Traditional Sensorimotor Approaches to Intervention

Neurologic Considerations for Traditional Sensorimotor Approaches to Intervention

Occupation performance frequently requires precise voluntary movement, which is controlled and monitored by the nervous system. Various structures within the nervous system are coordinated to selectively activate specific muscles to initiate, perform, and complete a desired task or activity. If a movement is performed poorly and thereby compromises performance of a task, feedback occurs through knowledge of the results of the action, and the neurologic commands to the muscles are modified so that accuracy of movement is achieved. Knowledge of the intricate working of the nervous system is of special importance to occupational therapists (OTs) concerned with refinement and improvement of the motor performance of clients with neurologic conditions.³ A brief overview of the flow of information associated with the control of movement is described in the following sections.

The Rood Approach

Margaret Rood drew heavily from both the reflex and the hierarchic models in designing her intervention approach.^56–58 Key components of the Rood approach are the use of sensory stimulation to evoke a motor response and the use of developmental postures to promote changes in muscle tone. Sensory stimulation is applied to muscles and joints to elicit a specific motor response. Stimulation has the potential to have either an inhibitory or a facilitatory effect on muscle tone. Types of sensory stimulation described by Rood include the use of slow rolling, neutral warmth, deep pressure, tapping, and prolonged stretch. Examples of how this stimulation may be applied include 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. Rood also described the use of specific developmental sequences believed to promote motor responses.⁵⁷ These sequences were proximal to distal and cephalocaudal. Treatment strategies move clients through these developmental sequences.

In current clinical practice, practitioners may use selected principles from Rood’s work as adjunctive or preliminary interventions to prepare an individual to engage in a purposeful activity—for example, application of quick stretch over the triceps before instructing a client to reach for a cup or glass to improve elbow extension.⁶⁷ A client may be instructed in ways to apply his or her own sensory stimulation to enhance performance of activities of daily living (ADLs). For example, during upper extremity dressing, the OT may ask Carlos to perform a prolonged stretch of the left biceps; this results in a reduction in muscle tone, which may, in turn, increase the ease with which the arm is moved through the sleeve of his shirt.

Limitations in the use of Rood’s approach are numerous and include the passive nature of the sensory stimulation (it is applied “to” an individual) and the short-lasting and unpredictable effect of some of the sensory stimulation. Please refer to the discussion later in this chapter for additional details regarding the Rood approach to intervention.

The Brunnstrom (Movement Therapy) Approach

Signe Brunnstrom, a physical therapist (PT), developed an intervention approach specifically for individuals who had sustained a CVA.^9,10 The approach that she designed draws strongly from both the reflex and hierarchic models of motor control. Brunnstrom conceptualized clients who had sustained a CVA as going through an “evolution in reverse.” Spastic or flaccid muscle tone and the presence of reflexive movements that may be evident after a client sustains a CVA are considered part of the normal process of recovery and are viewed as necessary intermediate steps in regaining volitional movement.⁶² Brunnstrom clearly detailed stages of motor recovery after a CVA (Table 31-2). These stages include the description of flexor synergy patterns and extensor synergy patterns for the upper and lower limbs and are used as descriptors of change following a CVA.²³ Carlos currently displays flexor tone dominating his left arm and extensor tone dominating his left leg. This dominating tone interferes with isolated control of his left extremities.

In the Brunnstrom approach, emphasis is placed on facilitating the progress of the individual by promotion of movement, from reflexive to volitional. In the early stages of recovery this may include the incorporation of reflexes and associated reactions to change tone and achieve movement. For example, to generate reflexive movement in the arm, resistance may be applied to one side of the body to increase muscle tone on the opposite side. This technique is applied until the client demonstrates volitional control over the movement pattern.

Proprioceptive Neuromuscular Facilitation Approach

The PNF approach is grounded in the reflex and hierarchic models of motor control. Developed through the collaborative efforts of a physician, Dr. Herman Kabat, and two PTs, Margaret Knott and Dorothy Voss, in the 1950s, this intervention approach continues to be used but has not been revised since its origins. The major emphasis in this approach is on the developmental sequencing of movement and the balanced interplay between agonist and antagonist in producing volitional movement.⁷⁴ PNF describes mass movement patterns, which are diagonal in nature, for the limbs and trunk. Intervention strategies use these patterns 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.

