Optimizing Motor Skill Using TaskRelated Training
(Trombly Ch#23)
Theoretical Framework: Dynamical
Systems Theory and CNS Plasticity
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Organisms demonstrate an inherent tendency to
self-organize throughout life.
Plasticity is a system’s capacity to reorganize after
disruption and to adapt to functional demands.
Neuroscience research has shown that functional
improvements after brain lesions are associated
with changes in metabolic activity or patterns of
neural connections in brain regions that were
previously inactive.
Functional task demands are used instead of
exercise to provide graded motor challenges.
The Rehabilitation Environment
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Environmental factors play a critical role in
determining the effectiveness of
interventions.
The rehabilitation environment can be
structured for enhanced efficacy in improving
motor skill.
The Rehabilitation
Environment: Therapist as
Coach
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The patient-therapist relationship in taskrelated training is an active, collaborative
mentorship with regard to motor
performance.
Therapist’s critical goals as coach are the
following:
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To encourage performance of the most important
mechanical features within a given category of
motor tasks.
To discourage behavioral adaptations that have
limited effectiveness.
The Rehabilitation
Environment: Practice
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Theories about motor skill acquisition emphasize the active problemsolving aspects of learning.
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Major goal is to relearn effective strategies for performing functional
movement.
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Patients practice tasks that require mild variations in movement
patterns during successive repetitions.
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Limb movements and postural adjustments are learned
simultaneously and in the context of task performance.
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Therapists structure a practice program for each patient to reinforce
activities performed during therapy sessions.
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Self-care activities (for example) provide logical opportunities for
task-based practice.
Intervention and General
Framework
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Positive and negative features of motor
impairment may not change through
rehabilitation (or our OT interventions).
Therapists play a critical role in preventing
and reducing the adaptive features
associated with CNS motor dysfunction.
Evaluation and Treatment Planning
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Analysis of performance of selected tasks in each of
four categories of motor performance (balance,
walking, standing up and sitting down, and reaching
and manipulation)
Performance in functional activities is observed and
compared to critical kinematic features associated
with tasks.
Observation enables therapists to develop
individualized treatment plans.
Evaluation and Treatment
Planning (Continued)
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Motor Assessment Scale
is a useful measurement
for looking at the
following:
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Sitting on the edge of the
bed
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Balanced sitting
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Sitting to standing
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Walking
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Upper arm function
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Hand movements
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Advanced hand activities
Balance
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The ability to maintain an upright posture against the
dynamically changing effects of gravity on our body
segments
For persons with motor impairments due to CNS
dysfunction, balance challenges arising from selfinitiated movement are important to daily function.
Postural adjustments are both task and context specific.
Research demonstrates that muscle activation patterns
for balance control vary according to the following:
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Position of the person
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Task being performed
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Context in which the activity occurs
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Person’s perception of which body part is in contact with the
more stable base of support
Essential Features of
Performance for Balance
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Effective balance requires adequate function in sensory
and motor systems.
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Sensory processing:
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Visual
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Vestibular
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Tactile
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Proprioceptive
Motor processing:
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Muscle contractions of appropriate amplitude and timing
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Sufficient joint mobility and muscle length
Assessment of Balance
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Assessed through observational analysis of
movements in sitting and standing:
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Looking in a variety of directions
Reaching forward, sideways, and down to the
floor to pick up objects
Walking in various conditions
Essential Features of
Performance for Walking
(Continued)
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Essential components of motor activity during the
stance phase include the following:
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Extensor muscle activity at the hip, knee, and ankle.
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Smooth alternation of eccentric and concentric
muscular activity in knee and ankle muscles.
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Muscle activity in the gluteus medius at midstance to
prevent excessive downward tilt of the pelvis on the
side of the swinging leg.
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Ongoing postural adjustments to balance the body
mass over a dynamically changing base of support.
Treatment of Balance
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Graded tasks to improve balance:
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Position of the person
Object placement
Object characteristics
Temporal demands
Walking
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Critical component of daily task engagement
is a reasonable expectation for many
individuals with CNS dysfunction.
Occupational therapists must help patients
reach their optimal walking potential for
kitchen, bathroom, leisure, or work pursuits.
