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Dynamical Systems Theory; Motor control is the "ability to regulate or direct movement".

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Movement is regarded as a function of the interaction between the client's neuromuscular system, the environment, the client's cognition, and the task. OT practitioners evaluate the systems and work on one or more systems to address a deficiency in occupational performance.

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Dynamical Systems Theory (cont'd)

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Neuromuscular skeletal system. Physical appearance. Symmetry, deformities, injuries. Postural mechanism. Postural tone. Refers to muscle tension in the neck, trunk, and limbs. Muscle tone. Resting state of mild contraction of a specific muscle. Muscle tone changes relative to the postural mechanism and extrinsic factors. Abnormal tone is described as hypotonicity, hypertonicity, or rigidity.

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Assessing Muscle Tone

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Objective evaluation of muscle tone is difficult. Dependent on so many variables, including posture, position, emotions, temperature of room, pain, illness. Preferred position of patient for assessment is upright in sitting or standing. Move joint slowly through full ROM and make note of how freely and readily the joint passively moves. The Ashworth Tone Scale can be used.

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Assessing Muscle Tone (contd)

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Degree of muscle tone can be documented at mild, moderate, or severe. Mild. - Resistance may be felt but full ROM is still attainable. Moderate. -Demonstrates consistent resistance during PROM, full ROM still attainable. You observe deviations during functional tasks. Severe. - Strong resistance during PROM throughout ROM. Significantly limited in ability to control involved extremities.

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Hypotonicity

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A decrease in muscle tone, aka flaccidity. Muscle feels soft and offers no resistance to passive movement. Limb feels "heavy". Patient cannot hold a position once it is placed and released by therapist. Usually result of peripheral nerve injury, cerebellar disease, frontal lobe damage. and is found temporarily in the "shock" phase after a CVA or SCI.

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Hypertonicity

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Increased muscle tone, aka spasticity. An increased resistance to passive stretch caused by an increased or hyperactive stretch reflex. Hyperactive DTR and clonus. Offer greater than normal resistance to passive ROM. Flexor hypertonicity is more commonly apparent in the UE and extensor hypertonicity in the LE. Hypertonicity found in patients with UMN disorder. Hypertonicity with cerebral damage equals combination with other motor deficits, such as rigidity or ataxia. Spinal cord hypertonicity is often violent, with episodic muscle spasms.

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Rigidity

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An increase in muscle tone in the agonist and antagonist muscles simultaneously. Result is increased resistance to PROM in any direction throughout range. "Lead-pipe rigidity" is identified in patients who demonstrate constant resistance throughout PROM in any direction. "Cogwheel rigidity" is a rhythmic "give" which occurs in the resistance throughout the ROM. Results from lesions of the extramparamidal system, ie Parkinsons, TBI, degenerative disorders, tumors.

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Dynamical Systems Theory (cont'd) #

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Reflexes and mass movement patterns. Innate motor responses elicited by specific sensory stimuli. Become integrated as voluntary motor control develops Automatic reactions. Protective extension reactions. Righting reactions. Equilibrium reactions.

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Upper Extremity Motor Recovery

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Observation of overall posture. Quality of movement is affected by muscle tone; neurologic, musculoskeletal, and sensory processing; and body awareness. Intervention focuses on the patient performing the desired occupation in specific contexts. Brunnstrom's stages of motor recovery guide intervention using meaningful occupations following a cerebrovascular accident (CVA).

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Brunnstrom's Stages of Motor Recovery

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No motion. Reflex responses. Associated reactions. Mass responses. Deviation from pattern. Wrist stability. Individual finger movement. Selected pattern with overlay. Selective movement

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Evaluating Functional Use of the Limbs

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The occupational therapist can use observation or structured tests, such as the functional independence measure (FIM) or physical performance test. The levels of functional assist must be established before setting goals. Minimal stabilizing assist Minimal active assist Maximal active assist Incorporation of the involved upper extremity into all bilateral tasks

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OT Considerations Based on Results of Functional Motion Assessment

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Occupation-based activity. The occupational therapist may use adaptations or may normalize tone (using neurodevelopmental treatment [NDT]) to achieve function. Facilitation. For hypotonia and limited to no motion. Inhibition. For hypertonia Casting or orthoses. To prevent contractures and maintain muscle length. May be used with peripheral nerve blocks. Physical agent modalities. Pain

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Coordination

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Interaction of muscles to produce accurate controlled movement. Type of lesion depends on which source of control is affected by disease and injury. Signs of incoordination include. Ataxia. Adiadochokinesia. Dysmetria. Dyssynergia. Tremor. Rebound phenomenon of Holmes. Nystagmus. Dysarthria. Choreiform or athetoid movements. Spasms.Dystonia.