In clinical occupational therapy practice, the inclusion of PNF patterns can often be seen in the way that functional activities are designed, especially in the placement of objects during purposeful activities. For example, a client is asked to reach into a shopping bag placed on his left side to retrieve objects that will then be placed in a cabinet on his right side. Specific information regarding the application of PNF is discussed later in Section 2 of this chapter. This approach has been used successfully to increase range of motion (ROM) and for stretching of tightened muscles.⁶⁴

Neurodevelopmental Treatment Approach

The NDT approach, also known as the Bobath treatment approach, is based on normal development and movement. Berta Bobath, a PT, and her husband Karel Bobath, a physician, provided the initial theoretic foundations of NDT in the 1950s.²⁷ At that time they drew from the hierarchic model of motor control. The primary objectives of NDT are to normalize muscle tone, inhibit primitive reflexes, and facilitate normal postural reactions.⁵ Improving the quality of movement and helping clients relearn normal movement patterns are key objectives of this approach. To achieve these objectives, therapists use numerous techniques, including handling techniques, weight bearing over the affected limb, use of positions that encourage the use of both sides of the body, and avoidance of any sensory input that may adversely affect muscle tone.¹⁶ In clinical practice today, many of these techniques and strategies are used within the context of purposeful activities.

NDT has continued to revise its theoretic framework in response to new evidence on the function of the CNS.²⁷ Discussions on the rationale for NDT include the current understanding of motor systems and motor learning. See Section 3 of this chapter for further descriptions.

Summary

Movement takes place within an occupational context. Emotional needs influence motor strategies. The spinal cord or brainstem can mediate reflexive responses, but interpretation and transformation of sensory signals by all areas of the sensorimotor system are essential for voluntary movement to occur with precision. The primary somatosensory cortex and posterior parietal cortex are primarily responsible for processing sensory information. The premotor area uses sensory information for planning movements, the supplementary motor area is important for bimanual coordination, and the motor cortex is important for execution.

The traditional sensorimotor intervention approaches have their theoretic basis in the reflex and hierarchic models of motor control. These approaches offer a valuable link between neurophysiologic principles and the rehabilitative treatment of clients with CNS dysfunction. In contemporary practice, many of the techniques described in these approaches are used as adjunctive or preliminary techniques or are incorporated into more task-directed treatment activities.

History

PNF originated with Dr. Herman Kabat, physician and neurophysiologist, in the 1940s. He applied neurophysiologic principles, based on the work of Sherrington, to interventions for paralysis secondary to poliomyelitis and multiple sclerosis. In 1948, Kabat and Henry Kaiser founded the Kabat-Keiser Institute in Vallejo, California. Here, Kabat worked with PT Margaret Knott to develop the PNF method of intervention. By 1951 the diagonal patterns and core techniques were established. PNF is now used to treat numerous neurologic, musculoskeletal, and general medical conditions.

In 1952 Dorothy Voss, a PT, joined the staff at the Kaiser-Kabat Institute. She and Knott undertook the teaching and supervision of staff therapists. In 1954 Knott and Voss presented the first 2-week course in Vallejo. Two years later, the first edition of Proprioceptive Neuromuscular Facilitation by Margaret Knott and Dorothy Voss was published by Harper & Row.

During this same period several reports in the American Journal of Occupational Therapy described PNF and its application to occupational therapy intervention.^{4,12,14,34,71,75} It was not until 1974 that the first PNF course for OTs, taught by Dorothy Voss, was offered. Since then, Beverly Myers, an OT, and others have offered courses for OTs throughout the United States. In 1984, PNF was first taught concurrently to both PTs and OTs at the Rehabilitation Institute in Chicago.^49,74 Today, courses are offered throughout the United States, as well as Europe, Asia, and South America.

