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Biomechanical, Rehabilitative, & Motor Frames

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Jennifer Fortuna

on 30 March 2016

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Transcript of Biomechanical, Rehabilitative, & Motor Frames

BIOMECHANICAL & REHABILITATIVE FRAMES
MOTOR CONTROL & MOTOR LEARNING

Jennifer Fortuna, MS, OTR/L
AUTHORS
The biomechanical frame of reference was developed by many notable practitioners. Today, this FoR is identified as one of the top five most frequently used models in occupational therapy practice.
(Cole & Tufano, 2008)
CORE CONCEPTS
"The biomechanical FoR applies principles of physics to human movement and posture with respect to forces of gravity"


(Cole & Tufano, 2008, p. 165)
PURPOSE
In occupational therapy practice, principles of movement, range of motion (ROM), strength, endurance, economics, and the impact of pain are considered within the context of occupation.
(Cole & Tufano, 2008)

THEORETICAL BASE
Range of Motion:
ROM involves the angles and directions of human movement, including extension, flexion, abduction, adduction, and rotation. ROM is a concern in OT practice when illness and injury cause long periods of immobility, or muscle imbalance.

(Cole & Tufano, 2008)
THEORETICAL BASE
Kinematics:
The amount, direction, speed and acceleration of human movement. Occupational therapy research on human movement applies to many activities of daily living.

(Cole & Tufano, 2008)
THEORETICAL BASE
Torque:
The effectiveness of force in causing rotary movement. Torque is dependent on the amount of force and resistance, as well as distance of the force from the axis (joint). In occupational therapy practice, this principle involves minimizing client effort (strength) needed to complete a movement by reducing resistance (weight to be lifted).

(Cole & Tufano, 2008)
THEORETICAL BASE
Strength:
Refers to both stability and motion produced by muscle tension. Normal activities of daily living require contraction of combined muscle groups to move and stabilize the body in learned patterns or sequences. Stability is necessary to achieve skilled movement patterns.
(Cole & Tufano, 2008)
THEORETICAL BASE
Endurance:
The ability to sustain muscular activity. Endurance involves other body systems and may be dependent on one's state of health (infection, amount of sleep, etc).


(Cole & Tufano, 2008)
FUNCTION & DISABILITY

Function:
Maintaining strength, endurance, and ROM within normal limits for one's age, gender, and characteristics. Function is also related to knowledge and use of proper body mechanics and ergonomics to prevent injury.
(Cole & Tufano, 2008)
FUNCTION & DISABILITY
Disability:
Biomechanical disability is often related to the inability to perform a specific task due to a restriction in joint ROM, strength or endurance interferes with biomechanical function. Common conditions include orthopedic injury, edema, pain, skin tightness (burns/scars), spasticity, or low muscle tone. Also, extended immobilization (disuse). OT goals are developed in regard to the task, situation, and context.
(Cole & Tufano, 2008)
ASSUMPTIONS
1. Maintaining/preventing limitations in ROM may be
accomplished through compression, positioning and
movement through full ROM.
2. Increasing ROM may be accomplished through passive
stretching, active stretching, and proprioceptive
neuromuscular facilitation (PNF) techniques.
3. Strength may be increased through exercise, daily
occupations and strengthening programs.
4. Endurance may be increased through light resistive
exercise, graded occupations and participation in
meaningful tasks and everyday activities.
5. Incorporating physical agent modalities (PAMS) may
reduce pain and edema to facilitate movement. Also,
to prevent atrophy and facilitate nerve regeneration.
(Cole & Tufano, 2008)
EVALUATION PROCEDURES
ROM is measured with a goniometer
Strength is measured with manual muscle testing, grip strength, and pinch strength
Endurance is measured as duration of an activity, or number of repetitions performed before the individual becomes fatigued
Evaluation of pain can be complex and involves subjective measurement such as a self-report (scale of 1-10). Pain levels may be influenced by one's perception of, and tolerance for pain.
(Cole & Tufano, 2008)
FOCUS
The biomechanical frame of reference is often used in occupational therapy practice to address deficits in ROM, strength and endurance. Also known as "body functions" in the OTPF. Areas of practice include musculoskeletal disorders, trauma, hand injuries, work hardening, ergonomics, and prevention.
DOMAINS OF CONCERN
(Cole & Tufano, 2008; Trombly, 2002)
Domains of concern for occupational therapy practice:
Performance areas for application
Analysis of task demands
Use of occupation to provide graded exercise
(Trombly, 2002)
SUITABLE POPULATIONS
The biomechanical FoR is suitable for individuals with sensorimotor problems resulting from motor unit or orthopedic disorders, but whose central nervous system in intact.
(Pedretti & Early, 2001)
INTERVENTION STRATEGIES
Changes in biomechanical abilities may be achieved by:
Positioning
Exercise
Graded tasks
Stretching
Lifting
Moving
Repetition
Practice
Environmental modifications
(Cole & Tufano, 2008)
PRINCIPLES OF CHANGE
1. Maintain or prevent limitations in ROM
2. Increase ROM
3. Increase strength
4. Increase endurance

