The information contained in these outlines and charts will discuss the various aspects of motor control, including frames of reference, evaluation, and treatment techniques.
Motor Learning: The development of movement resulting from multiple processes, including those related to sensory/perception, cognitive and motor systems. The integration of these processes into movement is associated with practice and may include experience, motivation, reinforcement and developmental progress, all leading to permanent change in a person’s capability for skilled action. Pathology in any of the systems involved can result in impairments that may limit functional movement.
Sensorimotor Approaches: The sensorimotor approaches use external sensory stimulation to elicit specific movement patterns. The intervention strategies used in these approaches frequently involve the application of sensory stimulation to muscles and joints to evoke specific motor responses, handling and positioning techniques to effect changes in muscle tone, and the use of developmental postures to enhance the ability to initiate and carry out movements.
The four traditional sensorimotor intervention approaches are:
1. Rood Approach
2. Brunnstrom Approach
3. Proprioceptive Neuromuscular Facilitation (PNF) Approach
4. Neurodevelopmental Treatment (Bobath or NDT) Approach.
Basic principles:
1. The CNS is an organized structure which is arranged in a hierarchy. The higher centers, specifically the cortical and subcortical areas, are responsible for regulation and control of volitional, conscious movement. The lower levels regulate and control reflexive, automatic, and responsive movement. When damage to the CNS occurs, it is believed that the damaged areas can no longer regulate and exert control over the underlying areas which results in a return to more reflexive and primitive movement patterns. When damage to the CNS occurs, there is a reappearance of reflexive motor activity and the inability to control these reflexive movements.
2. Reflexes are automatic, predictable, and stereotypic movements which are normal responses seen from early infancy. As the CNS matures, reflexes become integrated and become the foundation for volitional motor control. Reflexes are therefore the building blocks of movement and motor control.
In order to fully understand these approaches, hands on training and experience is necessary.
This table is designed to give you a broad understanding of how these approaches which can be incorporated into an OT intervention plan.
| ROOD | BRUNNSTROM **This intervention approach was specifically developed for individuals who had sustained a CVA |
Proprioceptive Neuromuscular Facilitation (PNF) | Neurodevelopmental Treatment Approach (NDT) Also known as the Bobath treatment approach |
|
| ASSUMPTIONS | 1. Normal muscle tone is a prerequisite to movement
2. Movement occurs in a developmental sequence (therefore treatment will follow the developmental sequence) 3. Motivation enhances purposeful movement and meaningful activities will encourage practice of desired movements 4. Repetition is necessary for the re-education of muscular responses |
1. Individuals who sustain a CVA regress to an older pattern of movements
2. Spastic or flaccid muscle tone and the presence of reflexive movements which are evident after a CVA are considered to be part of the normal process of recovery and are viewed as necessary in regaining volitional movement. |
Normal activity occurs in synergistic and functional movement patterns.
|
Individuals with CNS pathophysiology have dysfunction in posture and movement and subsequent functional activity limitations. All individuals with these impairments have the potential for enhanced function as the brain has the ability to reorganize itself due to neuroplasticity. Posture and movement impairments are changeable. |
| PRINCIPLES | • Normalization of tone • Muscular responses are achieved via controlled sensory stimulation.• Use of developmental sequences.• Purposeful movement: Purposeful activities can help to get the desired movement pattern. Meaningful activities are used to demand a purposeful response• Repetition/practice is necessary for motor learning. |
• Treatment progresses in a sequence from reflexes to voluntary to functional movements
• Normal movement requires muscles to work synergistically • Following damage to the CNS, movement recovery follows a specific sequence, known as the: Although patients proceed through these stages, a particular patient may stop at any stage. |
The definition of PNF encompasses the terms proprioceptive (which has to do with any of the sensory receptors that provide information concerning movement and position of the body); neuromuscular (involving the nerves and muscles); and facilitation.