Principles of Intervention

Voss presented 11 principles of intervention at the Northwestern University Special Therapeutic Exercise Project in 1966. These principles were developed from concepts in the fields of neurophysiology, motor learning, and motor behavior and are still essential to the practice of PNF today.⁷²

All human beings have potentials that have not been fully developed. This philosophy is the underlying basis of PNF. Therefore, during evaluation and intervention planning, the client’s abilities and potentials are emphasized. For example, a client who has weakness on one side of the body can use the intact side to assist the weaker part. Likewise, a client who has hemiplegia with a flaccid arm can use the intact head, neck, and trunk musculature to begin reinforcement of the weak arm in weight-bearing activities.

Normal motor development proceeds in a cervicocaudal and proximodistal direction. The cervicocaudal and proximodistal direction is followed in evaluation and intervention. When severe disability is present, attention is first directed to the head and neck region, with its visual, auditory, and vestibular receptors, and then to the upper part of the trunk and extremities. If the superior region is intact, an effective source of reinforcement for the inferior region is available.⁷⁴ The proximodistal direction is followed by developing adequate function in the head, neck, and trunk before developing function in the extremities. This approach is of particular importance in interventions that facilitate fine motor coordination in the upper extremities. Unless adequate control exists in the head, neck, and trunk region, fine motor skills cannot be developed effectively. For example, Leticia needs to strengthen her head, neck, and trunk muscles to regain adequate postural control before she can adequately perform the fine motor tasks required in her job, such as cutting with scissors. This illustrates how addressing a specific client factor of postural control can influence occupational performance.

Early motor behavior is dominated by reflex activity. Mature motor behavior is supported or reinforced by postural reflexes. As humans mature, primitive reflexes are integrated and available for reinforcement to allow progressive development, such as rolling, crawling, and sitting. Reflexes have also been noted to have an effect on changes in tone in the extremities. Hellebrandt, Schade, and Carns studied the effect of the tonic neck reflex and the asymmetric tonic neck reflex on changes in tone and movement in the extremities of normal adults.²⁵ They found that head and neck movement significantly affected arm and leg movement. In applying this finding to intervention, for example, weak elbow extensors can be reinforced with the asymmetric tonic neck reflex by having the client look toward the side of weakness. Likewise, the client can be assisted in assuming postures with the influence of reflex support. For example, Leticia can use the body-on-body righting reflex to support her ability to assume sitting upright on the edge of the bed from a side-lying position when she gets up in the morning.

Early motor behavior is characterized by spontaneous movement, which oscillates between extremes of flexion and extension. These movements are rhythmic and reversing in character. During intervention it is important to attend to both directions of movement. When the occupational therapy practitioner is working with a client on getting up from a chair, attention must also be given to sitting back down. Often with an injury, the eccentric contraction (e.g., sitting down) is lost and becomes very difficult for the client to regain. If not properly treated, the client may be left with inadequate motor control to sit down smoothly and thus may “drop” into a chair. This eccentric control would be particularly important for Leticia because she is required to sit in low chairs at her children’s school. Similarly, in training for ADLs the client must learn how to get undressed and dressed.

Developing motor behavior is expressed in an orderly sequence of total patterns of movement and posture. In a normal infant the sequence of total patterns is demonstrated through the progression of locomotion. The infant learns to roll, to crawl, to creep, and finally to stand and walk. Throughout these stages of locomotion the infant also learns to use the extremities in different patterns and within different postures. Initially, the hands are used for reaching and grasping within the most supported postures, such as supine and prone. As postural control develops, the infant begins to use the hands in side-lying, sitting, and standing positions. During intervention, to maximize motor performance, clients should be given opportunities to work in a variety of developmental postures. Use of the extremities in total patterns requires interaction with component patterns of the head, neck, and trunk. For example, when swinging a tennis racquet in a forehand stroke, the arm and the head, neck, and trunk move in the direction of the swing. Without the interaction of the distal and proximal components, movement becomes less powerful and less coordinated.

The growth of motor behavior has cyclic trends, as evidenced by shifts between flexor and extensor dominance. The shifts between antagonists help develop muscle balance and control. One of the main goals of the PNF intervention approach is to establish a balance between antagonists. Developmentally, the infant establishes this balance before creeping (i.e., when rocking forward [extensor dominant] and backward [flexor dominant] on hands and knees). Postural control and balance must be achieved before movement can begin in this position. During intervention it is important to establish a balance between antagonistic muscles by first observing where imbalance exists and then facilitating the weaker component. For example, if a client who has sustained a stroke demonstrates flexor synergy (flexor dominant), extension should be facilitated.

