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Motor Control Vs. Motor Learning

Approaches A Case Study

This chart will compare and contrast two treatment approaches as it applies to a particular patient. The two approaches considered are Neurodevelopmental Treatment, a motor control approach, and the motor learning approach.

The Patient

The patient’s name is Wally. He is a 68 year old African American male who has been married for 30 years. He works as a caretaker for a church and lives in an apartment in the church basement. Wally’s medical history includes a 9 year history of hypertension and a history of ulcers. He had retinal surgery 6 years ago. He has no history of psychiatric illness.

Current Diagnosis

Wally’s current diagnosis is left cerebrovascular accident with right hemiparesis, dysarthria, and depression.

Concerns

Wally is concerned that his wife will not be able to take care of him and that he will have to go to a nursing home. He also cannot work, so he is worried that he and his wife will have to go on welfare and will not be able to afford their apartment.

Mental and Physical Status

Wally appears very neat, clean and well groomed. He presents with the following symptoms:

-Inconsistent eye contact, especially when approached from the right side
-Motor ability is impaired, unable to walk -Flaccidity in right arm and leg

-Right facial droop

-Slurred speech and difficulty finding words

-Depressed affect since onset of the CVA

-Confused formal thought

-Perceptual deficits including visual disturbances, difficulty crossing midline, difficulty with figure-ground discrimination, and severe right side neglect

Treatment Approaches

The following chart will compare neurodevelopmental treatment (NDT) and the motor learning approach as they apply to Wally’s course of treatment.

Area of Treatment NDT Motor Learning
Overall focus of treatment Movement progresses from
head to foot, proximal to
distal, large movements to
small movements.

Addresses stability before
mobility.

Primary goal is to regain
control over primitive reflexes
for skilled voluntary
movement.

A general rehabilitative
approach to all forms of
movement abnormalities and
disorders.

Holistic or systems approach.

Directly relates to specific

task performance.

Primary goal is to restore
functional movement using
meaningful tasks to increase
motivation to continue with
treatment.

Specific disabilities and
treatment goals
Disabilities from an NDT
perspective:

-Loss of selective movement
control in Wally’s right arm.

-Abnormal muscle tone
(flaccidity) on affected side.
-Poor inhibition of primitive
reflexes and/or nonfunctional
movements.

Treatment goals from an NDT
approach:

-Refine tone in Wally’s
affected right side.
-Regain movement in
affected right side.

-Strengthen fine motor skills
and overall stability.

From the contemporary task
perspective, function is
defined with the context of
specific tasks. Skilled
movements are performed
with a gradual increase in
degrees of freedom.

Evaluation should be
conducted during
occupational and role
performance in natural
settings.
-dressing at home

Observe Wally performing
functional tasks in various
contexts.
-transfer wheelchair to bed,
toilet to wheelchair, etc.

The case implies that Wally
might work on the following:

-muscle strengthening
-crossing midline
-establishing independence
during ADLs, including
dressing, bathing and
transferring in natural settings
-practicing whole tasks, not
isolated parts of tasks

Therapist should provide
feedback and encourage self
evaluation and error detection

Activities of Daily Living Handling and practice during
ADL tasks

Discourage compensation

Encourage Wally to use his
affected side during ADL
tasks, including bathing,
dressing, feeding and
transfers.

Focus on a few common
routines or tasks, such as
transfers, bathing and
dressing.
-Wally has confusion of
formal thoughts during ADL
routines, so practicing a few
tasks repeatedly, he will be
able to remember and master
these tasks.

Focus on function during ADL
tasks

Areas identified as functional:

-ADLS – -Social participation –
although Wally has some
speech difficulties, he is able
to communicate and will
continue to regain speech
and language abilities.

Areas identified as impaired:
-Return to work – Wally is
unable to perform all the
tasks necessary to return to
his prior occupation.
-Mobility – Wally is unable to
ambulate. He will eventually
become mobile through the
use of his wheelchair as he
continues to strengthen his
transferring skills.

Recommendations for Wally’s
wife
Make sure Wally’s wife is
aware of what Wally is
capable of.

Have Wally’s wife encourage
Wally to use his affected side
more to strengthen bilateral
movement.

Tell Wally’s wife to place
items closer to Wally’s
affected side to induce
spontaneous movement of
the affected side.

Have Wally help with chores
around the house to
strengthen his affected side.

Increase Wally’s motivation

Have Wally perform
purposeful and meaningful
activities

Motivational Issues NDT assumes that training
and practice will produce
improvements without
intentional effort of the client’s
part. Therefore Wally’s
participation in activities that
are meaningful to him will be
his motivation.
Motor learning frame selects
tasks that are challenging
and meaningful to the client,
and that are identified by the
client themselves. We would
ask Wally what types of
things most important to him
and go from there.

Similarities between Neurodevelopmental Treatment and Motor Learning Theory

1. Both NDT and Motor Learning Theory rely on the plasticity of the brain to rewire and make new connections.

2. Both approaches use a collaborative approach with the client and family to determine occupational problems and priorities.

Differences between Neurodevelopmental Treatment and Motor Learning Theory

NDT Motor Learning
General Differences -Occupational dysfunction is
characterized by the inability
to control one’s own motor
movements.
-Goals of therapy include
trunk stability, increased
independence in self-care,
and restoration of safe
mobility.
-NDT focuses on establishing
sensorimotor components
that are prerequisites for
occupational performance.
-Three stages of function:
cognitive, associative, and
autonomous stage. Function
defined within context of
specific tasks.
-The goal is to restore
functional movement by
developing optimal motor and
cognitive strategies.
-Recovery is reached when
the person is restored to their
previous level of abilities as
before the accident.
Evaluation -Initially occurs in a clinical
setting.
-Involves both observation
and handling to determine
function/limitations.
-Responses to input are
evaluated as well as posture
and movement sequences.
-Selected control of arms and
legs is evaluated segment by
segment.
-Conducted in a natural
setting during normal
occupation and role
performance.
-May rely on self-report or
caregiver report to determine
functional capacity.
-Attributes of person,
environment, and task are
evaluated.
-The same task is observed
within various contexts.
Patient Motivation NDT assumes that training
and practice will produce
improvements without
intentional effort of the client’s
part.
Motor Learning frame selects
tasks that are challenging
and meaningful to the client.
These tasks are identified by
the client themselves.
Treatment Strategies and
Techniques
-Handling
-Use of facilitation and
inhibition techniques
-Placing hands at key points
of control
-Using reflex-inhibiting patterns/postures (RIPs)
-Considered preparatory
treatment because it’s
directed toward establishing
sensorimotor performance
components that are
prerequisites for occupational
performance.

-Task oriented approach
-Focus on assisting clients in
developing the optimal motor
and cognitive strategies for
achieving functional goals
-Remediation, adaptation,and compensation are not
separated, but represent one
holistic approach
-Practice of needed skills in
natural settings
-Practicing whole tasks, not
isolated parts
-Providing randomized
practice

Changes in Environment and
Task Demand
Task demands and home
environment must be
changed based on the
patient’s limitations.
-Early stages of learning:
Feedback is focused on
movement outcome and the
critical features of the task
and environment (not on
motor performance)
-Later stages: Clients are
encouraged to self-evaluate
their own movement
performance and outcome
by focusing on feedback from
their own body and
environment
Role of Adaptation and
Compensation
-Discouraged compensation
with one-handed strategies
for task performance as
counterproductive because it
encourages learned neglect
-Compensation continues to
be discouraged, and use of
hemi side encouraged for
performing activities of daily
living.
-Remediation (establish or
restore), adaptation, and
compensation are not
separated, but represent one
holistic approach.

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