THE USE OF FUNCTIONAL ACTIVITIES IN THERAPY AN INTEGRATION OF THE PRINCIPLES OF MOTOR CONTROL AND THE LEARNING PROCESS ■ Bakkes E S, BSc P hysiotherapy, BSc (Hons) Physiotherapy ■ G roenew ald S J, BSc Physiotherapy ■ H ughes } R, BSc Physiotherapy, BSc (Hons) Physiotherapy (Physiotherapists, C entre for C are and R ehabilitation o f the D isabled, U niversity o f Stellenbosch) INTRODUCTION Follow ing a CVA, a person rem ains an individual w ho m ust function w ithin the surrounding environm ent and com m unity. D aily life represents a constan t challenge and the individual will have to acquire new skills or re-acquire previous skills if they are to cope effectively. These skills m ay b e physical, cognitive, psy­ chological, em otional or social in nature. M ovem ent is seen as a m eans by w hich an individual interacts w ith the environm ent - a m eans by w hich problem s are solved ' . D aily tasks present a w ide variety o f dem ands to the individual; if the person is to fu nction effectively he will n ot only have to possess certain basic abilities, b u t he w ill also have to be an effective problem -solver. Therapists are interested in the d evelopm ent o f com petence and in how this degree o f com petence is reflected in the individ­ ual's behaviour and function . H ow ever, since it is not possible to cover each precise requ irem ent of the w ide range of daily tasks facing the client, the therapist w ill have to integrate treatm ent principles and techniques aim ed at im proving m otor skills with those aimed at prom oting problem -solving skills. As such, the physiotherapist is not m erely a coach of specific m ovem ents, "b u t is in essence a designer o f the learning situations''^. A B S T R A C T The successful rehabilitation of a patient following a CVA is largely dependent on the effective relearning of previous motor skills or the learning of new skills. An understanding of the components of motor function and control and the principles of the learning process is therefore essential. Functional activities may be used as an optimal means of combining these principles so as to improve the efficacy of physiotherapy treatment. Two case studies are used to illustrate this approach. A B S T R A K Suksesvolle rehabilitate van die pasient na SVO is grootliks afhanklik van die effektiewe aanleer van vorige vaardighede of die aanleer van nuwe vaardighede. Dit is van uiterste belang dat die terapeut die komponente van motorfunksie en beheer en die beginsels van die leerproses verstaan. Die effektiwiteit van die fisioterapeutiese behandeling kan verbeter word deur die gebruik van funksionele aktiwiteite. Hierdeur kan bg. beginsels optimaal geintegreer word. Die benadering word deur die gebruik van twee gevalle studies uitgelig. This view has two key features: • in addition to therapeutic skills, know led ge of m otor b ehav­ iour is required, as w ell as an un derstand ing o f the principles u n derlying the learning process and • the m odern trend o f incorporation of specific tasks or activities w ithin treatm ent sessions should n ot b e lim ited to the clinical setting, b u t should b e extended to inclu de b o th the client's h om e environm ent and his hom e-program m e. MOTOR BEHAVIOUR The classic view of m otor behaviour is based on the existence of jmotor engram s wjhich are specific to each m otor skill^. These engram s are taken to be stored in the m em ory and to contain detailed m uscle-specific inform ation fo r each m ovem ent. A con­ sequence of this view , how ever, is that there w ould have to b e as m any m otor program s as there are p ossibilities to m ove. Th u s the concept o f such a rigid m otor system h as b ee n rejected in favour o f a m ore flexible m odel, nam ely the d istributive m odel o f m otor control5. This relies on the concept of central p attern generators (groups o f neurons distributed throughout the central nervous system) responsible for the execution of m o tor program m es. It is these m otor program m es that then result in fu nctional m ovem ent synergies w hich are flexible enough to adapt to sim ilar tasks under different or varying conditions.