1. Increase the motor learning of the agonist through repetition of an activity (repeated contractions) and rhythmic initiation. There are 2 pairs of foundational movements for the upper extremities- 2 diagonal patterns crossing the mid-line for each major body part, often incorporating verbal commands UE Diagonal 1 Various PNF stretching techniques include Hold Relax, Contract Relax, and Contract Relax Antagonist Contract. |
• Normalize muscle tone • Inhibit primitive reflexes • Facilitate normal postural reactions. • Improve quality of movement. • Re-learn normal movement patterns. |
| TECHNIQUES
|
Use of sensory stimulation to evoke a motor response and use of developmental postures to promote changes in muscle tone
A. SENSORY Facilitation techniques to facilitate movement: Inhibition techniques to inhibit spasticity Examples of how this stimulation may be applied includes tapping over a muscle belly to facilitate (increase) muscle tone and applying deep pressure to a muscle’s tendinous insertion to elicit an inhibitory (decreased) effect. B. DEVELOPMENTAL SEQUENCE • These sequences progress from proximal to distal and cephalocaudal. • 8 ontogenetic motor patterns in the following sequence |
Brunnstrom approach uses associated reactions and synergies. A synergy is a total flexion or extension movement of a joint or limb.
• Promote movement from reflexive to volitional. In the early stages of recovery include the use reflexes and associated reactions to change tone and achieve movement • Patients are encouraged to think about the movement and to gain control |
OT practitioners use PNF to manually facilitate a group of muscles that are weak in comparison to adjacent muscles. | Handling is the main method for better functional and postural performance of tasks
Handling techniques |
| TREATMENT STRATEGIES
|
Move patients through these developmental sequences. In clinical practice, practitioners may use selected principles from Rood’s work as adjunctive interventions to prepare an individual to engage in a purposeful activity. • The OT practitioner applies a quick stretch over the triceps before instructing a patient to reach for a cup or glass to improve elbow extension. • A patient is instructed in ways to apply their own sensory stimulation to enhance performance of ADLs. For example, during upper extremity dressing, the patient can be taught to perform a prolonged stretch of their affected biceps which would result in a reduction in muscle tone, and thereby increase the ease with which the patient’s arm is moved through the sleeve of their shirt. |
• The primitive reflexes that are usually present are asymmetrical and symmetrical tonic neck reflexes, tonic labyrinthine reflexes. • Resisted grasp of noninvolved hand causes grasp reaction in the involved hand. • Flexor movement or tone may be elicited in involved arm when the patient attempts to flex the leg or leg flexion is resisted |
• Mass movement patterns are used to promote movement. • The use of sensory stimulation, including tactile, auditory, and visual input, is also actively incorporated into treatment to promote a motor response. • PNF patterns are used during purposeful activities by structuring functional activities, especially in the placement of objects. |
Key Point of Control: Key points are parts of the body that the OT practitioner chooses as optimal to control (inhibit or facilitate) postures and movement. Proximal key points include the shoulders and pelvis, which are used to influence proximal segments and trunk. Distal key points upper and lower extremities (typically the hands and feet). Key points of control are also used to provide inhibition of abnormal tone and postures.
Examples: • Key point of control: the thumb. Thumb abduction and extension with forearm supination decreases flexor tone of the wrist and fingers. • Facilitate a patient in sitting, when weight-shifting, and standing using an NDT approach • Use arm to weight-bear to get arm involved as soon as possible. Weight shift using arm, use arm to support while standing, use arm as prop when teeth brushing- even if not using, it will be used to bear weight. |
AUDIO-VISUAL EXAMPLES OF APPLYING THESE APPROACHES
| ROOD | BRUNNSTROM |
|
 |
|
. |
| PNF | NDT |
 |
|
| Pictures copied from Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti).
|
|
| Frame of Reference | Description | Example | Video |
| Neurodevelopmental Treatment (NDT).
Authors: Berta Bobath, PT and Karel Bobath, MD |
Normal movement patterns are facilitated through handling techniques while abnormal movement patterns are inhibited. Handling techniques are usually incorporated during therapeutic activities or play.
|
An occupational therapist positions a child with hemiplegia in a prone on elbows position and facilitates weight bearing through the affected elbow while the child uses the unaffected hand to play with toy cars. | An overview of NDT treatment is shown in this video. |
| Brunnstrom Movement Therapy.
Author: Signe Brunnstrom, PT |
Synergies and reflexes that occur normally during development are also viewed as a normal part of the recovery process following stroke. These synergies and reflexes are used to facilitate movement, and then are incorporated into normal movement patterns.
|
An occupational therapist provides moderate assistance to a boy who has had a temporal lobectomy while he reaches for toys using a flexor synergy movement pattern to initiate movement. | A presentation on the Brunnstrom approach. |
| Proprioceptive Neuromuscular Facilitation (PNF).