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Coordination (cont'd)

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Clinical assessment of coordination. Performed by neurologist. Observation of rate, rhythm, direction, and force. OT assessment. Activities and standardized tests can reveal the effect of incoordination of function. OTA observes for. Differences in performance with and without stabilization. Signs of incoordination, including tremor. Effect of environment on performance

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Summary

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Motor control results from the complex interaction of neurologic systems, the postural mechanism, selective movement, and coordination. The OTA observes how impaired motor control affects function. The OTA can assess aspects of the postural reflex mechanism and coordination using structured tests. The motor control evaluation and occupationbased interview guide treatment.

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Clinical Peral

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Observe the client sitting and performing simple weight shifting from side to side as a way to determine general postural tone. This can be done during the initial interview.

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Normal Muscle tone

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Continuous state of mild contraction, or state of readiness of a specific muscle. Muscle tone is the resting state of a muscle in response to gravity and emotion. It depends on the integrity of the peripheral nervous system and CNS mechanisms.

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Clinical Peral

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Practice assessing muscle tone on a variety of people to begin to feel the range of muscle tone.

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Clinical Peral

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Muscle tone increases with stress or difficulty. Observe muscle tone when a client is performing an activity to better understand what types of activities are suitable for intervention.

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Abnormal muscle tone. Hypotonicity

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Also called flaccidity. Is a decrease in muscle tone. Hypertonicity is usually the result of a peripheral nerve injury, cerebellar disease, or frontal lobe damage and is found temporarily in the shock phase after a stroke or spinal cord injury.

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Hypertonicity

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also called spasticity. refers to increased muscle tone. It is commonly defined as an increased resistance to passive stretch caused by increased or hyperactive stretch reflex. Any neurologic condition that alters upper motor pathways may result in hypertonicity

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Clinical Peral

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Eases, bright lights, cool temperatures, and bright colored Cluttered walls may simulate muscle tone. Practitioners may want to reduce the stimuli when clients who have hypertonicity

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Manual Muscle testing

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Appropriate for patient's who demonstrate abnormal muscle tone.

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Rigidity

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Rigidity is an increase in muscle tone in the agonist and antagonist muscles simultaneously. Both muscle groups contract continually, resulting in increased resistance to passive movement in any direction and throughout the joint range of motion.

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Lead pipe rigidity

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Is identified and patient to demonstrate a constant resistance they're out the joint range of motion when a limb is passively moved in any direction

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Cogwheel rigidity

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A rhythmic "give" occurs in the resistance through the range of motion, similar to the feeling of turning a cogwheel. The deep tendon reflex is our normal or only moderately increased.

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Clinical Peral

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When assessing range of motion, slowly, Hold and wait to feel a release. Do you not pull on extremities.

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Clinical Peral

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Always inform the client of what is happening in the process. This will ensure the best movement.

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Clinical Peral

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For clients who have persisting reflexes, the goal of therapy is to increase a persons ability to function in daily activities despite the influence of reflexes. Practitioners may suggest strategies to help clients be successful such as requesting caregivers present food at midline so as not to elicit the asymmetrical tonic neck reflex

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suck/swallow reflex

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Suckling. immature protrusion and reaction of the tongue as observed in neonate.

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Asymmetrical tonic neck reflex

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Extension of arm and leg on face side; flexion on arm and leg on the skull side.

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Symmetrical tonic neck reflex

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Flexion of arms and extension legs. Extension of arms and flexion of legs.

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Tonic labyrinthine reflex

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Extension of trunk and extremities or increased extensor postural tone. Flexion of trunk and extremities or increased flexor postural tone.

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Positive supportive reflex

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Extension in leg stimulated; hip and knee extension with plantar flexion of ankle. example toe pointing downward

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Crossed extension reflex

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Extension of opposite leg

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Palmar grasp reflex

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Flexion of digits into Palmer grasp

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Plantar grasp reflex

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Flexion of toes

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Clinical Peral

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For clients who still have the TLR, be sure to tilt their chairs forward; slightly so as not to get too much flexion; during feeding to encourage flexion required for swallowing.

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Clinical Peral

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Client's who have a persisting Palmer grasp may benefit from using build up handles for utensils and implements

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Clinical Peral

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Caregivers may need to be reminded to cleanse and dry the palms thoroughly and completely to avoid skin breakdown in clients with Palmer grasp reflex who may hold their hands fisted tightly.