• v ary ir^ ( A cco rd in g to Sabari , p e rs o n n e e d s in ta c t (m o to r p ro - ~j_ ^grammes, m otor m em ory, feedback m echanism s .and feedfor­ w a rd m echanism s for effectiv e jn o to r iu n c tioningyH ow ever, it is “A precisely these m echanism s w hich are d am aged in cases o f brain injury. Follow ing a C V A a person w ill attem p t to function using undam aged neural system s. By using these com p en satory m echa­ nism s to achieve his goal, alternative central pattern generators are established and the partially d am aged system s will not be stim ulated to recover5. This type o f fixed com p en satory pattern could greatly lim it the persons ability to achieve their full poten- tial . _________________________________ _____________ __ O ne o f the m ain aims o f therapy is to re-establish n o r m a j 'm o v e m e n t patterns. A n understanding o f the principles o fle a rn - J'M otor learning is n£>t the learn ing o f m uscle control o r m ove­ m ent control, b u tjth e acquisition o f program m ing rulesjthat en­ able the subject to"Behave flexibly under d ifferent con d ition s" . In this article w e will focus on elem ents o f learning that can be m anipulated b y the therapists. In the authors' opinion, there are four crucial elem ents w h ich w ill influence the acquisition o f these program m ing rules: 7 ing w ill enable the therapist to lfacilitate stim u lation o f these J vpartially dam aged central pattern generators optim ally. J RELEVANT ASPECTS OF THE LEARNING PROCESS "A large part of therapy can be seen as a learning process during w hich clients m ust m aster new skills (eg. propelling a w heelchair) or m ust reacquire old skills (eg. w alk in g )" "L earning is seen as a set of processes associated w ith practice or experience and leading to a relatively stable change in behav- •___lid SA J o u r n a l P h y s io th e r a p y , V o l 5 2 N o 2 M a y 1996 P a g e 33 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 2 6• E nvironm ental aspects or context ' • N ature o f the task '7 • Type o f feedback4,7'8 7 8• D esign o f the p ractice schedule ' E N V IR O N M E N T A L A S P E C T S : The fam iliarity o f the environm ent as well as the type of environm ent (physical, social and cultural) can influence learn­ ing. Inform ation that can easily be related to previous know ledge, experience and skills w ill b e m ore easily learned and rem em ­ bered. Furtherm ore, know led ge o f and fam iliarity w ith the task affects b oth processing speed and strategy selection*’. Subsequent to a CV A, an individual m ay have difficulty in accessing previous know led ge and experiences, associating new inform ation with previous experiences, or in b eing able to elaborate new inform a­ tion. Subsequently, an un fam iliar, crow ded environm ent, filled w ith visual and aud itory distractions, can affect the learner's ability to draw on previou s know ledge as well as their attitude tow ards and ability to process and m onitor in form ation. — !X llo w in g a person to practise skills w ithin an environm ent w ith w hich they are fam iliar or w hich at least bears a close ‘resem blance to a k now n environm ent-can assistin-the-retrieval or - ' accessing o f previous knowledg^. It has been argued that if what is tau ght is abstract and rem oved fro m the context and conditions o f its application, not only w ill it be unrelated to previous experi­ ence, b u t it w ill be learnt as an isolated, fragmented entity*’. A p erson should therefore be trained in the environm ent m ost a p p rop riate to the type o f task and to w h ere the task w ilLbe- pgrform ed in the real w orld, j T H E N A T U R E O F T H E T A S K The environm ent places certain dem ands on m otor actions becau se it influences the choice o f m otor strategies. As the envi­ ronm ent, ie. the surface (terrain), objects and people, m ay rem ain stationary or be in m otion, tasks m ay be classified as being either closed or open tasks. fclo se d task s: Exam ples o f these tasks include eating, drinking