The Use of Meaningful Activity in
Neurological Rehabilitation
An Occupational Therapy
Approach to Motor Control and Motor Learning
Heiko Lorenzen, Bc. of Health in OT
Döpfer School for Occupational Therapy
Cologne, Germany
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Overview
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Introduction to Occupational Therapy
Introduction to CIMT
Application of CIMT in Occupational Therapy
Case Example „Musician“
Discussion
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Basic Assumptions in Occupational
Therapy
• „Occupation“ refers to all meaningful activities
that make up an individual life
• The engagement in occupations is associated
with participation, health, well-being and quality
of life
• Occupational therapists aim to engage their
patients in activities that are meaningful to them
in order to facilitate participation
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Occupational Therapy in Motor Control
and Motor Learning
• Motor control is the ability to fixate the body and to
move the body (Gilmore & Spaulding 2001)
• Motor learning refers to changes in movement
behavior as a result of practice or experience (Gilmore
& Spaulding 2001)
• Occupational therapists make use of three different
interventions in motor learning (AOTA 2008):
▫ Preparatory methods
▫ Use of purposeful (therapeutic) activities
▫ Engagement in desired occupations
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Introduction to the Constraint Induced
Movement Therapy (CIMT)
• CIMT is based on the learned disuse after the
onset of neurological disorder
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Development of learned
disuse
(figure adapted from: brainworksrehab.com)
Injury / Stroke
Unsuccessful
motor attempts
Positively
reinforced
Feelings of
failure
Compensatory
behavior
Behavior
suppressed
Less effective
behavior
strengthened
Learned
disuse of limb
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Introduction to CIMT
• The downward spiral of disuse leads to greater
disability of the affected arm and hand (Wolf et al
2006)
• Use it or lose it!
• Affected limb needs to be „forced“ into activity
• Typical CIMT program: 3 hours/day of therapy,
5 days/week for 4 weeks + 5 – 6 hours at
home (Earley et al 2010)
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Introduction to CIMT
• Criteria for application of the CIMT method (Wolf et al
2006):
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≥6 months post-stroke
No or mild cognitive impairments (MMSE ≥24)
Ambulatory without the use of assistive devices
≥45° shoulder flexion and abduction
45° external rotation at the shoulder
Full elbow extension
45° forearm supination and pronation
≥ 5° wrist extension
5° digital exension (specifically thumb, index + middle finger)
Ability to grasp and release a washcloth 3 times within 1 min.
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Application of CIMT in Occupational
Therapy
• Application of preparatory methods
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stretching of the affected upper extremity
joint mobilization
training the strength of the hand
taktile stimulation
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Application of CIMT in Occupational
Therapy
• Use of purposeful (therapeutic) activities
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practicing to unscrew a bottle of water
practicing to use cutlery
practicing to grasp and move a table tennis racket
practicing the typical movements for playing a
certain musical instrument
▫ practicing to use a jig saw
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Application of CIMT in Occupational
Therapy
The chosen preparatory methods
and purposeful activities need to match
the demands of the desired occupation!
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Application of CIMT in Occupational
Therapy
• Performance of meaningful activities (ideally within
the own context)
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using cutlery at home or in a restaurant
playing table tennis with a friend or in a club
playing the musical instrument
doing craftswork at home or at work
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Case Example „Musician“
from Earley et al (2010)
• 52 year old woman, 4 years after lefthemispheric stroke
• Decreased gait functions
• Decreased strength and decreased use of the
affected right upper extremity
• Difficultuies in performing several basic ADL´s
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Case Example „Musician“
• Preparatory methods
▫ Manual stretching of anatomic structures
▫ Progressive resistive exercises
▫ Weight bearing and joint compression
• Performance of purposeful activities
▫ Simulation of violin playing
▫ Engagement in cooking activities
▫ Arranging a photo album
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Case Example „Musician“
• Engagement in a variety of meaningful activities
at home during 5 – 6 hours daily
• After functional improvements and increased
self-confidence this included also practicing to
play her violin
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Case Example „Musician“
• Some of the results:
▫ 50% increase of grip strength and pinch strengh
▫ Improvement of fine motor hand use measured
with the Nine-Hole-Peg Test (intake score 28 s /
discharge score 21 s)
▫ 4 years after the stroke and 1 month after the
CIMT intervention the „musician“ returned to her
role of playing the violin in a community
symphony orchestra
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Literature
• American Occupational Therapy Association (AOTA) (2008) Occupational Therapy
Practice Framework: Domain and Process (2nd ed.). American Journal of
Occupational Therapy, 62, 625-683
• Earley D, Herlache E, Skelton DR (2010) Use of occupations and activities in a
modified constraint-induced movement therapy program: a musician´s triumph over
chronic hemiparesis from stroke. American Journal of Occupational Therapy, 64,
735-744
• Gilmore PE, Spaulding SJ (2001) Motor control and motor learning: implications for
treatment of individuals post stroke. Physical & Occupational Therapy in Geriatrics,
20(1), 1-15
• Townsend E, Polatajko H eds.(2007) Enabling occupation II: advancing an
occupational therapy vision for health, well-being and justice through occupation.
Ottawa: CAOT
• Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D et al. (2006) Effect of
constraint-induced movement therapy on upper extremity functions 3 to 9 months
after stroke. JAMA, 296, 2095-2104
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Heiko Lorenzen
• Referent and Lecturer for Occupational Therapy
• Referent for ICF in Neurological Rehabilitation
• Referent for Fatigue Management
Contact: heiko.lorenzen@web.de