Essential Features of
Performance for Walking
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Successful walking requires the following:
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Production of a basic locomotor rhythm
Support and propulsion of the body in the desired
direction
Dynamic balance control of the moving body
The ability to adapt movement to changing
environmental demands and goals
Assessment of Walking
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Physical therapists determine initial walking
goals based on observation and comparison
against well-researched critical kinematic
features of walking.
Treatment goals:
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To prevent soft tissue shortening
To improve muscle strength and control for
support, propulsion, balance, and toe clearance
To improve rhythm and coordination during
functional walking
Treatment of Walking
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Methods include:
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Soft tissue stretching
Active exercises to lengthen shortened muscles
Strength training to improve force generation and
speed of muscle contraction
Step-up, step-down, and side-stepping exercises
Actual walking practice on a variety of surfaces,
slopes, and naturalistic settings
Treatment of Walking
(Continued)
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Early walking training
and use of partial body
weight support training is
advised especially over a
treadmill.
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Occupational therapists
play a critical role in
maximizing walking
during interventions that
require walking while
performing carrying or
pushing tasks consistent
with activities in home,
work, and leisure
environments.
Standing Up and Sitting Down
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For patients who demonstrate potential to walk,
learning how to stand up and sit down has greater
functional implications and is more natural to learn
than traditional transfer techniques.
Demands balance of mobility and stability in the
pelvis, trunk, and limbs
Treatment also improves the following:
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Sitting posture
Sitting and standing balance
Functional reach
Gait
Essential Features of Performance for
Standing Up and Sitting Down
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Two Phases to Normal Kinematics:
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Pre-Extension Phase (Forward Phase)
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Hips flex to move the center of mass forward
Extension Phase (Upward Phase)
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Begins at “thighs off”
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Hips and knees extend to move the center of mass upward to final
standing alignment
Forward foot placement has been found to interfere with both
phases.
Trunk positioning during pre-extension phase affects the
kinematics and kinetics of the extension phase.
Forward flexion at the hips is important for the extension phase.
Mechanics of standing are also affected by arm movement and
speed of performance.
Assessment and Treatment of
Standing Up and Sitting Down
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Passive muscle lengthening may be
necessary if patients demonstrate mobility
limitations in ankle dorsiflexion, knee flexion
or extension, hip flexion or extension, or
sagittal plane pelvic motion.
Whole task practice is important to train
sequencing and timing during functional
performance.
Sitting down is different from standing up and
must also be practiced.
Reach and Manipulation
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The arm and hand function as a single unit in
reach and manipulation with the hand
beginning to open for grasp at the start of
reaching action.
Reach and grasp are not exclusively upper
limb activities.
All reaching activities from sitting or standing
are preceded and accompanied by postural
adjustments.
Essential Features of
Performance for Reach and
Manipulation
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Forward reach entails the following:
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Anterior movement of the pelvis
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Flexion of the trunk at the hips
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Active use of the legs to aid in balancing by creating
an active base of support
Reaching while standing requires the following:
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Establishment of an appropriate base of support with
one’s feet
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Shifting body weight and center of mass toward the
direction of the goal object
Assessment of Reach and
Manipulation
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Clinical assessment of reach and
manipulation is achieved through detailed
observation of each patient’s attempts to
perform selected functional tasks.
Treatment of Reach and
Manipulation
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Training is individualized.
Early control of weak muscles is facilitated by the following:
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Finding an optimal length for muscle contraction
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Providing early opportunities for eccentric exercise
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Positioning the limb so that gravity assists rather than resists the
muscle
Constraint-induced movement therapy is supported when
appropriate.
Bimanual tasks provide a natural framework for encouraging active
use of available hand function.
Variety of interventions can augment training:
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Specialized feedback
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Functional electrical stimulation
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Use of functional orthoses
Summary
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Occupational therapists who apply the ideas
optimizing motor control use their skills in
analyzing kinematic and kinetic requirements of
specific activity performance to develop
individualized goals and treatment.
Occupational therapists structure tasks and
environments to assist patients in developing
motor strategies and problem-solving skills.