an d self-care activities. These tasks can b e successfullyltrained or [relearnt by repetition in a stationary environm ent. Transfer occurs w eight is equally distributed over b o th legs w h ilst standing. E xtrin sic fe e d b a ck is inform ation from an extern al sou rce that augm ents the intrinsic feedback, egTthe therapist, i jwo kinds of extrinsic ieed back-can . be-Riven; know led ge o f results (KR) and 'know led ge o f perform ance (KP). r K n o w led g e o f resu lts m ight b e verbal feedback a^out m ove- m ent outcom e that is given after a m ovem ent. This provides inform ation about errors a îd w ill assist the learn er in know ing how to m odify the m ovem ent on the next attem pt, eg. "Y o u r feet are too close together." or "Y o u 're sitting in a slum ped p o sition ." Know ledge oLperform ance is ( V e r b a l feed b ack about the n atu re of j the m ovem ent that j s given d uring a response, eg. "Y o u need to shift m ore w eight to your left le g ." or "Y o u r strid es are n ot o f equal len gth ." Therapists m ore often use this type o f feed b ack as J H s aim ed .atxorrecting the m ovem ent pattern rath er than m erely j I the outcom e. ! ~ Either type o f feedback can facilitate and accelerate the learn­ ing process. ^ D E S IG N O F T H E P R A C T IC E S C H E D U L E , ^ D uring a treatm ent session, the therapist uses a specially de­ s i g n e d practice schedule. The therapist can m anip u late several factors o f a practice schedule, nam ely: • rest periods, the order o f skills practised, cond itions o f the task and the am ount o f task that is being practised. J Com pared w ith sportsm en w ho m ay train eight hours a day or m ore to perfect skills, therapists usually spend no longer than one hour per day retraining m otor skills in stroke victim s. Con- relatively easily. O p en tasks: E xam ples o f these tasks.includeJcrossing a street, b all gam es, sitting in a m oving train or ta x i. These tasks cannot be .trained successfully b y repetition in a stationary environm ent? /Transfer does.not.occur spontaneously Since the natu re o f tasks differ, the dem ands on postural control and d exterity differ. A lso, even in the sam e task, the cond itions of the environm ent m ay change betw een two consecu­ tive perform ances or even b etw een tw o successive trials. There­ fore therapists cannot lim it their clients to practising m ovem ents eg. flexion/extension, in isolation in the clinical setting w ith the goal jaf_ imp roving -task p e rfo rm a n ce .T n s te a d ,^ T a ctis In g o 7 re­ learn ing o f tasks or part o f tasks should be used in different environm ents and is the only way to im prove task performance^ T Y P E O F F E E D B A C K Feedback m ay b road ly b e divided into three areas: • inform ation available p rior to m ovem ent • inform ation available to guid e an ongoing response • i n fo rrna tion .a va i 1 a b 1 e as a re sult o f the m ovem ent._________ __ in tr in s ic fe e d b a c k is inherent-sensoiy inform ation from recep^ tors in the m uscles, jo in ts, tendons and skin as w ell as receptors in the visual and aud itory system s/lntrinsic feedback m ay occur d̂uring or after m ov em ent p ro d uction, ^g. a patient senses his sidexing-the fac-t-that "sk ill increases directly in relatio n to the [a m o u n t o f p ractice " , <^neTealises- that- whlTFhappens outside therapy is a s J m portant as w hat hap p ens d uring treatm ent. It is clear thaLanl effective and relevant h om e-p rog ram m e shou ld be jintrod uced as early as p o ssible-to ensure m axim al transfer o f functional skills practised in th e ra p y ___________________________ R e st period s: A rest period of|more than the p ractice period 'i (distributive practice) is appropria teTor rehabilitation in the acute J stage. M assed practice (rest time less than practice tim e) is ap p ro­ priate for final rehabilitation. The p ractice tim e refers not only to J the treatm ent session, and therefore shou ld inclu de a full-tim e, "A ppropriate and integrated hom e program m e. O rd er o f tasks: Practising d ifferent tasks