Normal motor development has an orderly sequence but lacks a step-by-step quality. Overlapping of skills occurs. A child does not perfect performance of one activity before beginning another, more advanced activity. When trying to ascertain in which total pattern to position the client, normal motor development should be heeded. If one technique or developmental posture is not effective in obtaining the desired result, it may be necessary to try the activity in another developmental posture. For example, if a client who has ataxia, such as Leticia, is unable to perform a fine motor task while sitting, it may be necessary to practice skills in a more supported posture, such as prone on the elbows or with her elbows supported on a surface such as a table. Just as the infant reverts to a more secure posture when attempting a complex fine motor task, so must the client. On the other hand, if the client has not perfected a motor activity such as walking on level surfaces, he or she may benefit from attempting a higher-level activity such as walking up or down stairs, which in turn can improve ambulation on level surfaces. It is natural for the client to move up and down the developmental sequence, and this allows multiple and varied opportunities for practicing motor activities. The cognitive demands of the task in relation to the developmental posture must also be considered. When the client’s position is varied, either by changing the base of support or by shifting weight on different extremities, the quality of visual and cognitive processing is influenced.¹

Locomotion depends on the reciprocal contraction of flexors and extensors, and maintenance of posture requires continual adjustment for nuances of imbalance. Antagonistic pairs of movements, reflexes, and muscles and joint motion interact as necessary with the movement or posture. This principle restates one of the main objectives of PNF—to achieve a balance between antagonists. An example of imbalance is a client with a head injury who is unable to maintain adequate sitting balance for a tabletop cognitive activity because of a dominance of trunk extensor tone. Another example is a client who has hemiplegia with tight finger flexors secondary to a flexor-dominant tone in the hand. During intervention, emphasis is placed on correcting the imbalances. In a client with spasticity, first the spasticity is inhibited and then the antagonistic muscles, reflexes, and postures are facilitated.

Improvement in motor ability is dependent on motor learning. Multisensory input from the therapist facilitates motor learning in the client and is an integral part of the PNF approach. For example, the therapist may work with a client on a shoulder flexion activity such as reaching into a cabinet for a cup. The therapist may say, “Reach for the cup,” to add verbal input. This approach also encourages the client to look in the direction of the movement to allow vision to enhance the motor response. Thus, tactile, auditory, and visual input is used. Motor learning has occurred when these external cues are no longer needed for adequate performance.

Frequent stimulation and repetitive activity are used to promote and retain motor learning and to develop strength and endurance. Just as a therapist who is learning PNF needs the opportunity to practice the techniques, a client needs the opportunity to practice new motor skills. With practice, habits will be formed that support motor performance in occupation. In the process of development an infant constantly repeats a motor skill in many settings and developmental postures until it is mastered, as becomes apparent to anyone who watches a child learning to walk. Numerous attempts fail, but efforts are repeated until the skill is mastered. After the activity is learned, it becomes part of the child. He or she is able to use the activity automatically and deliberately as the occasion demands.⁷⁴ The same is true for a person learning to play the piano or to play tennis. Without the opportunity to practice, motor learning cannot occur successfully. Just as Leticia’s students may be given homework to help them practice the material that they learn in school, Leticia will also need to be given a home program that encourages her to practice the postures and movements facilitated in therapy.

Goal-directed activities coupled with techniques of facilitation are used to hasten learning of total patterns of walking and self-care activities. When facilitation techniques are applied to self-care, the objective is improved functional ability, but improvement is achieved by more than instruction and practice. Correction of deficiencies is accomplished by direct application of manual contact and techniques to facilitate a desired response.²⁹ During an intervention session, this approach may mean applying stretch to the finger extensors to facilitate release of an object or providing joint approximation through the shoulders and pelvis of a client who has ataxia to provide stability while the client is standing to wash dishes. With repetition of appropriate facilitation techniques, Leticia will have the opportunity to feel more normal movement and need to rely less on the therapist’s external input.