The use of physical agent modalities (PAMS) to increase movement, or minimize pain may also be included to facilitate change.
(Jackson et al., 2002)
GUIDELINES FOR INTERVENTION
Occupational therapists utilizing the biomechanical FoR develop interventions that focus on the client's identified roles and meaningful activities. Methods of intervention include activity adaptation, compensatory strategies, use of technology and physical reconditioning.
(Cole & Tufano, 2008)
REFERENCES
Cole, M.B. & Tufano, R. (2008). Applied theories in occupational
therapy: A practical approach. Thorofare, New Jersey: Slack
Incorporated.

Pedretti, L.W., & Early, M.B. (2001). Occupational performance and
models of practice for physical dysfunction. In L.W. Pedretti, &
M.B. Early (Eds.),
Occupational therapy: Practice skills for
physical dysfunction
(5th Ed.). St. Louis: Mosby.

Trombly, C. (2002). Conceptual foundations for practice. In C.
Trombly & M.V. Radomski (Eds.),
Occupational therapy for physical dysfunction
(6th Ed.). Philadelphia: Lippincott, Williams & Wilkins.

REHABILITATIVE APPROACH
According to Trombly (2002) the rehabilitative approach aims to make the individual as independent as possible in spite of impairment.

While rehabilitation is often associated with the medical model, the term remains relevant to occupational therapy as long as practitioners continue to work in clinical rehabilitation.


(Sabari, 2008; Cole & Tufano, 2008)
FOCUS
The rehabilitative approach consists mainly of environmental adaptation and compensatory strategies.

An updated understanding of the rehabilitative approach in occupational therapy practice acknowledges the need to combine both physical and psychological factors. In other words, to view occupational performance holistically.
(Cole & Tufano, 2008)
CORE CONCEPTS
The client's mental and physical functions impact occupational performance.

People exhibit different levels of frustration when presented with physical limitations. Some may be willing to adapt the way they perform a task, while others use compensatory strategies.

This illustrates the need for a client-centered and systems-oriented approach when using the biomechanical and rehabilitative frames of reference.
(Cole & Tufano, 2008)
The biomechanical FoR and rehabilitative approach are closely connected. Therefore, the two approaches have been combined for the remainder of this presentation.
A COMBINED APPROACH
AUTHORS
Berta & Karel Bobath – Neurodevelopmental Treatment (NDT)
Margaret Rood – Sensorimotor Approach
Margaret Knott & Dorothy Voss – Proprioceptive Neuromuscular Facilitation (PNF)
Signe Brunnstrom – Movement Therapy

Motor control frames of reference:
PURPOSE
The Motor Control and Motor Learning Frames of Reference represent the traditional motor control approaches commonly used in practice today.

Theories of motor control use principles of normal neurological development to restore functional movement. Motor learning theory provides a backdrop for motor skill acquisition across the lifespan.
(Cole & Tufano, 2008)
CORE CONCEPTS
The combined theories of motor learning represent the paradigm shift from older reflex-hierarchical models of motor control to holistic and systems oriented theories of learning.


THEORETICAL PRINCIPLES
NDT: (Neuromaturational Approach)
1. Neurology
2. Medicine
3. Physical Therapy
4. Human Development
5. Brain Injury

Combined Theories: (Holistic/Systems Approach)
1. Psychology
2. Behavioral Science
3. Neurology
4. Medicine
5. Allied Health Research

(Cole & Tufano, 2008)
SUITABLE POPULATIONS
Children and adults with a broad range of health conditions affecting motor control.
(Cole & Tufano, 2008)
CORE CONCEPTS
Meaningful tasks of the client’s choosing are used to recover and refine skilled voluntary movements.

