy and avoiding “goal confusion”
■ Structuring the environment
Using normal regulatory conditions
■ Promoting selective attention
Using an external focus and accentuating regulatory conditions
Observing, mentally organizing, visually scanning
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Initial phase Initial phase of skill learningof skill learning
■ Planning the movement
General advice on movement organization
Whole practice, unless task is naturally “breakable”
Typical-performance speed and accuracy
Mental practice
■ Performing the movement
Avoiding interferences: cues, feedback, manual guidance
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Initial phase Initial phase of skill learningof skill learning
■ Augmented feedback
Unambiguous
Intermittent
Knowledge of results
Knowledge of performance
■ Decision making
Modify task?
Modify environment?
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Later phases Later phases of skill learningof skill learning
■ Organizing practice by structuring the environment
Use of different types of tasks
Use of random practice
Increased practice time to increase movement efficiency
■ Organizing practice using an effective practice schedule
Use of distributed practice, unless fatigue is of little significance
Mental practice
■ “Fading” augmented feedback
Terminal feedback using KP or KR
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The patient as an active learnerThe patient as an active learner Some basic concepts and guidelines
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The patient as an The patient as an active learneractive learner
■ Involves ACTIVE PRACTICE of everyday tasks instead of passive receiving of therapeutic intervention
■ Involves being given the opportunity to practice tasks as much as possible (e.g., practice outside the clinical setting)
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The patient as an The patient as an active learneractive learner
■ Configuring the organizational structure for active learning
Function of staff, role of patients, and interaction of these
Clarifying policies and procedures (e.g., via drawing up contracts)
Promoting autonomy and responsibility in patients consistently
Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.
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The patient as an The patient as an active learneractive learner
■ Configuring the physical structure for active learning
Architecture / design of therapy workspaces
Providing suitable materials to enable “intra-clinical” practice
Providing suitable materials to enable “extra-clinical” practice
Ada L & Canning C (Eds) (1990). Key issues in neurological physiotherapy. Oxford, Butterworth-Heinemann.
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The patient as an The patient as an active learneractive learner
■ Active learning through independent practice
Explicit (written / illustrated / diagrammed / recorded) instructions
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.
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Intervention models Intervention models to improve to improve motor functionmotor function
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Intervention modelsIntervention models – an overview
■ FUNCTIONAL / TASK-ORIENTED training model
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Intervention modelsIntervention models – an overview
■ NEUROMOTOR DEVELOPMENTAL training model
Neurodevelopmental Treatment (NDT)
Proprioceptive Neuromuscular Facilitation (PNF)
Neuromuscular / Sensory stimulation techniques
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Intervention modelsIntervention models – an overview
■ COMPENSATORY training model
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Intervention modelsIntervention models – an overview
■ ECLECTIC training model
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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.