Motor Learning

Motor learning requires a multisensory approach. The auditory, visual, and tactile systems are all used to achieve the desired response. The correct combination of sensory input in each client should be ascertained, implemented, and altered as the client progresses. The developmental level of the client and the ability to cooperate should also be taken into consideration.⁷⁴ The approach used with a client who has aphasia differs from that used with a client who has a hand injury. For example, verbal instructions would be better understood by the client with a hand injury than the client with aphasia. Less verbal and more tactile and gestural cues would be appropriate with the client who has aphasia. Similarly, the approach used with a child varies greatly from that used with an adult. Interventions with Leticia must take into consideration her visual deficits in addition to any cognitive impairment that remains as a result of her head injury.

Assessment

Assessment of the client requires astute observational skills and knowledge of normal movement. An initial assessment is performed to determine the client’s abilities, deficiencies, and potential. After the intervention plan is established, ongoing assessment of the client is necessary to ascertain the effectiveness of intervention and to make modifications as the client changes.

The PNF assessment follows a sequence from proximal to distal. First, vital and related functions are considered, such as breathing, swallowing, voice production, facial and oral musculature, and visual-ocular control. Any impairment or weakness in these functions is noted. Because Leticia fatigues quickly, breathing patterns and efficiency need to be closely evaluated as she engages in her daily activities.

The head and neck region is observed after vital functions. Deficiencies in this area directly affect the upper part of the trunk and extremities. Head and neck positions are observed in varying postures and total patterns during functional activities. It is important to note (1) dominance of tone (flexor or extensor), (2) alignment (midline or shift to one side), and (3) stability and mobility (more or less needed).⁴⁹

After observation of the head and neck region, the assessment proceeds to the following parts of the body: upper part of the trunk, upper extremities (UEs), lower part of the trunk, and lower extremities (LEs). Each segment is assessed individually in specific movement patterns, in addition to during developmental activities in which the body segments interact. For example, shoulder flexion can be observed in an individual UE movement pattern, in addition to during a total developmental pattern such as rolling.

During assessment of developmental activities and postures, the following issues should be addressed:

When applying these questions to Leticia’s evaluation, the following observations can be made. First, Leticia will need to work on developing stability to diminish the effects of her ataxia. She is not dominated by either flexor or extensor tone but, when fatigued, has more difficulty maintaining an upright posture. She will therefore need to have facilitation of the head, neck, and trunk extensors when fatigued. She can move in all directions but has less stability when walking backward. Her major limitations are poor motor control and rigidity, but prevention of a wrist contracture is also a concern. Leticia is having difficulty assuming kneeling, sitting, and standing postures because of her instability. Once in an upright posture, she can maintain it for a few minutes, but fatigue then sets in. She will therefore need to build endurance in more supported lower developmental postures. When moving into more upright postures, she will need PNF techniques to build strength and endurance. Her inadequate proximal control and trunk rigidity affect her ability to effectively use her extremities, especially in higher developmental positions. Visual sensory input may not be the best to start with because of her diplopia; however, facilitation of oculomotor control using PNF techniques will be of benefit as she progresses. The facilitation techniques that Leticia responds to best are rhythmic stabilization, stabilizing reversals, and approximation.

Finally, the client is observed during self-care and other ADLs to determine whether performance of individual and total patterns is adequate within the context of a functional activity. The client’s performance may vary from one setting to another. After the client leaves the structured setting of the occupational or physical therapy clinic for the less structured home or community environment, deterioration of motor performance is not unusual. Thus, the intervention plan must accommodate the practice of motor performance in a variety of settings in locations appropriate to the specific activity.

Intervention Implementation

After assessment, an intervention plan is developed that includes goals that the client hopes to accomplish. The techniques and procedures that have the most favorable influence on movement and posture are used. Similarly, appropriate total patterns (developmental postures) and patterns of facilitation are selected to enhance performance.

Summary

The PNF approach emphasizes the client’s abilities and potential so that strengths assist weaker components. Strengths and deficiencies are assessed and addressed during intervention within total patterns of movement and posture. Carefully selected techniques are superimposed on these total patterns to enhance motor response and facilitate motor learning.

PNF uses multisensory input. Coordination and timing of sensory input are important in eliciting the desired response from the client. The client’s performance should be monitored, and sensory input should be adjusted accordingly.