Author: Herman Kabat, PhD, MD
|
The development of movement patterns is facilitated using the shift between flexor and extensor muscles, using diagonal movement patterns to encourage this shift.
|
An occupational therapist provides minimal assistance while a teenage girl with a diagnosis of cerebral palsy uses a diagonal movement pattern to reach for cups in a cupboard and place them on a cart on the opposite side of her body. | An occupational therapy instructor demonstrates PNF diagonal movement patterns with a student. |
| Rood Approach.
Author: Margaret Rood, MA, OT |
Sensory stimulation is applied to specific sensory receptors to facilitate and normalize movement patterns.
|
An occupational therapist uses an electric brush to stimulate the receptors on the biceps muscle while a boy who has had a traumatic brain injury works to actively bend his elbow. | A man demonstrates three Rood approaches to sensory stimulation. |
..
The evaluation of motor control is a dynamic process with no specific order. The therapist observes the child, the task, the environment, and the interaction of all three. The therapist then applies the knowledge gained through observation to treatment, again considering child, task and environment.
| Child | Task | Environment | Interaction of child, task and environment |
| 1. Observe the child doing each prioritized task in the environment where the task is usually performed. 2. Evaluate motor and process skills or factors within the child that are most likely to influence motor skill acquisition. 3. May conduct standardized functional evaluations. 4. Discuss skills and factors with child, family, teachers and caregivers. |
1. Analyze requirements and characteristics of each prioritized task. 2. Explore components of task. 3. Look at the aspects of each task that the child can do well and the parts where the child experiences difficulty. |
1. Analyze demands and characteristics of the environment in which each task will be performed. 2. Consider physical characteristics, regulatory conditions, and sociocultural contexts. |
1. Tasks need to be analyzed from the perspective of closed and open task taxonomy. -number of steps -sensory, motor, cognitive and psychosocial demands -degree of structure -characteristics of materials 2. Examine a series of questions related to a child’s task performance in relation to the environment. 3. Explore possible modifications of task and environment. 4. Reassess motor skill acquisition by the child’s task performance, with preliminary modifications, feedback, and practice provided. 5. Interpret the evaluation and recommendations for intervention. |
Resources:
Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti)
https://www.physiosimplified.com/rood-s-approach
https://www.physio-pedia.com
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In order to fully understand these approaches, hands on training and experience is necessary. This table is designed to give you a broad understanding of how these approaches can be used as part of an OT intervention plan.
| ROOD | BRUNNSTROM **This intervention approach was specifically developed for individuals who had sustained a CVA |
Proprioceptive Neuromuscular Facilitation (PNF) | NDT Also known as the Bobath treatment approach |
|
| ASSUMPTIONS | 1. Normal muscle tone is a prerequisite to movement
2. Movement occurs in a developmental sequence (therefore treatment will follow the developmental sequence) 3. Motivation enhances purposeful movement and meaningful activities will encourage practice of desired movements 4. Repetition is necessary for the re-education of muscular responses |
1. Individuals who sustain a CVA regress to an older pattern of movements
2. Spastic or flaccid muscle tone and the presence of reflexive movements which are evident after a CVA are considered to be part of the normal process of recovery and are viewed as necessary in regaining volitional movement. |
Normal activity occurs in synergistic and functional movement patterns.
|
Individuals with CNS pathophysiology have dysfunction in posture and movement and subsequent functional activity limitations. All individuals with these impairments have the potential for enhanced function as the brain has the ability to reorganize itself due to neuroplasticity. Posture and movement impairments are changeable. |
| PRINCIPLES | • Normalization of tone
• Muscular responses are achieved via controlled sensory stimulation. • Use of developmental sequences. • Purposeful movement: • Repetition/practice is necessary for motor learning. |
• Treatment progresses in a sequence from reflexes to voluntary to functional movements
• Normal movement requires muscles to work synergistically • Following damage to the CNS, movement recovery follows a specific sequence, known as Brunnstrom’s Stages of Recovery 1. Flaccid paralysis. No reflexes. 2. Some spastic tone. Synergies elicited through facilitation. During this stage, patient has mainly two type of synergy pattern in UL. 3. Spasticity is marked. Synergistic movements may be elicited voluntarily. 4. Spasticity decreases. Synergistic movements predominate. 5. Spasticity diminishes. Can move out of synergies although synergies still present. 6. Coordination and movement patterns near normal. Trouble with more rapid complex movements. 7. Normal function returns Although patients proceed through these stages, a particular patient may stop at any stage. |
The definition of PNF encompasses the terms proprioceptive (which has to do with any of the sensory receptors that provide information concerning movement and position of the body); neuromuscular (involving the nerves and muscles); and facilitation.