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Automatic reactions. Protective extension reactions

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Extending the arms. To protect the head and face when a person is off-balance or falling

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Righting reactions

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Maintain or restore the normal position of the head in space; eyes parallel to the horizon; and it's normal relationship with the trunk and limbs.

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Equilibrium reactions

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Maintain and restore a person's balance in all activities.

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Clinical peral.

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Observe Clients in a variety of environments and performing a variety of activities. This helps the practitioner understand the clients volition for activities and his or her reaction to different environments. Client's perform better when doing activities that are meaningful to them or give them identity

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Clinical peral

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Providing a mirror so that the client can see her performance may help her adjust movements. Providing tactile cues and simple brief feedback may be effective in improving movement.

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Clinical peral

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The MOHOST provides an occupation based screening that allows practitioners to objectively examine a clients volition for occupation. Using this helps health practitioners better understand their clients and design meaningful interventions

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Brumnstoms stages of recovery. No Motion

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No motion can be elicited from the involved upper extremity

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Reflex responses

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Movements are limited to generalized or localized motor responses to specific sensory stimuli

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associated reactions

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Abnormal increases in muscle tone in the involved extremities occurs when activity requires intensive effort of the unaffected limbs

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Mass responses. Synergistic

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voluntary motion is limited to total limb movements in flexion or extension. The patient is unable to isolate individual joint motions or deviate from the stereo typical movement pattern.

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Flexion Pattern response

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Consist of scapular abduction and elevation, humeral adduction and external rotation, elbow flexion, forearm supination, wrist flexion, and digit flexion.

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Extension pattern response

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Consists of scapular abduction and depression, humeral abduction and internal rotation, elbow extension, forearm pronation and wrist and finger flexion or extension

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Deviation from pattern

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Voluntary motor control deviates from the synergy through movement and is patterned predominantly when functional tasks are attempted

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Clinical peral

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Constraint iinduced therapy helps clients regain motor functioning by promoting the use of the affected extremity and daily activities. Practitioners are urge to examine this intervention technique

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facilitation

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For hypotonia and limited to no motion in the upper extremities that OT practitioner must facilitate increased muscle tone necessary for stability

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inhibition

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for hypertonia the OT practitioner uses inhibitive techniques to decrease the abnormal muscle tone and patterns of movement

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occurrence of incordination. Ataxia

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Is impaired gross coordination and gait

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Adiadochokinesia

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Not moving together. Is an inability to perform rapidly alternating movements such as forearm supination and pronation or elbow flexion and extension

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dysmetria

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Faulty distance between two points. Is an inability to estimate the range of motion necessary to reach the target of movement

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dyssynergia

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Faulty working together. Is a decomposition of movement in which voluntary movements are broken into their component parts and appear jerky

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tremor

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Is an involuntary shaking or trembling motion. classified according to type. intention tremor- occurs during voluntary movement, is often intensified at the termination of movement, and is often seen in patients with MS.

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resting tremor

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is present In the absence of voluntary movement; occurs while the patient is not moving

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pill-rolling tremor

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In which the individual appears to be rolling a pill between the thumb and index and middle fingers, is a type of resting tremor often seen in patients with Parkinson's disease

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rebound phenomenon of holmes

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To bounce or spring again. Is a lack of the check reflex, or the inability to stop a motion quickly to avoid striking something

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nystagmus

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Is an involuntary movement of the eyeballs in and up and down, back-and-forth, or rotating direction

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dysarthria

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Or faulty speech production, is explosive or slurred speech caused by the incoordination of the speech mechanism

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choreiform movements

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are uncontrolled, irregular, purposeless, quick, jerky, and dysrhythmical movements of variable distribution that may occur during sleep

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athetoid movements

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or movements without stability, are slow, wormlike, arrhythmical movements that primary affect the distal portion of the extremities. Athetosis occurs in predictable patterns in the same subject and is not present during sleep

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spasms

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are sudden, Involuntary contraction of a muscle or large group of muscles. In a patient with a spinal cord injury, spasms often cause violent and involuntary straightening of the legs

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dystonia

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Is faulty muscle tension our tone. Dystonic movements tend to involve large portions of the body and produce grotesque posturing with bizarre writhing movements

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ballism

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or projectile movment, is a rare symptom produced by continuous, gross, abrupt contractions of the axial and proximal musculature of the extremity. It causes the limb to fly out suddenly and occurs on one side of the body.

Early: Chapter 6: Assessment of motor control and functional movement – Flashcards

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