a j rand om (random practice), rather than m ain tain in e the sam eorkarTfblocked_prac- tice) im p ro v es learning as it im proves con cen tratio n and m otor [m em ory. 1 1 / C o n d itio n s o f the task: V ariability o f the task also im proves learning, as the environm ental dem ands m ad e on the person change continuously - thereby dem anding heightened con cen tra­ tion and at the sam e tim e acting as a rand om practice trial. A m ou nt o f task: A task can be practised as a(w h ole, or~just as a part o f a tasM. Practising com ponents o f a task is useful w hen relearning com plicated tasks, eg. retrainin g com p on en ts o F g a lf before having the p atient w alking fuhctionaHy7[Part-task training can be used in early rehabilitatioi^ w h en certain aspects o f the task can be used to achieve relevant aim s even though execu tion o f the entire task m ay be too d ifficult o r com plicated at that stage; supported standing w hile dusting is effective sin ce the client is learning to cope w ith the postural dem ands o f the up right p o si­ tion required in p reparation for independ en t dynam ic standing balance. T w o case studies will be used to illustrate the above. B la d s y 3 4 M e i 1996 SA T y d s k rif F is io te r a p ie , D e e l 5 2 N o 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) CASE 1 H is to ry Mrs I A is a 72 year old lady w ho suffered a CVA on 7 March 1990, resulting in a left sided hem iplegia. She w as referred to the Centre for Care and Rehabilitation of the Disabled by a com m u­ nity nurse more that five years after the incident. Before adm is­ sion, two hom e visits w ere m ade in order to start retraining during the time that she was on the w aiting list for adm ission. She w as admitted for in-patient rehabilitation on 12 Ju ne 1995 and discharged after seven weeks. A hom e visit was done subsequent to discharge. P h y s ic a l s ta tu s Even though active, selective m ovem ents w ere present in both the upper and low er limb, she had a high degree of spasticity. Together with severe loss of proprioception and tactile sensation in both affected lim bs, this often caused her to ignore the left upper limb and it would pull up into a m ass flexion spastic pattern. At discharge, she w as able to inhibit the mass patterns and use the arm functionally, even though com ponents o f the m ass pattern w ere still visible. S o c ia l b a c k g ro u n d Mrs 1 A shares a house with her daughter and granddaughter w ho is in prim ary school. Her daughter works full time. After the CVA, M rs I A resum ed her household chores w ithout assistance. T w o activities will be discussed, namely, w iping the sink and hanging up the washing. S t a n d i n g in w a lk - stance, left leg forw ard, supporting on left upper limb, w iping surface with right upper limb. Segm en­ tal flexion and rotation are present in the trunk, de­ pending on how far is be­ ing re ach e d w ith rig h t hand. Both affected limbs are in inhibitory patterns. Note the presence of asso­ ciated reactions in the sec­ on d and f i f t h fin g e r s . T h e re is m o b ile w eig h t b e a rin g on b oth lim bs. W e ig h t is b e in g tra n s ­ ferred laterally and anteri­ orly from the right leg be- Fiq 1: Wiping the sink hind, onto the left leg in fr o n t, p r e p a r i n g fo r w eight shift during gait. O ne should be careful that the patient is not only bearing w eight on the right hand side. The left upper limb should not be a medial rotation. There should be no retrac­ tion of the left side o f the pelvis, nor should the left knee be hyperextended. H anging up w ashing The two illustrations show incorrect patterns (Fig. 2) and im ­ proved patterns (Fig. 3). In figure 2 it is evident that the associated reactions o f the upper and lower lim bs result in com plete and m arked asym m etry. The task is difficult, d em anding very good dynam ic standing balance, as well as distal function. As the task is difficult, the tone increases considerably all throughout the body. As she is not using the left Figure 2: Hanging up Figure 3: Hanging up washing - incorrect patterns w ashing - correct patterns upper limb functionally it is in the m ass spastic position, increas­ ing the asym m etry. The pelvis is notably retracted on the left side, with inversion, plantarflexion of the foot. If spasticity during difficult activities is not controlled, spasticity will increase over time, decreasing function at the sam e time. In addition, the patient dem onstrates poor back care tech­ niques and kinetic handling skills. In figure 3, Mrs IA is repeating the action. H er starting position is unchanged, but she is now using both upper limbs. The upper limb is now used functionally, despite increased tone still being present. Because of the im proved activity in the upper limb, the trunk is now sym m etrical. There is still asym m e­ try present in the lower limb, but less than before. Ideally, the basin should be lifted onto a chair or stool. The problem is that the patient cannot carry a big object like that herself, nor does she w ant to leave anything outdoors. Back care should be introduced into her hom e program m e. CASE 2 H is to ry Mr G v B is a 26 year old teacher. On 31 A u gust 1995 hesu ffered a CV A, resulting in a right sided hem iplegia. A t the time o f the incident, he was adm itted to a private m edical clinic and from there referred to the Centre for Care and R ehabilitation of the Disabled. He spend three w eeks at hom e prior to his adm ission at the Rehabilitation Centre. In-patient rehabilitation lasted seven weeks. P h y s ic a l s ta tu s On discharge, M r G v B had good, active, selective m ovem ent in his upper limb. Even though proxim al tone w as slightly d e­ creased, distal tone in hands and fingers w as slightly increased. The lower limb had slightly decreased tone, w ith underlying increased tone, only visible during hard physical activity. S o c ia l b a c k g ro u n d M r G v B is unmarried and lives with his parents. H e shares a bedroom with his brother. A p art from teaching, M r G v B also has to help with household chores, such as gardening. In his spare time, he reads a lot. Tw o activities will be discussed, nam ely, m ow ing the law n and reading. SA Journal Physiotherapy, Vol 52 No 2 M a y 1996 P ag e 35 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Figure 4: M o w in g the lawn M ow ing the lawn (Fig 4) T his activity allow s the upper limb to be in a reflex i n h ib it in g p o s i t i o n . T h e w eigh tbea ring control o f the low er limb is facilitated by the fact that the trunk re­ m ain supported and sym ­ metrical. R eading (Fig 5 and 6) In the uncorrected pos­ ture (Fig 5 ), the tru nk is slum ped and the arm is in a n on -fu nctional p o sition in the m ass spastic pattern. In the leg, the com ponents of the exten so r sy nerg y pat­ tern are visible. In the im proved posture (Fig 6), the trunk is active w ith e x t e n s i o n a n d in ­ creased rotation to the right. The neck is less rotated. Both a rm and leg are in good alignm ent, w ith no evidence of increased tone. CONCLUSION R E F E R E N C E S Figure 6: Reading - correct L Hissins s - M otor ski11 acquisi- D O S tu re t io n . P h y s i c a l T h e r a p y ----------------------- ^---------------------------------- 1991:71(2);124-139. 2. Sa b a n J S. M o to r learning co ncep ts applied to activity-based interven­ tion w ith adults w ith hem iplegia. T he A m erican jou rn al o f O ccupational T herapy 1991:45(6);523-530. 3. M u ld er T. A process-orientated m odel of hum an behaviour: Tow ard a The advantages of using a f u n c t i o n a l a p p r o a c h w hich incorporates both the com ponents of m otor func­ tioning and control and the p rin cip le s o f the learn ing p r o c e s s h a v e b e e n h ig h ­ lighted in the above discus­ sio n. In itia lly , in teg ratin g th is a p p r o a c h in to d a ily therapy may dem and extra thought and planning from the therapist but the benefit should soon be apparent, as such an approach assists in th e e f f e c t i v e tr a n s f e r o f fu nctional tasks according to the dem ands of the envi­ ronm ent. Since the approach is not o n ly aim ed at im p ro v in g motor skill but also at equip­ ping on e's client w ith prob- lem -solving skills, retention and transfer of that w hich is learned in therapy sessions should be facilitated. Figure 5: Reading - incorrect _________ posture_________ theory-based rehabilitation approach. P hysical T herapy 1991:71(2);157- 1645. 