1. Increase the motor learning of the agonist through repetition of an activity (repeated contractions) and rhythmic initiation. There are 2 pairs of foundational movements for the upper extremities- 2 diagonal patterns crossing the mid-line for each major body part, often incorporating verbal commands UE Diagonal 1 Various PNF stretching techniques include Hold Relax, Contract Relax, and Contract Relax Antagonist Contract. |
• Normalize muscle tone • Inhibit primitive reflexes • Facilitate normal postural reactions. • Improve quality of movement. • Re-learn normal movement patterns. |
| TECHNIQUES
|
Use of sensory stimulation to evoke a motor response and use of developmental postures to promote changes in muscle tone
A. SENSORY Sensory stimulation has the potential to have either an inhibitory or a facilitatory effect on muscle tone Facilitation techniques to facilitate movement: Proprioceptive facilitatory techniques. Inhibition techniques to inhibit spasticity Examples of how this stimulation may be applied includes tapping over a muscle belly to facilitate (increase) muscle tone and applying deep pressure to a muscle’s tendinous insertion to elicit an inhibitory (decreased) effect.
B. DEVELOPMENTAL SEQUENCE Rood incorporates the use of specific developmental sequences believed to promote motor responses which leads to skilled and finely coordinated These sequences progress from proximal to distal and cephalocaudal. 8 ontogenetic motor patterns in the following sequence
|
Promote movement from reflexive to volitional.
In the early stages of recovery include the use reflexes and associated reactions to change tone and achieve movement Brunnstrom approach uses associated reactions and synergies. A synergy is a total flexion or extension movement of a joint or limb. Patients are encouraged to think about the movement and to gain control |
OT practitioners use PNF to manually facilitate a group of muscles that are weak in comparison to adjacent muscles. | Handling is the main method for better functional and postural performance of tasks
Handling techniques |
| TREATMENT STRATEGIES
|
Move patients through these developmental sequences. In clinical practice, practitioners may use selected principles from Rood’s work as adjunctive interventions to prepare an individual to engage in a purposeful activity.• The OT practitioner applies a quick stretch over the triceps before instructing a patient to reach for a cup or glass to improve elbow extension. • A patient is instructed in ways to apply their own sensory stimulation to enhance performance of ADLs. For example, during upper extremity dressing, the patient can be taught to perform a prolonged stretch of their affected biceps which would result in a reduction in muscle tone, and thereby increase the ease with which the patient’s arm is moved through the sleeve of their shirt. |
• Mass movement patterns are used to promote movement. • The use of sensory stimulation, including tactile, auditory, and visual input, is also actively incorporated into treatment to promote a motor response. • PNF patterns are used during purposeful activities by structuring functional activities, especially in the placement of objects. |
Key Point of Control: Key points are parts of the body that the OT practitioner chooses as optimal to control (inhibit or facilitate) postures and movement. Proximal key points include the shoulders and pelvis, which are used to influence proximal segments and trunk. Distal key points upper and lower extremities (typically the hands and feet). Key points of control are also used to provide inhibition of abnormal tone and postures. – Key point of control: the thumb. Thumb abduction and extension with forearm supination decreases flexor tone of the wrist and fingers .Used within context of purposeful activities. Can be prep activity then incorporate into AD.– Can facilitate a patient in sitting, weight-shifting, and standing using an NDT approach – Use arm to weight-bear to get arm involved as soon as possible. Weight shift using arm, use arm to support while standing, use arm as prop when teeth brushing- even if not using, it will be used to bear weight . |
| ROOD | BRUNNSTROM |
|
|
|
|
. |
| PNF | NDT |
|
|
| Pictures copied from Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti).
|
|
Resources:
Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti)
https://www.physiosimplified.com/rood-s-approach
https://www.physio-pedia.com
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