Assessing Motor Function - Part 1 PDF

Assessing Abilities and Capacities: Motor Function Part 1 OT 211 Dr. Qussai Obiedat  INTRODUCTION Several models and theories of motor behavior were produced over the years. Advancement in technology has led to an explosion of information...

Assessing Abilities and Capacities: Motor Function Part 1 OT 211 Dr. Qussai Obiedat  INTRODUCTION Several models and theories of motor behavior were produced over the years. Advancement in technology has led to an explosion of information about the control, development, and acquisition of movement. Thus, our understanding of motor behavior and motor control, motor development, motor learning, and motor skill continues to evolve. 2  INTRODUCTION Neurophysiological approaches: Rood’s sensorimotor approach Knott and Voss’s proprioceptive neuromuscular facilitation Brunnstrom’s movement therapy Bobath’s neurodevelopmental treatment. Task- related approaches: Task-oriented approach Carr and Shepherd’s approach 3  MODELS OF MOTOR CONTROL SYSTEMS-BASED TASK-RELATED NEUROPHYSIOLOGICAL APPROACHES APPROACHES Reflex-hierarchical systems The movements are organized by the functional needs/goals. Movements are elicited by sensory input or controlled by central programs. Movement emerges from the interaction of many systems. Open-loop and closed-loop controls are used. Systems are dynamical, self-organizing, and heterarchical. Feedback and feed-forward influence movements The proffered movement pattern is the most efficient to achieve the functional goal. Central nervous system (CNS) is hierarchically organized, with higher centers controlling lower centers. Changes in one or more systems can alter behavior. Reciprocal innervation is essential for coordinated movement. 4  THEORIES OF MOTOR DEVELOPMENT/REDEVELOPMENT SYSTEMS-BASED TASK-RELATED NEUROMATURATIONAL SYSTEMS APPROACHES Changes are due to CNS maturation. Changes are due to interaction of Development follows a predictable multiple systems. sequence (e.g., cephalocaudal, proximal- Progression varies because person and distal). environmental contexts are unique. CNS damage leads to regression to CNS damage leads to attempts to use lower levels and more stereotypical remaining resources to achieve functional behaviors. goals. 5  ASSUMPTIONS OF THERAPEUTIC APPROACHES SYSTEMS-BASED TASK-RELATED NEUROPHYSIOLOGICAL APPROACHES APPROACHES CNS is hierarchically organized. Personal and environmental systems, including the CNS, are heterarchically organized. Sensory stimuli inhibit spasticity and abnormal movement Intensive and variable functional task practice improves the motor behavior. and facilitate normal movement and postural responses. The environment interacts with the individual influencing the occupational Repetition of movement results in positive permanent performance. changes in CNS. Individuals’ functional relearning strategies are not necessarily the same. Recovery from CNS damage follows a predictable Recovery is variable because personal characteristics and environmental sequence. contexts are unique. Behavioral changes after CNS damage have a Behavioral changes reflect attempts to compensate and to achieve task performance. neurophysiological basis. 6  EVALUATION SYSTEMS-BASED TASK-RELATED NEUROPHYSIOLOGICAL APPROACHES APPROACHES Primary Focus on Performance Components Primary Focus on Occupational Performance Abnormal muscle tone. Using a Client-Centered Perspective: Abnormal reflexes and stereotypical movement Task analysis to determine performance patterns leading to incoordination. components and contexts that limit function and Postural control. to identify preferred movement patterns for specific tasks in varied contexts. Sensation and perception. Variables that cause transitions to new patterns. Memory and judgment. Stage of recovery or developmental level. Secondary Focus: Selected Performance Components and Contexts That Limit Secondary Focus: Occupational Performance Function 7  EVALUATIONS USED BY NEUROPHYSIOLOGICAL APPROACHES Patient evaluation focuses primarily on abilities and capacities impaired by CNS damage. It is important to determine the patient’s stage of recovery or developmental level. Finally, occupational performance is evaluated secondarily on the assumption that any deficits in these areas are due to impaired performance components. This bottom-up evaluation framework is not consistent with the Model of Occupational Functioning. 8  EVALUATIONS USED BY NEUROPHYSIOLOGICAL APPROACHES The evaluations used by the neurophysiological approaches still provide valuable information for patients who have not recovered to the level required to engage in task- related approaches. Evaluating muscle tone, strength, and sensation can help clinicians to address their clients’ specific motor behavior challenges to enhance treatment individualization. 