To use PNF effectively, the therapist must understand the developmental sequence and the components of normal movement. The therapist must learn the diagonal patterns and how they are used for ADLs, must know when and how to use the techniques of facilitation and relaxation, and must be able to apply patterns and techniques of facilitation to occupational therapy evaluation and intervention. Attaining these skills requires observation and practice under the supervision of a therapist experienced in the PNF approach.

Historical Context of the Neurodevelopmental Treatment Approach

“Neurodevelopmental treatment,” as it is currently referred to in the United States, originally began as the “Bobath concept,” a treatment approach developed by Berta and Karel Bobath in the 1940s. Berta Bobath received her early training as a remedial gymnast at the Anna Herrmann School of gymnastics in Germany, where she stayed on as an instructor of gymnastics after graduation.⁶³ She described the focus of her educational program at Anna Herrmann:

In the 1930s, when the Nazis came to power in Germany, Berta Bobath lost her job as a gymnastics instructor because the school would not retain a Jewish teacher. Berta subsequently moved to London and eventually worked at the Princess Louise Hospital.

Based on her background and skills in analyzing normal movement, Berta Bobath was repeatedly asked to see special cases of both children with cerebral palsy and adults with hemiplegia. At the time, it was assumed that individuals with upper motor neuron (UMN) lesions could not recover from their motor deficits. Because of her background in dance, her training in posture and analysis of movement, and probably also her “heretical or eccentric” (p. viii) views,⁶⁸ Mrs. Bobath did not ascribe to this belief. She began by repositioning these clients into more neutral and symmetric alignments. She examined the impact of her handling on their tone and ability to move. Berta described the basis of her approach as “…the inhibition of released and exaggerated abnormal reflex action, the counteraction of abnormal patterns, and the facilitation of more normal automatic voluntary movements.”⁶³

After much experience and success with her techniques, Berta eventually studied to become a physiotherapist and passed the examination in 1950. Dr. Karel Bobath, Berta’s husband and a psychiatrist, became interested in the approach and spent much of his career studying and explaining the neurophysiology behind Berta’s observations.

Together, Berta and Karel Bobath are credited with development of the Bobath concept and the NDT approach. They established the first Bobath Centre in London in 1951 and soon began training other physiotherapists in her approach to the treatment of children with cerebral palsy and adults with hemiplegia. Today, courses on this approach are taught both nationally and internationally to OTs and PTs, speech-language pathologists, and in some countries, nurses, physicians, and teachers.²⁷ Information regarding continuing education courses in the United States (for OTs) can be found at the Neuro-Developmental Treatment Association Website, www.ndta.org.

Several contemporary authors describe NDT as a treatment approach that is based on a hierarchic view of the nervous system, given the time period in which it was established. Although it is true that the accepted view of the nervous system at the time that the approach began was a hierarchic model, it does not appear true, or consistent with the writings of the Bobaths and other historians, that the approach was originally based on a hierarchic perspective. The approach was based on Berta’s experiences—her skilled observations of alignment, posture, and movement—which were then interpreted in light of the reflex-hierarchic model of the time.^54,63 This inductive sequence, from observations to development of theory, is discussed in many historical accounts of the approach. Even though dynamic models of CNS function and specifically motor control did not exist at the time, contemporary dynamic perspectives seem to support Berta’s original observations and experiences more accurately than reflex-hierarchic models do. Her handling resulted in changes in tone and movement capacities that seem unlikely (or could not have resulted) if the client’s tone and movement patterns were exclusively reflexive in nature. Her handling tapped into a dynamic system controlling motor output that is reflected in contemporary models.⁶⁶

Whether the original NDT approach was founded on a reflex-hierarchic perspective or simply explained in terms of that model, it was clearly suggested as a “living concept” from its inception²⁷ that consisted of concepts that were intended as “working hypotheses” (p. 9). Dr. Bobath used this terminology to stress the need for the approach to change over time with new information. Because it was grounded in an understanding of and appreciation for normal movement rather than pathology, he emphasized that the approach would continue to evolve as the understanding of normal movement advances through new discoveries and development of theories.

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