The combined motor theories are used today by occupational therapists, physical therapists, and speech - language pathologists to treat a broad range of health conditions.
(Cole & Tufano, 2008)
ASSUMPTIONS
A. Movement control progresses from:
1. Head to foot (cephalo-caudal)
2. Trunk to limbs (proximal to distal)
3. Large to small (gross to fine)

B. Children gradually gain control over their primitive reflexes (based on
sensory input) in order to perform skilled voluntary movement.

C. Children internalize the sensation of movement creating motor sequences
or patterns of movement (internalized sequences of stability and mobility).
Examples of patterns include: Rolling, sitting, crawling, standing, and walking.

D. In recovery of movement, stability precedes mobility.
1. Stability is created by co-contraction of complementary
(opposite) muscle groups holding the body in place and
mediating the effects of gravity which makes skilled movement possible.
2. Mobility represents a way to engage the environment through
purposeful voluntary movements.

(Cole & Tufano, 2008)
FUNCTION & DISABILITY
NDT:
• Function refers to the capacity to perform voluntary
skilled movements needed for everyday life.
• Dysfunction in adults includes lack of postural control,
loss of selective movement on the contralateral side,
abnormal tone, associated reactions, poor inhibition of
primitive reflexes and nonfunctional movements, and
sensory disturbances.

• Dysfunction in children is motor dysfunction where the
child is unable to control their own movements.
• Dysfunction in children with cerebral palsy includes lack
of postural control, abnormal tone, generalized
spasticity, poor inhibition of nonfunctional movements,
and sensory disturbances.

(Cole & Tufano, 2008)
FUNCTION & DISABILITY
Combined Theories:
Functioning is defined within the context of specific tasks.

Acquisition of skills separated into:
1. Early (experimental) stage.
2. Late (refinement) stage.

Three-stage model of motor learning:
1. Cognitive Stage
2. Associative Stage
3. Autonomous Stage

(Cole & Tufano, 2008; Fitts & Posner, 1967)
EVALUATION PROCEDURES
NDT:
1. Evaluation involves both observation and handling.

2. During observation, the clinician notes:
Typical postures, preferred movement patterns, compensatory strategies, spontaneous use of affected side.

3. Handling includes postures/movement sequences
that relate to occupational performance.
Trunk movement, response to weight bearing and weight shifting, protective responses.

4. Control of arms/legs is evaluated in segments.
Proximal to distal pattern

5. Evaluation involves collaborative goal setting with
the client and family.
Goals vary by client, motivation, preferences
(Cole & Tufano, 2008)
EVALUATION PROCEDURES
Combined Theories:
1. Evaluation is conducted while performing occupations
in a natural setting (various contexts recommended).

2. The OT collaborates with the client to determine
occupational problems with role and task priorities.

3. To determine appropriate interventions, OT evaluates:
• The attributes of the client
• The task
• The environmental contexts.

4. The Self-Report can help to determine the client’s
functional capacity if client is unable to perform activities.

(Cole & Tufano, 2008)
INTERVENTION STRATEGIES
1. Compensation with one-handed tasks is discouraged.

2. Prevention of abnormal tone, including:
- Asymmetrical postures
- Contracture of spastic muscles
- Possible shoulder subluxation
- Abnormal movement pattern development.

3. Initial movement training is practiced using occupation to
incorporate specific movement strategies.
- Weight bearing on affected arm using bed motility.
- Weight shifting and trunk realignment during transfers.
- Bilateral arm use in wheelchair management.

4. The OT watches for signs of spasticity.

(Cole & Tufano, 2008)
EXPECTED OUTCOMES
Treatment results in:
1. Using normal movement patterns.
2. Increased independence in ADL’s.
3. Increased balance and postural control
during daily tasks and occupations.
4. Increased bilateral coordination

(Cole & Tufano, 2008)
REFERENCES
Bobath, B. (1990). Adult Hemiplegia: Evaluation and
treatment (3rd Ed). Oxford: Butterworth Heinemann.

Cole, M.B. & Tufano, R. (2008). Applied theories in
occupational therapy: A practical approach. Thorofare, New Jersey: Slack Incorporated.

Fitts, & Posner, (1967). International Bobath Instructors
Training Association (IBITA). (2006). Theoretical
assumptions and clinical practice. Education Committee, last version September 13, 2008.

Neuro-Developmental Treatment Association (NDTA).
(2011). Treatment. Retrieved from http://www.ndta.org/whatisndt.php.

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