4. Lee T D, Swanson L JR, Hal 1A L. W hat is repeated in a repetition? Effects of practice conditions on m otor skill acquisition. P hysical Therapy 1991:71(2);150-156. 5. Irw in-Carruthers S H. Inductive and deductive processes in developing n e w s t r a t e g i e s fo r n e u r o l o g ic a l p h y s i o t h e r a p y . Physiotherapy 1989:45(3);68-72. 6. Toglai J P. Generalisation of treatment: A m ulticontext approach to cognitive perceptual im pairm ent in adults with brain injury. The A m eri­ can Jou rn al o f O ccupational T herapy 1991:45(6)^ 05-515. 7. Poole J L. Application of m otor learning principles in occupational therapy. T he A m erican Jou rn al o f O ccu pational T herapy 1991:45(6)^ 31- 537. 8. Winstein C J. K now ledge of results and m otor learning- Implications for physical therapy. Physical T herapy 1991:71(2);140-149. f CONTINUING EDUCATION COURSES IN STROKE ^ REHABILITATION • Basic Course - IBITAH and SANDTA certified A 3-week basic course on the assessment and treatment of adult hemi­ plegia (the Bobath concept) will be held in Johannesburg from 29 July to 16 August 1996. The course leader Michele Gerber, and Advanced Course Instructor from Switzerland who has taught courses in Europe and Switzer­ land. Further details are available from: Lynn Fearnhead, Department of Physiotherapy, University of the Witwatersrand, Medical School, 7 York Road, Parktown 2193. Tel. (011) 448-3450 or Fax. (011) 643-4318 • Advanced Course - IBITAH and SANDTA certified A one-week advanced course on the assessment and treatment of adult hemiplegia and related neurological conditions (the Bobath concept) will be held in Cape Town from 26 - 30 August 1996. The course leaders are Sheena Irwin-Carruthers, Senior Instructor, and Michele Gerber, Advanced Course Instructor. Further details are available from: Sheena Irwin-Carruthers, De­ partment of Physiotherapy, University of Stellenbosch, P 0 Box 19063, ^Tygerberg 7505. Tel. (021) 938-9300 or Fax. (021) 931-7810.___________ j O G R A D Y P E Y T O N in t e r n a t io n a l S O U T H A F R IC A 17 G a m b o n ia Rd R o n d e b o s c h 7700 Tel: W (021) 419 -50 70 H /F (0 2 1 )6 8 5 -1 3 8 1 BO STO N 470 A t la n tic A ve B o s to n , M A 02210 Tel: (617) 482-5655 F ax: (617) 482-1551 S A V A N N A H 7 373 H o d g s o n M em . D riv e S a v a n n a h , G A 31405 T el: (912) 353-9341 Fax: (912) 353-9341 QUALIFIED PHYSIO/OCCUPATIONAL THERAPISTS NEW GRADUATES JO IN THE 0 ’ GRADY PEYTON TEAM IN THE USA FOR THE EXPERIENCE OF A LIFETIM E ! * S n o w s k iin g in th e R o c k ie s , W h ite w a te r R a ftin g on th e C o lo ra d o , C y c lin g th r o u g h th e W in e C o u n tr y CHOOSE YO U R STATE * A c u te Care, In d u s tria l R ehab, H o m e H ealth, O rth o p a e d ic O u tp a tie n ts CHOOSE YO U R FACILITY * D o w n P a y m e n t on a car, S e ttlin g o f S tu d e n t B u rs a rie s , C o n tin u in g E d u c a tio n , A c c o m m o d a tio n A llo w a n c e CHOOSE YO U R PACKAGE B E N E F I T S R e tu rn A irfare s L o ca l R e p re s e n ta tiv e to h e lp y o u se ttle in - c o m p re h e n s iv e “ M EET AND G R E ET” O rie n ta tio n P ro g ra m m e O b ta in y o u r GREEN CARD M a rrie d ? Y ou can b o th o b ta in y o u r G reen Cards b e fo re d e p a rtu re to th e USA A s s is ta n c e w ith E m p lo y m e n t tor S pouse L o ca l s u p p o r t in S o u th A fr ic a re g a rd in g s tu d y m a te ria l, US S c h o o ls a nd d ay ca re , A c c o m m o d a tio n PLEASE CALL IRENE S TEE N K AM P (U S A LICENCED PT) FOR FU R TH ER IN F O R M A T IO N OR TO SCH ED U LE AN A P P O IN T M E N T . W O R K (0 2 1 ) 4 1 9 -5 0 7 0 H O M E /F A X (0 2 1 ) 6 8 5 -1 3 8 1 Blodsy 36 M e i 1996 SA Tydskrif Fisioterapie, Dee152 N o 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )