Introduction To Theories of Neurological Rehabilitation

Introduction to theories of
neurological rehabilitation
Prepared by:
Dr. Qindeel Shafaq
 Neurological rehabilitation approaches can be
used to improve motor control and motor
learning in neurological patients
 Motor control is ability of CNS to control and
direct the neuromotor system in purposeful

movements and posture adjustment
 Motor learning is acquisition of skilled
movement based on previous experience

Theories of motor control
• Theories of Motor Control describe the
viewpoints regarding how movement is
controlled.
• A theory of motor control is a group of
abstract ideas about the control of
movement.
• A theory is a set of interconnected statements
that describes unobservable structure or
processes and relate them to each other and
to observable events.
Theory and Practice
 Do theories really influence what therapist do
with their patients?
 Yes, rehabilitation practice reflects the
theories or basic ideas we have about the

cause and nature of function and dysfunction.
 Theory provides;
• A guide for clinical action

• New Ideas; dynamic and evolving
Theories of Motor Control
 Reflex Theory
 Hierarchical Theory
 Motor Programing Theory
 Systems Theory
 Ecological Theory
Reflex theory
• Stimulus applied to muscles
or joints results in
responses that are called
reflex movements
• 3 parts:
1.receptor,
2.pathway,
3.effector
• Reflexes were the building
blocks of complex behavior
• Reflexes worked together
or in sequence to achieve a
goal
 Movement can be reflexive(a stimulus is
provided and movement occurs without
conscious thought),
 Movement can be volitional(A conscious
decision to move like to get out of bed) or

combination
Limitations of reflex theory
 There are number of limitations of a reflex theory of Motor Control:
1. Reflexes can not be considered as the Basic unit of
behavior Because Reflex must be activated by an
outside agent
2. It does not explain and predict movement that
occurs in the Absence of sensory stimulus as animal
move in a relatively coordinated fashion in the
absence of sensory input.
3. doesnt explain: how people can produce
movements spontaneously, wihtout any change in
sensory input, how diff responses can result from
the same stimulus
HEIRARCHICAL THEORY
 There are Higher, Middle, and Lower levels
of motor control
 Top down approach
 the motor cortex , midbrain and spinal level
of motor function
 As the child grows, the movement is
controlled by successively more complex
level of CNS
 AT the time of birth SC develop, 6-9
months mid brain develop and 12-15
months cortex matures
 Limitations: Only focus on CNS e.g. a patient
comes with frozen shoulder due to
musculoskeletal system pathology
 Neuromaturational Theory
Limitation of Hierarchical theory
 doesnt explain why sometimes health
individuals control of motor output is
dominated by lower levels
- examples: some kids learn to walk before
they can crawl
System Theory
 It focus on interaction of many different
systems of body that contribute to movement
 Forces needed to generate movement are
different depending upon 2 factors:

 1. the environment in which action occurs
 2. internal forces generated to complete the
action
 E.g. to open a door
 Different systems decide how to accomplish
the task
Motor Programming Theory
 movement patterns or rules of action are stored in
the CNS as motor programs and can either be
triggered by sensory input or initiated centrally
- addresses some of the limitations of the reflex
theory - explains how movements can occur in the
absence of sensory input and allows for
spontaneous and voluntary movements\
 there are central pattern generators(CPG) in the CNS
 exist in the organism at birth, such as CPGs or can
be learned, such as postural strategies or
handwriting
Motor Programming Theory
 Instead of the CNS being just and always “reactive”, this
theory states that CNS can act on its own as a result of
prepared motor programs
 There is an abstract motor program stored on the higher
levels and sent down to be interpreted and carried out

depending on the situation and context.
 The term motor program may be used to identify a central
pattern generator (CPG) that is a specific neural circuit

represents neural connections
 Individual can still act in the absence of a stimulus
 Higher level stores the rules for generating movements
patterns so that we can perform the tasks with a variety of

effector systems
 Intervention invovles teaching the pt new
motor programs or teaching the pt to apply
surviving motor programs to perform desired
activities
 Examples for using motor program theory:
- if patient does not use an ankle strategy
- if a patient who had a stroke can only move
the arm in a flexor synergy
 teach the pt to perform this motor program
- teach him a variety of other motor programs
Ecological Theory
 Motor control evolved so that animals could cope with the
environment around them.
 Motor control evolved to enable organisms to interact with their
environments in order to perform goal-oriented behavior.

 LIMITATION:
Emphasis has shifted from the nervous system

to the organism- environment interaction
 doesnt address other aspects of neuromotor control
Affordance n opportunity for action that the environment

offers to the organism (living thing)
- the concept of affordances takes into account characteristics
of the organsim as well as characteristics of the environment
 Movement in the environment allows the
 individual to translate meaningless sensory input (eg
color and light) into meaningful perception (objects

and surfaces)
 Therapists must:
 Evaluate pt's ability to perceive the relevant features of
the environment
 provide intervention to facilitate pts perception
 evaluates the extent to which a pt is interpreting the
environment in a way that enables the pt to be

successful at goal-oriented behavior
Types of Approaches of motor
control
Neurological treatment to improve motor control have been
developed taking into consideration:
1-Primitive approaches
CNS is hierarchically organized.
Movement is controlled by sensory stimulation and through
encoded motor programs of higher centers.
Development and learning results from changes in CNS
2-Contemporary approaches
Emphasize on systems theory.
It stresses learning the entire task rather than discrete parts.
Enhance problem solving abilities by allowing persons to find their
own solutions to motor problems rather than relying on
instructions.
Focus on functional tasks performed in most efficient way
 Neurodevelopmental approaches focus on
learning through:
1. task repetition
2. with constant assistance
3. and feedback from therapist
 Emphasize developmental progression from
learning parts of task to combine parts into

whole and perform movement
 Recovery occurs from proximal to distal
control and from reflex to voluntary control

Primitive Approaches
Remediation and facilitation approaches

 Roods approach
 Bobath approach(neurodevelopmental theory)
 Kabat, Knott, Voss (Proprioception
neuromuscular facilitation PNF Approach).

 Bernstorm Approach.
 Sensory Integration Therapy
Contemporary approaches
• Motor Control / Motor Learning Approach
• Neural plasticity/ adoptability
• Constraint induced movement therapy (CIMT)
• Modified Constrained Induced Movement Therapy
(mCIMT)
• Task-Related Training Approach
• Compensatory Training Approach
• Normal Reach, Grasp and Manipulation.
Primitive approaches
 Rood Approach – develop by Margret Rood (1967)
 Bobath Approach – developed by Karl and Berta Bobath
(1975).
 Brunnstrom Approach – Developed by Signe Brunnstrom
(1966).
 Proprioception Neuromuscular facilitation (PNF) -
developed by Kabat and Knott. (1954) and expanded by
Voss et al (1985).
 Sensory Integration Therapy developed by Ayres (1972).
 These approaches were based largely on assumptions
drawn from both the reflex and hierarchical theories of
Motor Control.
Neurofacilitation
 Concept of neuro-facilitation
• Retraining motor control through techniques designed
to facilitate and/or inhibit different movement
patterns.
• Facilitation refers to intervention techniques that
increase the patients ability to move in a way judged
to be appropriate by the clinicians.
• To encourage normal reflexes, muscle tone, movement
• Inhibitory Techniques decrease the patient’s use of
movement pattern considered to be abnormal.
• To inhibit abnormal reflexes, muscle tone, movement
Assumptions for practice
 Clinical Practice developed based on

assumptions regarding:
1. The nature and cause of Normal motor
Control
2. Abnormal Motor Control
3. And Recovery of Functions.
 Then key assumptions are :
1. Functional skills will automatically return once abnormal
moment patterns are inhibited and normal movement
pattern facilitated.
2. Repetition of these normal movement pattern will
automatically transfer to functional tasks.
 Examination of motor control focus on:
1. The presence or absence of normal and abnormal

reflexes.
2. Interventions directed at modifying reflexes.
3. The importance of sensory input for stimulating normal
motor output  suggest an intervention focuses on
modifying the CNS through sensory stimulation.
 This approaches suggest that normal
movement results from the chain of reflexes
organized with CNS
 Thus the emphasis on incoming sensory
information stimulates and drive normal

moment pattern
 The physiological basis for abnormal motor
control suggest a disruption of normal reflex

mechanism resulting in abnormal moment
control.

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Introduction to theories of

direct the neuromotor system in purposeful

movement based on previous experience

theories or basic ideas we have about the

• A guide for clinical action

decision to move like to get out of bed) or

different depending upon 2 factors:

levels and sent down to be interpreted and carried out

pattern generator (CPG) that is a specific neural circuit

patterns so that we can perform the tasks with a variety of

environments in order to perform goal-oriented behavior.

Emphasis has shifted from the nervous system

Affordance n opportunity for action that the environment

color and light) into meaningful perception (objects

 Evaluate pt's ability to perceive the relevant features of

 evaluates the extent to which a pt is interpreting the

environment in a way that enables the pt to be

learning parts of task to combine parts into

control and from reflex to voluntary control

Remediation and facilitation approaches

neuromuscular facilitation PNF Approach).

 Clinical Practice developed based on

1. The presence or absence of normal and abnormal

information stimulates and drive normal

control suggest a disruption of normal reflex

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