9  MUSCLE TONE ASSESSMENT Muscle tone: the resistance of a muscle to passive elongation or stretching. Slight resistance in response to passive movement characterizes normal muscle tone. When the therapist moves the arm, it feels relatively light, and if the therapist lets go of it, it is able to maintain the position. Hypotonia: is less than normal resistance to passive elongation. When the therapist moves the arm, it feels floppy and heavy. If the therapist lets go of it, it cannot maintain the position or resist the effects of gravity. Hypertonia: more than normal resistance of a muscle to passive elongation, is due to neural and mechanical factors. The neural factor (i.e., spasticity) is due to hyperactive stretch reflexes frequently seen after CNS damage. In a spastic muscle, there is a range of free movement, then a strong contraction of the muscle in response to stretch (i.e., stretch reflex), and free movement again when the muscle suddenly relaxes (i.e., clasp knife phenomenon or reflex) 10  MODIFIED ASHWORTH SCALE FOR GRADING SPASTICITY Grade Description 0 No increase in muscle tone Slight increase in muscle tone manifested by a catch and release or by minimal resistance 1 at the end of the range of motion when the affected part or parts are moved in flexion or extension Slight increase in muscle tone manifested by a catch, followed by minimal resistance 1+ throughout the remainder (less than half) of the ROM 2 Marked increase in muscle tone through most of the ROM, but affected parts are easily moved 3 Considerable increase in muscle tone; passive movement difficult 4 Affected part or parts rigid in flexion or extension 11  EVALUATION FRAMEWORK FOR THE SYSTEMS- BASED TASK-RELATED APPROACHES 1. Role Performance: Determine interest in, and definition of, self-maintenance, self-advancement, and self- enhancement roles. Identify past roles and whether they can be maintained or must be changed. Determine how future roles will be balanced: worker, student, volunteer, home maintainer, hobbyist, amateur, participant in organizations, friend, family member, caregiver, religious participant, other. 12  EVALUATION FRAMEWORK FOR THE SYSTEMS- BASED TASK-RELATED APPROACHES 2. Occupational Performance Tasks: Areas of Occupation Determine abilities in the following areas of occupation: Activities of daily living (ADL): feeding, grooming, functional mobility, dressing, oral and toilet hygiene, bowel and bladder management, and bathing/showering. Instrumental ADL: care of others and/or pets, communication device use, community mobility, home management, meal preparation and clean-up, safety procedures, shopping, and others unique to the patient. Work-related tasks: employment seeking and acquisition; job performance; volunteer exploration and participation; and retirement preparation and adjustment. Play-leisure: exploration and participation. 13  EVALUATION FRAMEWORK FOR THE SYSTEMS- BASED TASK-RELATED APPROACHES 3. Task Selection and Analysis The therapist observes a functional task important to the client to identify which performance components and/or performance contexts limit or enhance occupational performance. The task setup should be as similar to the client’s natural environment and tools as possible. 4. Person: Performance Components Cognitive: orientation, attention span, memory, problem solving, learning, and generalization. Psychosocial: values, interests, self-concept, interpersonal skills, self-expression, coping skills, time management, and self-control. Sensorimotor: strength, endurance, range of motion, coordination, sensory awareness and processing, perceptual processing, and postural control. 14  EVALUATION FRAMEWORK FOR THE SYSTEMS- BASED TASK-RELATED APPROACHES 5. Environment: Performance Context: Physical: objects, tools, devices, animals, and built and natural environments. Socioeconomic: social supports, including family, friends, caregivers, social groups, and community and financial resources. Cultural: ethnicity, family, attitudes, beliefs, values, customs, and societal expectations. 15  ASSESSMENTS OF MOTOR BEHAVIOR AND MOTOR FUNCTION Motor Assessment Scale (MAS): An easily administered and relatively brief (15–30 minutes) assessment relevant to everyday motor activities. The Arm Motor Ability Test (AMAT): An assessment of functional ability and quality of movement as a result of CIMT. Some of the 13 functional tasks are simulated (e.g., “cut meat” uses Play-Doh®) and thus are not as natural as most functional assessments. 16  ASSESSMENTS OF MOTOR BEHAVIOR AND MOTOR FUNCTION The Wolf Motor Function Test (WMFT): Quantifies upper extremity movement ability through timed single- or multiple-joint motions and functional tasks. It was also developed to assess the effects of CIMT. The Motor Activity Log (MAL): A structured interview that assesses the persons’ poststroke insight of how much they use the affected UE to perform 30 common functional activities. There are two other versions of the test, 1 with 14 tasks and 1 with 28 This test has two subscales: the Amount of Use Scale and the Quality of Movement Scale, where the average of 0–5 scale scores are computed for common upper extremity daily life tasks. The Fugl-Meyer Motor Assessment (FMA): Was developed to evaluate motor function, balance, some aspects of sensation, and joint function in persons post stroke. The items were based on earlier studies on the sequential stages of motor recovery post stroke (Brunnstrom, 1970; Twitchell, 1951). The maximum points are 66 for the upper extremity, 34 for lower extremity, 14 for balance, 24 for sensation, 24 for position sense, 44 for range of motion, and 44 for joint pain (total possible score, 250). Each section can be scored separately. 17  ASSESSMENTS OF BALANCE Balance is assessed through observational analysis as the person performs self-initiated movements in sitting and standing. These include the following: Looking in a variety of directions (e.g., up at the ceiling, behind oneself) Reaching forward, sideways, and down to the floor to pick up objects Walking in various conditions The Berg Balance Scale (BBS): Evaluates a client’s performance on 14 items common in everyday life. Functional Reach Test: A quick, clinical measure of dynamic balance that uses a continuous scoring system to assess the risk of falls in the elderly. 18 Thank You! 19